w:
25¢ per day per item

RETURNING LIBRARY MATERIALS:

New in bookre mrenoto
charge from circulation records

 
  
 
 
  

 

 

 

THE IMPACT OF INTERPERSONAL PROCESS
RECALL UPON MEDICAL STUDENTS AS A FUNCTION

OF SOCIAL VALUES: TEN CASE STUDIES

BY
Ronald John May

A DISSERTATION
Submitted to
Michigan State University

in partial fulfillment of the requirements
for the degree of

DOCTOR OF PHILOSOPHY

Department of Counseling and Educational Psychology

1980

ABSTRACT
THE IMPACT OF INTERPERSONAL PROCESS

RECALL UPON MEDICAL STUDENTS AS A FUNCTION
OF SOCIAL.VALUES: TEN CASE STUDIES

BY
Ronald John May

Interpersonal Process Recall is a video-tape training
technique designed to increase the effective facilitation of
interpersonal communication by increasing people's awareness
of their interpersonal style in interviews. Although the
method was originally developed for counselor education and
psychotherapy, IPR has been applied to a variety of profes-
sional and nonprofessional groups, including medical students.

IPR training begins with instruction in four response'
modes, then affective stimulation experience, followed by a
brief presentation of constructs from personality theory.
However, the central focus is upon reviewing video-taped
interpersonal interactions to explore communication styles
and covert processes. These recall sessions are facilitated
by a neutral observor called the inquirer.

A number of studies have demonstrated the usefulness of
IPR for increasing the interpersonal effectiveness of medi-
cal students (Werner and Schneider, 1974; Benedek and Bieniek,
1977; Novik, 1978). However, since these studies have typi-
cally used pre-post assessments with group comparisons de-
signs, there is little knowledge of the relative impact of

the diverse content and formats within the IPR model. ,In

Ronald John May

addition, Heiserman (1971) and Werner and Schneider (1971)
suggested that the level of interpersonal values moderates
the potential effectiveness of IPR.

The purpose of this study was to identify more specifi-
cally the nature, rate and sources of gains in interpersonal
skills during IPR training for students with high and low
social values. In addition, choice of curriculum format and
the provision of additional experiential lab sessions provid-
ing physiological feedback were used as additional variables
to be explored. However, the main purpose of the study was
to determine what learning curves existed. This information
could then lead to the design of more effective training.
Another goal was to generate hypotheses for future controlled
research.

The theoretical base for the course was derived from
the holistic view of treating the patient-with-a-disease
rather than the disease alone. In this model, medical inter-
views interpret physical symptoms as communications of the
patient's overall physical, mental and emotional well-being
within the context of their relationships with themselves and
others (Kimbal, 1969; Clyne, 1972). This view purports that
successful physicians must integrate their medical knowledge
with a facilitative interpersonal style.

The population was all 106 first-year medical students
in a School of Medicine of a large Midwestern university.

These students were enrolled in a required IPR course during

Ronald John May

winter term, 1980. Ten subjects were randomly selected to
equally represent the upper and lower quartiles of the p0pu-
lation's distribution on the Social subscale of the Study of
Values. The ten-week course included six workshop sessions
presenting the IPR method and specific psychosocial applica-
tions in medicine. In addition, the students met in weekly
two-hour lab groups conducting practice interviews and recall
sessions.

EValuations of interview skill development were made
five times during the training through interviews with gradu-
ate students who expressed actual health concerns. Addition-
al evaluations were made through pre-post training interviews
of drama students trained as patient models.- Taped record-
ings of these interviews were rated by doctoral counseling
students for the use of effective interview responses using

the Counselor Verbal Response Scale and empathic responding

 

using the Empathic Understanding in Interpersonal Processes
Scale. The interviewees also made ratings of the therapeutic
quality of the relationship using a modified form of the

Barrett-Lennard Relationship Inventory. Each subject's per-

 

sonal reactions to the training were collected through five
semi-structured face-to-face interviews. Overall assessments
of the affective sensitivity and psychosocial attitudes
towards the doctor—patient relationship were also made using

pre-post measures with the Affective Sensitivity Scale and

 

Ronald John May

Doctor-Patient Relations subscale of the Attitudes Towards

 

Social Issues in Medicine Scale, respectively.

Case studies including graphs of interview ratings were
created for each subject. These case studies related the
elements of the IPR model to changes in interview functioning.
In addition, group comparisons of class reactions and inter-
personal skill development were identified and interpreted.

The results indicated little overall change in affective
sensitivity and psychosocial attitudes towards the doctor-
patient relationship perhaps because of the initial high
levels of these assessments. The learning curves reflected
considerable practice of training responses during mid-
training with a gradual integration of these responses into
the students' own interpersonal style. Students with high
social values and a preference for a less traditional curri-
culum achieved this integration sooner than their counter-
parts. Lab experiences were often described by students as
opportunities to resolve emotional concerns inhibiting inter-
personal skill development.

Significant differential feedback towards the components
of the IPR methOd was discovered. High social students
valued the lab groups and inquirer training for exploring
their interpersonal styles, while low social students found
affective stimulation, personality constructs and recalls
most helpful for becoming more initially aware of the rele-

vance and complexity of human interaction in medical care.

Ronald John May

Students in the more traditional of two curricula available
to students reported that role models of effective interview-
ing helped to desensitize their anxieties to interviewing and
affective learning, while the students in a group-centered,
issue-oriented curriculum valued affective stimulation and
recalls as stimuli for their own personal growth.

This study concluded with a discussion of implications
for future training and research. Recommendations were made
to orient the length and designs of training programs to spe-
cific individual and group needs. Multiple outcome measures
and mid-training and follow-up assessments were reported to
be needed in future research. The relative training value of
'simulated and actual interviewees was proposed as a potential
research hypothesis. The confirmation of group differences
suggested by this study was also recommended for future

investigations.

ACKNOWLEDGMENTS

Many persons contributed to the successful completion of
this study. I wish to express my gratitude to the following
individuals . . .

Norman Kagan . . . for his encouragement to accept the chal-
lenge of innovation and his penetrating insights into

the intricacies of human communication.

Albert Aniskiewicz . . . for his steadfast support of my pro-
fessional autonomy and growth throughout my doctoral

studies.

Arthur Kohrman . . . for serving as a model of the kind of
physician this training attempts to develop.

Sam Plyler . . . for helping me to learn the meaning of inte-
grity within the human experience.

Bruce Burke . . . for sharing the wealth of his experience
in the study of interpersonal communication.

Patti Stifler . . . for her careful management of the needs
of research and the welfare of her students.

Ten medical students . . . for their willingness to share
their struggles and triumphs during their training

experience.

Melissa Andrea, Barbara Honeyman, Patrick Lustman, James
Milhouse, Dennis O'Hara, Frank Pascuiti, Daniel Price,
Michael Talmo and Daniel Wasserman . . . for serving
as interviewees in this study.

Michael Lieberman . . . for his technical assistance in data

collection.

ii

James Conklin, Judith Ellickson and Russell Hogan . . . for
serving as raters of interview tapes.

Maxine Hire . . . for her incredible patience and endurance
in the production of this manuscript.

Melissa Andrea, Patrick Lustman and Dennis O'Hara . . . for
their colleagueship in sharing the agonies and joys of
becoming a professional.

Christina Rideout . . . for her companionship, her caring and,
most of all, her willingness to be there during the hard

times.

iii

Chapter

II

TABLE OF CONTENTS

INTRODUCTION . . . . . . . . . . .

Purpose of the Study . . . . . .

Statement of the Problem . . . . . . .
Incidents of the Problem . . . . . . .
The Interpersonal Process Recall Model . .
Rationale for the Study . . . . . . .
Theoretical Considerations . - - - .
Holistic Medicine and the Doctor—Patient
Relationship . . . . . . . .

The Psychological Development of the

Medical Student . . . .
Definition of Terms . .
Delimitations of the Study
Basic Assumptions . . .
Research Questions . . .
Overview . . . . . .

REVIEW OF THE LITERATURE . . . . . . .

Interpersonal Skills and Medical Practice .
The Doctor-Patient Relationship and
Satisfaction with Treatment . . . . .
The Doctor-Patient Relationship and
Compliance with Treatment . . . . . .
Summary and Discussion . . . . . .
Interview Training in Undergraduate Medical
Education . . . . . . .
Courses Emphasizing Cognitive Understanding
Courses Emphasizing Experienceing Doctor-
Patient Ihteraction . . . . . . . .
Summary and Discussion . . . . . .
The IPR Method, Theory, and Research . . .
The Development of the IPR Method . . .
Applications of IPR in Nonmedical Settings
Applications of IPR in Medical Education
Summary and Discussion . . . . . . .
Social Values of Medical Students . . . .
Normative Levels of Social Values for
Medical Students , . . . . .
Changes in Social Values During Medical
.EduCation - .v a e 9 1 e o a o 0
Summary and Discussion . . . . . . .

iv

Page

mmUleH l—‘

11
15
16
l7
17
18

19
19
20

21
24

25
25

29
38
40
40
43
49
54
55

56

'59

67

'Chapter Page

Attitudes Toward Soci 1 Issues in

III DESIGN AND PROCEDURES . . . . . . . 68
Population . . . . . . . . . . . 68
Sampling . . . . . . . . . . . 68
The IPR Course . . . . . . . . . 71

Class Format . . . . . . . . . 71
The IPR Class . . . . . . . . . 7S
Instrumentation . . . . . . . . . 75
Study of Values . . . . . . . . 75

a

Medicine (ATSIM) . 76

Affective Sensitivity Scale (ASS) . . 77
Relationship Inventory (RI) . . . 78
Counselor verbal Response Scale (CVRS) . 79

Empathic Understanding in Interpersonal

Process Scale (EU) . . . . . . . 80
Tape Ratings . . . . . . . . . . 82
Selection of Raters . . . . . . . 82
Rating Procedures . . . . . . . . 82
Design . . . . . . . . . . . 83
Intensive Case Study . . . . . . . 83
Summary of the Design . . . . . . 87
Data Analysis . . . . . . . . . . 87
Summary . . . . . . . . . . . . 88
IV RESULTS, DISCUSSION AND CONCLUSIONS . . 89
Deletions of Data . . . . . . . . 90

Pre-Post Changes in Affective Sensitivity
and Attitudes towards the Doctor-Patient
Relationship . . . . . . 91
Case Studies of Students Who Scored in
the Upper Quartile on Social Subscale

Physiological Feedback vs.
Physiological Feedback .

of Study of Values . . . . . . . . 94
George . . . . . . . . . . . 94
Mary . . . . . . . . . . . . 99
Fred . . . . . . . . . . . . 102
Claire . . . . . . . . . . . 107
Carolyn . . . . . . . . 112

Case Studies of Students Who Scored in

the Lower Quartile on Social Subscale

of Study of Values . . . . . . . . 117
Alan . . . . . . . . . . . . 117
Margaret . . . . . . . . . . . 123
Mark . . . . . . . . . . . . 128
Brian .. . . . . . . . . . . . 133
Susan . . . . . . . . . . . 137

Group Comparisons . . . . . . . . 141
High Social vs. Low Social . . . . . 141
Track I vs. Track II . . . . . . . 147

N

. . . . 152

V

Page

Summary and Discussion . . . . . . . 154
Implications for Training . . . . . . 157
Implications for Research . . . . . . 158

BIBLIOGRAPHY . . . . . . . . . . 161

APPENDICES
A. Role and Function of the Inquirer . 172
B. Consent Form for IPR Research
Project . . . . . . . . 173
C. Biographical Information . . . . 174
D. Reactions to IPR Class . . . . 175
E. Relationship Inventory

(Modified) . . . . . . 177
F. Empathic Understanding in Inter-
personal Process Scale . . . . 179

G. Counselor Verbal Response Scale . 182

vi

Table
3.1

3.2

3.3

3.4

3.5

3.6

4.1

4.2

LIST OF TABLES

Mean and Z Scores on the Social Subscale
of the Study of Values for High and Low

Social Groups Compared to the Population
Distribution . . . . . . . . . .

Mean and Z Scores on the Social Subscale
of the Study of Values for Males in High
and Low Social Groups Compared to a Nor-
mative Group of First-Year Male Medical
Students . . . . . . . . . . .
Mean and Z Scores on the Social Subscale
of the Study of Values for Females in
High and Low Social Groups Compared to a
Normative Group of First-Year Female
Medical Students . . . . . . . .

Summary of Training Program and Inter-
view Assessment Schedule . .' . . . .

Reliabilities of the Average Ratings
Between Two Judges on the CVRS and EU
Scales for Actor Patient Interviews . .

Reliabilities of the Average Ratings
Across Pairs of Judges on the CVRS and
EU Scales for Psychologist Patient
Interviews . . . . . . . . . .

Pre- and Post-test Mean Scores by Subject
and Comparison Groups . . . . . . .

Pre- and Post-test Mean Scores Prorated
for Fifteen Responses for Interviews
with Actor Patients by Subject . . . .

Pre- and Post-test Mean Scores Prorated
for Fifteen Responses for Interviews
with Actor Patients by Comparison

Groups . . . . . . . . . . . .

vii

Page

70

7O

71

73

84

84

92

98

145

Figure
4.1 Graphs
During
4.2 Graphs
During
4.3 Graphs
During
4.4 Graphs
During
4.5 Graphs
During
4.6 Graphs
During
4.7 Graphs
During
4.8 Graphs
During
4.9 Graphs
During
4.10 Graphs

During

LIST OF FIGURES

of Changes in Interview Skills
Training for George . . . .

of Changes in Interview Skills
Training for Mary . . . .

of Changes in Interview Skills
Training for Fred . . . .

of Changes in Interview Skills
Training for Claire . . . .

of Changes in Interview Skills
Training for Carolyn . . .

of Changes in Interview Skills
Training for Alan 0 o ' o o

of Changes in Interview Skills
Training for Margaret . . .

of Changes in Interview Skills
Training for Mark . . . .

of Changes in Interview Skills
Training for Brian . . . .

of Changes in Interview Skills
Training for Susan . . . .

viii

Page

95

101

104

109

115

120

125

130

135

139

CHAPTER I
INTRODUCTION

Purpose of the Study

The purpose of this study is to examine the progressive
development of counseling skills for first year medical students
participating in Interpersonal Process Recall (IPR) training.
Past research has demonstrated pre-post gains in the counseling
skills of medical students as a result of IPR training. The
present study attempts to identify the components of the IPR
model producing changes, key change points, the rate of change
and barriors to changes as medical students develop counseling
skills through this training.

The study explores differences in these training effects
as a result of the students' level of social values. Although
not a major part of the study, some examination is made of
variance in these training effects due to the studentts choice
of curriculum style and participation in optional laboratory
sessions providing physiological feedback of emotional respon-
siveness during interview situations.

The goals of the study are related to both educational
practice and research. First, the study is designed to determine
the appropriate content emphasis, delivery format and length of
training for IPR programs. Secondly, the study attempts to

generate hypotheses for future IPR research.

Statement of the Problem

Throughout the history of medicine, the holistic
treatment of the patient has been advocated by noted medical
authorities. In 1899, Sir William OSler, the father of
American medicine, told medical students that it was ”more
important to know what sort of patient has the disease than
what disease the patient has" (Fine and Therrien, 1977, p. 775).

In earlier times general practitioners had an intimate
knowledge and understanding of their patients. However,
the growing complexity of society and the increasing speciali-
zation of medical practice have led to more impersonal doctor-
patient associations. In a survey by Menzel, Coleman, & Katz
(1959), 51 percent of the physicians recognized deficiencies
in social-psychological skills. Post-1945 medical graduates
reported these skill deficits at nearly double the rate of
physicians graduating from medical school prior to 1929.

In the 1960's, the medical profession and, in particu-
lar, medical education were attacked for ignoring the impor-
tance of psychosocial variables in medical practice (Tournier,
1964; Evans, 1964; Rosinski; 1969). These authors stressed
that medicine's emphasis on science and technology threatens
the loss of the human quality of medical practice. Post-war
educational developments in preventive medicine and psychiatry
were declared to have been lost in the bureaucratic structure
of the medical school, leaving the total pattern and philoso-
phy of medical education unaffected (Evans, 1964).

In recent years, however, medical schools have given

more attention to the psychosocial aspects of medicine at
least with regard to the doctor-patient relationship. In a
1977 survey of American medical schools, Kahn et. a1. (1979)
reported that 68 percent of the total sample selected
offered training in interpersonal skills. However, 80
percent of these programs were less than five years old.
Twenty-seven percent of these programs employed IPR as a
training model.

Although many interpersonal skill programs have been
initiated recently in medical schools, little research has
been conducted regarding the impact of these programs. The
Kahn et. a1. survey revealed that only one-third of the programs
used any kind of outcome measures for evaluation. Thus, the
further development of these training programs will require
greater efforts in evaluation to increase the impact of these
programs on the interpersonal effectiveness of medical students.
This study attempts to enhance the utilization of the IPR model
by studying its impact relative to social values and other

characteristics.

Incidents of the Problem
During the summer of 1979, the author interviewed ten
students from a school of medicine at a large Midwestern
university who had recently completed an IPR course. The
students equally represented a traditional, lecture-based
curriculum (Track I) and a student-centered, focal problems

curriculum (Track II) offered by the school.

The interviews focused upon the students' reactions to
the IPR course and perceptions of differences between Track I
and Track II students. These interviews were designed as a
brief pilot study for the current study.

The Track I students generally expressed dissatisfaction
with the IPR course. These students felt that the course
offered little for them to learn, that they either possessed
the necessary skills already or else mastered them early in
the course. Most of the course content and experiential
offerings were described as irrelevant to their medical
learnings and unnatural with regard to their interpersonal
contacts. Track I students reported often feeling "like they
were being analyzed” and described their peers as nonrespon-
sive in group discussions.

On the other hand, Track II students expressed satis-
faction with the course. These students reported that the
course helped them to be more aware and honest with them-
selves. At the completion of the course, they viewed them-
selves as asking a broader range of questions and listening
more effectively in helping situations. Positive comments
were most frequent for the opportunities to videotape them-
selves, recall session and the group support among their peers.

Thus, students choosing an issue-oriented curriculum
using a small group format responded to IPR far more favorably
than students choosing a traditional curriculum. These group
differences highlight the need to study the interactive rela-

tionships between training methods and student characteristics.

Both these interviews and interviews with seven faculty
members confirmed that Track I and Track II students differ
significantly with regards to social orientation. Track II
students tend to be more social in their interests, values,
and personal styles. Therefore, this study focused upon
social values as an intervening variable for the effectiveness

of IPR training with medical students.

The Interpersonal Process Recall Model
Interpersonal Process Recall (IPR) is a videotape
training technique designed to increase interpersonal function-
ing. Originally developed by Kagan et. a1. (1967) for counse-
lor training, IPR has also been used successfully with a vari-
ety of paraprofessional and professional helpers as well as

college students, couples, and prison inmates.

The purposeof IPR is to help the trainee become more
aware of their thoughts and feelings in interpersonal inter-
actions. Videotaped recordings of these interactions are
viewed immediately following the conversation in "recall
sessions."

With the facilitative probing of a trained inquirerl,
the participant(s) attempt to relive the interaction by re-
calling thoughts, feelings, and bodily sensations which may
have gone unnoticed in the interview. These recollections
are then used as stimuli for exploration of the participants'
interpersonal sytles, their perceptions of others, and the

reciprocal dynamics of their relationships.

 

1A description of the role and function of the inquirer
is found in Appendix A.

The basic IPR.method consists of the following five

components:

1. Elements of Facilitative Communication - Exploratory
listening, affective, and honest labeling responses
are taught and practiced as specific skills in
effective communication.

2. Affect Simulation - Filmed vignettes of stressful
interpersonal situations are shown to help the
participant identify affective reactions.

3. Inquirer Training - An assertive but nonjudgmental
probing style is taught and practiced to facilitate
the personal exploration of others in recall ses-
s1ons.

 

4. Theoretical Constructs - A conceptual framework of
interpersonal response patterns based upon the
work of Karen Horney is presented. These responses
consist of the tendencies to attack, withdraw, and
conform.

5. Recall Sessions - Interactions are videotaped, then
viewed by the helper (interviewer recall), helpee
(client recall) or both participants (mutual recall)
immediately following the interview. An inquirer
facilitates the viewer's exploration of their experi-
ences during the interview.

 

Rationale for the Study

In spite of positive gains reported in most IPR studies,
the method has had limited success with individuals with low
psychosocial orientations. Several studies have indicated that
individuals giving low priority to the role of empathy and
understanding in their work do not benefit from IPR (Heiserman,
1971; Weiner & Schneider, 1974). Practical experience with
IPR training has indicated that these persons are unmotivated
during training and often overly critical, if not hostile,
towards the course.

Apparently, low social persons fail to perceive the

complexity of interpersonal relationships or the potential to
systematically improve one's interpersonal effectiveness. The
content of IPR is considered to be unimportant, or else,
easily mastered in the first few hours of training. These
attitudes inhibit these participants from taking the neces-
‘sary risks for experiencing self-discovery in the IPR process.
Whether these learning difficulties result from partic-
111ar components of the IPR model, the style of delivery, the
:structure of the learning situation, or any other variables
is; unknown at this time. Since IPR has proved to be success-
fhil with prison inmates, policemen, and other populations dif-
fering vastly from the counseling orientation, it appears that
IPR has the potential to impact a variety of personality types.
. Previous reSearch has failed to examine differential
reactions to IPR by differing personality types within the
same occupational group. Furthermore, the pre-post change de-
Signs of these studies have failed to uncover specifically
Which.aspects of the IPR model produce change in participants.
Thus, it is the intent of this study to closely analyze the
POSitive and negative impacts of the varying aspects of IPR
orldifferent types of individuals (focusing upon social values)
u$1119 an intensive design.2
An awareness of the differential impact of IPR on stu-
dentsdiffering in the level of social values is useful only
if a population includes a fairly wide distribution of social

Values. There is evidence that the social values of

-—~____11
2See Chapter III for a description of intensive designs.

medical students vary significantly by one's attraction to
medicine (Olmsted, 1973), year in school (Eron, 1958; Gordon
& Mensh, 1962) and historical era (Coe, Pepper, & Mattis,
1977; Funkenstein, 1977). If the effectiveness of elements
of the IPR model are related to social values, this variance
in social values necessitates adjustments in the presentation
of IPR to these various student groups. This study seeks to
identify the relationship between features of IPR and the
level of social values in medical students which may stimu-

late modification in the use of the IPR model.

Theoretical Considerations

A variety of theoretical constructs have been developed
during the past decade which expand the physician's role in
patient care. Basically, these views envision medical care

within a holistic perspective of the patient's life situa-
tion.

This section has a twofold purpose. First, it will
summarize the theoretical implications of h01istic medicine
for the doctor-patient relationship. Secondly, it will pre-
sent theoretical perspectives of medical student development

relevant to preparation for this relationship.

Holistic Medicine and the Doctor-Patient Relationship

In the traditional disease model of medicine, the phy-
sician serves in an expert role to diminish or eliminate the
disease from the patient's physical condition. More recently,

a patient-with-a-disease model was evolved which conceptualizes

physical health and illness holistically as an interaction of
organic, social, and psychological factors in the patient's
life.

In the patient-with-a-disease model, physical symptoms
are viewed as statements about the patient's physical, mental,
and emotional condition. Kimball (1969) viewed the physician's
role in this model as an interpreter of the physical symptoms
requiring ”multilingual” abilities to understand the patient
within each of these three perspectives. This interpretation
process is facilitated by providing the patient with oppor-
tunities for ventilation, clarification, and support.

The diagnostic interview has been viewed as an oppor-
tunity for the physician to understand the patient's stresses
in living and develop a working rapport in addition to gather-
ing information. Hayes, Hutaff, and Mace (1969) indicated
the need for sensitivity in the physician to determine the
relative importance of somatic and emotional causes of
physical illness. These authors also point out that the
patient must experience trust with the physician before
sharing relevant diagnostic information of an intimate nature.
Furthermore, this trusting relationship motivates the patient
to carry out the prescribed treatment plan.

Clyne (1972) outlined two models of diagnosis which
reflect the changing role of the doctor-patient relationship.
In the "traditional.diagnosis," the physician is an objective
observer using a questioning mode to gather information in

history-taking and examination sessions. Disease is

10
diagnosed as an abstract concept leading to a general prognosis
based upon statistical probability. Clyne stated that neglec-
ting the emotional concommitants of disease precludes specific,
personal prognoses or treatments for individual patients.

In contrast, Clyne described "overall diagnosis" as
assessing both the patient's physical and emotional condition
within the context of their relationships with themselves and
others. The patient is viewed as a human being whose con—
flicts and suffering can be felt and understood. The overall
diagnosis relies primarily upon a listening mode and continues
throughout every doctor-patient interaction. Diagnoses are
based upon the specific needs of the patient rather than
probability. Clyne cited greater accuracy in patient assess-
ments and more detailed prognoses and treatment plans as the
major advantages of overall diagnosis.

The holistic view towards medical treatment deempha-
sizes the application of medical drugs and procedures in hopes
of curing the disease. Rather, physical wellness is promoted
and, once a illness presents itself, natural healing proces-
ses are preferred. In this regard, Younge (1965) compares
the healing process with psychotherapy. Quoting Jesse Taft,
Younge contends that medical care "cannot do anything to any-
body, hence it can better represent a process going on,
observed perhaps, understood perhaps, assisted perhaps, but
not applied (p. 748)."

This treatment orientation has definite implications

for the physician's exercise of authority in the doctor-

11

patient relationship. Once the physician understands the
patient's condition, Pellegrino (1974) discusses the increased
role of personal influence in treatment in contrast to the
authoritative delivery of regimines. The physician must
handle their authority in a humane way that respects the life
values of the patient. Pellegrino supports this view
by quoting Dag Hammarskjold in Markings:

Your position never gives you the right to

command. It only imposes on you the duty

of so living your life that others can re-

ceive your orders without being humiliated
(p. 105).

The Psychological Development
of the Medical Student

Zabarenko and Zabarenko (1978) outlined five develop-
mental tasks leading to the development of the "mature opera-
ting physician." This model physician is defined as "a
physician who has successfully integrated medical knowledge
and appropriate personality attributes into a functioning
whole (p. 14)." Operationally,_this physician provides quality
medical care while receiving adequate satisfaction in his or
her work.

The five developmental issues tend to arise in a syste-
2matic order although considerable overlap does exist. In
order of occurrence, the developmental tasks are as follows:

1. Balancing the oscillation between objectivity
and empathy.

2. Appropriate management of nurturant tendencies
and executive necessities.

3. Adequate regulation and control of needs for

12

omnipotence by appropriate appreciation of
the results of medical work, especially
those related to the tolerance for ambiguity.

4. Formation of an internal ideal of physician-
hood --a professional ego-ideal.

5. Maturation of an operational professional
identity.

Knight (1973) discussed how the resolvement of these
developmental tasks is mediated by the personality dynamics
of the individual student. Excessive needs for security,
to be needed, to rescue, or to control a fear of death were
cited as potential bases for one's attraction to medicine.
Knight identified how these need structures produced "con-
ceived purposes" for assuming the role of physician. The
existence of these needs does not preclude establishing
integrated professional identities, but an awareness and
working through of those needs greatly facilitates effective
functioning in the doctor-patient relationship.

7 Several authors (Eron, 1955; Becker, 1961; Coombs,

1978) have focused upon the effect of the stressful medical

school environment upon the development of the medical

student. Eron identified these stresses as:

l. the initial experiences with the cadaver
2. the death of patients with chronic disease
3. a fear of error in diagnosis

4. a fear of contagion in diagnosis

5. the threat of failure in school

6. the dependent role of the medical student

7. limited recreational and social outlets

13

8. the realization that other persons do what
he/she orders in spite of his/her limits and
inadequacies

Coombs (1978) related this academic stress to disillu-

sionment resulting from the incongruence of the initial expec-
tations of the beginning medical student and the realities of
medical school. Coombs cited these incongruities as:

1. Students expecting to enjoy the recognition and
respect of the physician role, but experiencing
less autonomy and personal freedom than in col-
lege.

2. Students expecting to experience the physician
role while learning from first class clinicians,
but then forced to learn seemingly irrelevant
material, receiving little or no patient con-
tact and learning from professors with little
clinical experience.

3. Students assuming that medicine is a humanistic
profession with an assortment of cures, but
realizing that medicine has limits in its
treatment of illness and that many physicians
operate on self-interest.

The loss of these illusions regarding the medical student
role decreases self-esteem making it more difficult for the
student to tolerate stress.

Experiencing emotional stress during medical school also

threatens the successful mastery of medical knowledge. In a
classic study of University of Kansas medical students repor-

ted in Boys in White, Becker (1961) noted that as students

 

PrOgress through their training they develop a tendency to
see patient cases as Opportunities to learn new knowledge and
Practice new skills. The arousal of intrapsychic and inter-
Personal fears from close personal contacts with patients is

perceived as a barrier to achieiving academic success.

14

Medical students develop an assortment of defense
mechanisms in reaction to these emotional stresses. Several
authors have observed a tendency to establish emotional dis-
tance from patients by intellectualizing the patient's case
consistent with the disease model of medicine. This phenomena
luas been described as ”detached objectivity” (Parsons, 1951)
and "regression to scientism" (Zabarenko & Zabarenko, 1978) .

Having experienced academic success in the past, this intel-
lectual approach offers protection against the consequences
of error.

Fox (1957) highlighted the uncertainty involved with
stressful experiences in medical training. The student must
learn to c0pe with the limits of the current available know-
ledge in the medical profession as well as their own mastery
Of that knowledge, yet maintain the patient's confidence in
their competence. Fox observed that medical students "train
for uncertainty" by masking their affective responses.

In summary, several theoretical perspectives exist
which emphasize the interpersonal effectiveness of the phy-

Sician and describe the development of these skills in medical
training. Advocates of a holistic medical approach emphasize
the importance of interpreting physical symptoms within the

cKmtext of the organic, social, and psychological aspects of
the patient's life. This model accentuates the physician's

abilities to listen to and understand the patient in order to
deVElOp diagnoses, prognoses, and treatment plans specific to

the individual needs of the patient.

15

Zabarenko and Zabarenko (1978) stressed the successful

integration of cognitive and affective abilities in developing

these relationship skills. Other writers, however, have

demonstrated how personality need structures, disillusionments

over expectations of medical school and excessive needs to
master medical knowledge as stresses inhibiting the students'

ability to deal effectively on an affective level with

patients. The masking of affective responses and intellectu-

alization of patient cases were identified as typical coping

mechanisms used in reacting to this stress.

Definition of Terms

Special terms used in this study will be defined as
follows:

Doctor-Patient Relationship. This term refers to all
of the thoughts, feelings, and behaviors of a physician or

Physician-in-training and their patient which originate from

their professional medical contact.
Social Values. This term refers to the degree of

worth a person attributes to other human beings relative to

Other objects in their life. A person with high social values

relates to other as ends having intrinsic value rather than
means for the fulfillment of their own ends.

Thus, a high
social person exhibits altruistic and unselfish behaviors.

Effective Helping Responses. This term refers to the

phYBician behaviors which facilitate the collection of accurate

psyehosocial patient data, the development of rapport with the

16

patient, and the enhancement of the patient's understanding

of the psychosocial determinants and implications of their
illness. Effective helping responses 1) are exploratory rather
than non-exploratory, listening rather than non-listening,
affective rather than cognitive, and honest labeling rather
than distorting (Kagan et. al., 1967), 2) demonstrate an
adequate level of empathic understanding (Carkhuff, 1969),

and 3) influence the patient to describe their physician as

empathic (Barrett-Lennard, 1962).

Delimitations of the Study
The following factors delimit generalizations from the
results of this study.

1. For the purposes of data collection, the subjects
in this study conductedlfive interviews beyond
the standard training format. Interpretations of
the results must consider the practice effect of
these additional interviews.

2. The interviewees in this study were doctoral
students in counseling. Generalizations of
interview performance must consider the high leVels
of interpersonal senSitivity and communication
skills of these interviewees.

3. The time series design used in this study did
not control for non-treatment learning influences.
Therefore, changes in outcome measures may have
been influenced by the facilitative or inhibitory
effects of other experiences occurring during the
course of the study.

4. In this study, Interpersonal Process Recall was
not compared with any other training method.
Therefore, no attempt was made to draw conclusions
for training approaches other than IPR.

17

Basic Assumptions

The basic assumptions of this study are:

l.

The students' social values, affective sensitivity,
psychosocial attitudes in medicine, and effective
interview functioning can be measured and changes
on these dimensions determined.

The students used in this study were similar to
first year medical students at other institutions
and do not differ in their ability to learn
interpersonal skills.

The reactions to class sessions provided by

students represent the accurate and independent
views of these students.

Researchfiguestions

Five broad research questions were explored:

1.

Will there be a change from pre-training to post-
training in affective sensitivity, attitudes
towards the doctor-patient relationship, and
effective interview responses for each subject.

Will subjects with high and low social values
make differential pre-training to post-training
changes in affective sensitivity, attitudes
towards the doctor-patient relationship, and
effective interview responses.

Will subjects in Track I and Track II make.
differential pre-training to post-training
changes in affective sensitivity, attitudes
towards the doctor-patient relationship, and
effective interview responses.

Will subjects participating and not participating
in additional experiential lab sessions providing”
physiological feedback make differential changes
in affective sensitivity, attitudes towards the
doctor-patient relationship, and effective inter-
view responses.

Is there a learning gradient which suggests a
point during IPR training of diminishing returns
for gains in effective interview responses for
high and low social students, Track I and Track II
students, and participants and non-participants

in additional lab sessions providing physiological
feedback.

18

Overview

 

A review of the literature relevant to training medical
students in interpersonal skills will be presented in Chapter II.
In Chapter III, the intensive design used in this study and
the procedures for implementing that design will be discussed.
The results of the study, conclusions related to these results,
and implications for training and research will be presented

and discussed in Chapter IV.

CHAPTER II
REVIEW OF THE LITERATURE

Chapter I was focused upon the nature of the research
problem and the rationale for this study. This chapter will
review the relevant literature for the training of different
types of medical students in interpersonal skills.

The impact of interpersonal functioning on patient
satisfaction and compliance with treatment will first be
discussed. Next, various methods for training medical stu-
dents in interpersonal skills will be presented. The develop-
ment and application of the IPR method will then be discussed
specifically. Finally, normative levels and changes of social

values during medical education will be discussed.

Interpersonal Skills and Medical Practice

 

A number of studies have explored the impact of the
nature of the doctor-patient relationship with outcomes of
medical treatment. Basically, these studies have assessed the
impact of relationship variables with the patients' satisfac-
tion with treatment and their eventual compliance with the
treatment plan outlined by their physicians. These studies

cum satisfaction and compliance will now be presented.

19

20

The Doctor-PatientwRelationship and
Satisfaction with Treatment

_Koos (1955) randomly surveyed one thousand families
from a Northeastern urban area. The sample was stratified
by socio-economic status. The survey indicated that 64 per-
cent of the respondents felt that modern medicine lacked the
human warmth of the old-time general practitioner. Further
analysis indicated that this opinion was more prevalent in
families where the husband was under age forty, discounting
nostalgia as a basis of this finding.

Two hundred adult patients in‘a chest hospital were
interviewed by Palmer (1966) regarding the personalness of
their attending physician. Patients identifying their phy-
sician as "personal" tended to ask more questions regarding
their treatment. However, no significant relationships were
found between perceived personalized care and satisfaction
with doctor-patient communication, the quality of information
received, or the patient's image of the hospital. Palmer
suggested that personal physicians are more approachable for
questioning.by patients.

Freeman, Negrete, Davis, and Korsch (1971) studied the
doctor-patient communication process of 285 patient visits at
a pediatric walk-in clinic with 415 other patient visits as
controls. These medical consultations with mothers were tape
.recorded and analyzed with Bales' (1950) Interaction Process
.Analysis. Further data was obtained from chart reviews and

followbup interviews with the mothers. A11 attending physicians

21

had one to four years of pediatric experience.

The mothers expressed satisfaction in their follow-up
interview when their physician had expressed positive affect,
friendliness, and a sense of solidarity during their visit.
High satisfaction was also associated with physicians who
gave more information, asked fewer questions, and engaged in
nonmedical socialconversation. The mother's dominance of the
medical consultation and the expression of negative affect by
either the mother or doctor led to low satisfaction.

Davis (1968a) explored the satisfaction experienced by
physicians and fourth year medical students in their work at
a large, Eastern teaching hospital. Questionnaires were sent
to 132 physicians and 84 students asking about the rapport
and satisfaction they felt with their patients. Good rapport
correlated with satisfaction in patient treatment, particular-
ly for the physicians.

The Doctor-Patient Relationship
and Compliance with Treatment

 

In a review of the literature, Davis (1966) established
that at least one-third of the patients in most studies fail
to comply with medical advice. As a result, the Davis (1968a)
study also questioned physicians and students regarding their
awareness of their patients' compliance with their prescribed
treatment plan. The report indicated that rapport was also
positively related to compliance. Again, this relationship was
more apparent for experienced physicians.

The Freeman, Negrete, Davis, and Korsch (1971) study

22

also examined the process of the doctor-patient interaction
with regard to compliance as rated by expert judges on the
taped interviews. Like satisfaction, compliance was also
positively related to the physicians' expression of positive
affect, friendliness and solidarity, provision of information,
and involvement in social conversation. Low compliance was
also associated with the expression of negative affect. In
addition, low compliance followed either the mother or phy-
sician's dominance of the consultation and the longer the
consultation lasted.

The Interaction Process Analysis was also used by
Davis (1968b) to study interviews with new patients seen by
fourth year medical students or senior physicians. Compliance
was defined by a composite index of patient perceptions,
physician perceptions, and an independent review of medical
records. Davis found that noncompliance was related to an
imbalance in the relative activity level of the doctor and
patient, i.e., active doctors and passive patients.

A factor analysis of this data revealed that compliance
was related to specific interpersonal processes. High com-
pliance was related to joking, laughing, showing satisfaction
with the relationship, and other forms of tension reduction.
Noncompliance was associated with either participant appearing
formal, the patient acting authoritatively with their own
diagnosis, the physician's failure to provide information,
explanations, or orientations, and the physician's request

for information without providing the patient with feedback.

23

Davis concluded that the data emphasized the reciprocity in
the doctor-patient relationship. Both participants were said
to have particular rights and obligations which needed to be
maintained in the relationship for successful treatment.

Davis and Eichhorn (1963) studied the self-reported
compliance of a narrowly defined population of farmers with
cardiovascular impairment. The authors hypothesized that
greater compliance would result with more formal physicians
theorizing that an informality would create role ambiguities
making it easier to reject the doctor's authority. The
farmers were asked to rate their attending physicians as
"friendly" or "business-like." Compliance rates were 47 per-
cent for "friendly" doctors and 53 percent for "business-like"
doctors.' In addition, 88 percent of the patients of "business-
like" doctors preferred that type of physician.

Compliance with oral penicillin prescriptions for 459
children aged two to 12 was assessed by Charney, . al.
(1967). Compliance was measured by urine analyses. Charney
et. al. found that compliance was more likely if the penicil-
lin was prescribed by the child's usual physician and if the
child's family had been cared for by that physician for a
number of years.

Francis, Korsch, and Morris (1969) followed-up 587
Eflflort-term patient visits at Children's Hospital in Los
(Angeles. The mothers' perceptions of the attending physicians
were compared with compliance measured by ratings of responses

11> nonjudmental, open-ended questions in a seven to 14 day

24

followbup interview. Compliance rates were 46 percent for
"friendly" doctors and 31 percent for "business-like" doctors.
Also, doctors who "did understand the concern" received 44 per-
cent compliance compared to 37 percent compliance for doctors
who "did not understand" the concern. Viewing these results

in conjunction with the findings of Charney et. a1. (1967),
Francis et. a1. conluded that doctor-patient relationship
variables may have more impact on compliance in more long-term

relationships.

Summary and Discussion

The literature confirms that patient dissatisfaction and
noncompliance with their medical treatment are modern day health
concerns. The quality of the doctor-patient relationship
appears to be one factor influencing these two variables.

Satisfaction and compliance with treatment seem to be
facilitated by physicians demonstrating a more personal ap-
proach with their patients. The provision of clear and accur-
ate information with a minimum of interogation also supports
the treatment process. A model for reciprocity for doctor and
patient role relationships has also received validation.

Several variables might serve to mediate the impact of
tflae doctor-patient relationshiop on satisfaction and compli-
ance. It appears that different populations might be best
served by different styles of medical care. These relation-
8hir>variables also seem to bear more impact with long-term

Contact between patients and their physicians.

25

Interview-Trainingyin Undergraduate
'Medical Education

A variety of courses have been develOped during the
past decade in response to the need for undergraduate medical
students to learn how to develop effective doctor-patient
relationships. These programs have given differing emphases
to the cognitive and experiential components of this training.
This section will provide descriptions and report evaluations

of courses leaning on both sides of this continuum.

Courses Emphasizing Cognitive Understanding

One of the earliest and most widely used training pro-
grams was a film series developed by Enelow, Adler, and
wexler (1970) entitled Programmed Instruction of Medical

Interviewing. The program was aimed at helping students inter-

 

view so that "the greatest amount of accurate information rele-
vant to diagnosis and management is obtained in realistic time
limits (p. 1843)." The authors' philosophy of interviewing was
outlined in a set of ten principles and techniques contributing
to the successful application of these principles. These prin-
ciples emphasized a nondirective, supportive approach designed
to help the patient speak openly.

The film series presented clinical situations using
actors and actresses to demonstrate each interview principle.
4A programmed learning approach was employed by stopping the
:Eilm.at various points and asking the trainee to select one
offthree proposed responses. The fiLm then provided immediate

feedback by proceeding to demonstrate the probable consequences

26

of the one appropriate and two inappropriate responses.

Using a self-developed film instrument within a pre-
post, no control design, these authors reported significant
gains (p(_.01) in the cognitive gains in understanding of
these principles in six of 13 classes. The method was more
effective for practicing nonpsychiatric physicians and second
year medical students than for clinical psychology graduate
students, vocational rehabilitation counselors, and nonpsychia-
tric residents.

Adler, ware, and Enelow (1970) compared this film-
based program with group supervision using closed-circuit tele-
vision in training orthopedic residents. Using the same film
instrument assessing 27 interview behaviors, they reported
significant differences (p<:.05) on eight of 15 scales for the
film series and only one of the scales for the group super-
vision. The authors also reported a significant decrease
(p( .05) in the residents' perceptions of a physician's use of
authority for the film series group on a self-developed atti-
tude scale (Enelow & Adler, 1965). No such change was
reported due to group supervision.

The Enelow, Adler, and wexler (1970) film series was
used with beginning second year students at the University of
Minnesota by Cline and Garrard (1973). However, it was used in
conjunction with live demonstrations by instructors, role plays
with other students, and actual interviews with hospitalized
patients. This program also revealed pre-post gains (p< .001)

in the cognitive understanding of interview principles.

27

However, student course ratings indicated that "interviewing a
hospital patient," "having a student observe a fellow student
interviewing," and "demonstrations by the group leader," were
all more valuable than the film series.

Extensive lectures on interview principles and a seminar
series were combined with limited role-plays and patient inter-
views to train first year students by Hayes, Hutaff, and Mace
(1969). The seminars, "The Physician and Sexual Problems" and
"Family and Social Pathology," consisted of presentations by
community professionals and discussions of attitudes. Once
again, Hayes, Hutaff, and Mace reported cognitive gains on the
Adler, Ware, and Enelow (1970) assessment film (p< .05) and
decreases in authoritarian attitudes with the Enelow and Adler
(1965) scale (p.(.001). Student evaluations revealed that
the patient interviews were most helpful and 100 percent of
the students recommended that the course remain in the curri-
cula. The authors indicated that future course planning
intended to replace the lectures with panel discussions, in-
clude a seminar on death and bereavement, and introduce
demonstration interviews and role-plays earlier in the course.

Zakus (1976) described a structured course on inter-
viewing including lectures, readings, and class discussion.
Positive and negative interview behaviors were defined and
used on checklists to evaluate interviewing assignments. No
evaluative data was presented.

In spite of the short term gains of these cognitive

approaches, several studies have presented evidence questioning

28

their long term impact on the physician-patient relationship.
Zuker (1968) conducted a study comparing_graduates of
medical schools with many offerings in psychiatry courses
with schools having little psychiatric training. He found
no differences in the students' abilities to feel comfortable
in relationships with patients or to deal effectively with
emotional problems tied to nonpsychiatric illness.

Jarrett, waldron, Bura, and Handforth (1972) found
that pencil and paper tests of cognitive interviewing know-
ledge did not correlate with interviewing performance. Using
Enelow, Adler, and Wexler's (1970) film series as a training
method for sophomores, Ware and Strassman (1971) actually
found a significant negative correlation (p( .01) between
cognitive gain scores on the Adler, ware and Enelow (1970)
instrument due to the course and psychiatric clerkship ratings
by supervisors on the Interview Evaluation Scale (Hollifield,
Rousell, Bachrach, & Pattishall, 1957) during the junior
year.

Marshall and Feeney (1972) found that structured inter-
views based upon a cognitive, skill-based orientation did
obtain more information in the areas directly questioned.
However, more intuitive interviewers were more productive in
revealing personal information such as personal problems,
spiritual beliefs, and suicidal ideation.

A study by Taylor and Berven (1974) at the University
of washington suggested a reason for the limitations of cogni-

tive training approaches. The authors compared the

29

observational skills of 95 second—year students completing
interview training with 15 members of the next year's class
just prior to training. They found the trained students to

be superior in their observation of a psychotic, an alcoholic,
and a severely depressed patient, but no difference in observ-
ing a relatively normal patient. Taylor and Berven hypothe-
sized that, similar to the findings of Rosenhan's (1973) "On
Being Sane in Insane Places" article, the students followed role
expectations and applied the medical model even when it was
inappropriate. In the process, the students ignored their
personal experience and failed to perform as objective observ-
ers.

Following an extensive review of the literature, ward
and Stein (1975) concluded that interview training approaches
have overemphasized the content of the interview leading to
the development of techniques relying upon checklists in an
attempt to extract quantities of information. Ward and Stein
advocate greater focus upon the process of the interview in
an attempt to help individual students develop personalized
styles of relating to patients.

Courses_Emphasizing Experiencing
Doctor-Patient Interaction

Fine and Therrien (1977) attempted to train medical
students at the University of Hawaii to respond empathically
to their patients rather than merely attending to their
medical problems. They developed a basic interview course

around two role-playing techniques. First, the teacher

30

role-played a patient while students took turns responding to
her statements. She then provided immediate personal feed-
back intended to increase the students' sense of empathic
accuracy, immediacy, and personal meaning. Later, students
in triads rotated in the roles of physician, patient, and
evaluator.

The authors evaluated the course by comparing 20 volun-
teer trainees with 20 volunteers choosing to take the course
the following semester. Blind ratings of audiotapes of role-
played interviews using the Accurate Empathy Scale (Truax,
1961), indicated that the experimental group was significantly
(p( .001) more empathic. In addition, the experimental sub-
jects focused significantly more (p( .001) on the patient-
with-a-problem in contrast to the problem alOne.

Fine and Therrien stressed that their program was ori-
ented to establishing initial rapport with a patient. They
suggested additional interpersonal skills in genuineness and
self-disclosure for sustaining rapport in the doctor-patient
relationship,.

Pacoe, Naar, Guyett, and Wells (1976) also used role-
plays to develop empathy, but integrated this training with
experiential group sessions aimed at fostering genuineness.
These later sessions used an encounter format to resolve
personal concerns. The authors compared first-year volunteers
receiving eight of each type of session with nonvolunteers
from the same class. No initial differences between groups

were found on the dependent variables. The trained students

31

demonstrated more empathy on modified versions of Carkhuff's-
(1969) Index of Communication and Index of Discrimination.
The results of the Personal Orientation Inventory (Shostrom,
1966) showed greater gains for the experimental group in
self-acceptance, existentiality, feeling reactivity, and
synergy.

Although the earliest possible experience with patients
in medical training is often advocated in the literature,
beginning medical students often experience anxieties that
patient care might suffer from their inexperience (Engel,
1971; Froelich, 1969). Jason, Kagan, Werner, Elstein, and
Thomas (1971) circumvented this difficulty by developing a
model for the use of simulated patients. Primarily drama
students received one to four hours of training to portray
patients with particular medical problems and the concommitant
emotional stress.

In the training model designed by Jason et. al., each
first year student conducted a minimum of five 15 minute
taped interviews with a simulated patient. The student then
spent 45 minutes in class processing the interaction with
the benefit of a recall of the tape. The advantages of simu-
lation were outlined as:

1. it approximates a real world setting

2. the use of a real clinical patient may be
inappropriate

3. experience has demonstrated that the inter-
views are totally engaging, honestly demand-
ing, and free of artificial distractions

4. problems and patient characteristics can be

32

custom-designed

5. students can compare the performances of
several students with the exact same
patient.

6. the simulated patients can participate in
recall and give feedback

7. the simulation reduces anxiety

8. it is easier to evaluate students with an
exact knowledge of the patient

Secundy and Katz (1975), Meadow and Hewett (1972) and
Froelich (1969) have all used videotaped practice interviews
with simulated patients which were later reviewed with fellow
students and faculty. Secundy and Katz have used Interper-
sonal Process Recall "in limited but effective ways" during
playback. A recommendation to review the tape four to 10
days after the taping was made by Meadow and Hewett who
found that students too near the experience displayed consid-
erable defensiveness in reviewing their interview. Froelich
used the simulated patients in the middle of training to
bridge the progression from student role-plays to interviews
with live patients.

Although students have expressed reservations with
interviewing actual patients, there is little evidence of
destructive consequences for using live patients in training
programs (Engel, 1971; Froehlich, 1969). Goroll, Stoeckle,
and Lazare (1974) supervised first year students interviewing
outpatients at a large, general hospital. Their survey of
18 patients seen by the students revealed that 16 patients

felt their visit was as good or better than their last visit

33

with a professional while the dissatisfaction of the remaining
patients was not related to the students' performances.

Kimball (1970) used "trial—and—error" interviews with
real patients following brief instruction and demonstration
interviews. These practice interviews were then discussed
in small groups of six to eight students with a faculty super-
visor. Kimball gradually extended the length of time, depth
of content explored, and difficulty of the patient over the
course of at least six interviews. The students began with
a five-minute introductory session with a normal patient and
finished with complete hour long initial interviews with
delirious, severely disturbed patients.

Third-year students at the Queen's Medical School,
Kingston, Ontario, were trained in diagnostic interviewing
with live patients by Waldon (1973). Although the students
received written critiques on their taped interviews by
instructors, videotape playback by the student alone or among
peers was encouraged. The students reported that these play-
backs were far more valuable than the written feedback.
Feeling that entering students possess sufficient knowledge
and communication skills, the students recommended that the
course be offered during the first year of their medical train-
ing.

At the Medical College of Wisconsin, Rasche, Berstein,
and Veenhuis (1974) trained second-year students by starting
them interviewing patients at bedsides and their-conducting

group discussion of these interviews and providing

34

demonstration interviews. After 16 four hour weekly sessions,
students were evaluated pre and post using a verbal response
classification scheme on a self-developed Physician-Patient
Sitatuions Test. Rasche, Bernstein, and Veenhuis (1974)
found that the students increased their understanding and
facilitative probing responses and decreased their evaluative
and nonfacilitative probing responses after training. They
reported no change in reassuring and hostile responses.

Bernstein, Headlee, and Jackson (1970) also started
their training of second-year students with live, bedside
interviews. Following group discussions of these interviews,
however, the group chose one of the interviewed patients to
be interviewed by their tutor. This demonstration interview
elicited further concepts and implications for discussion.
Using the first-year class as controls, Bernstein, Headlee,
and Jackson assessed the trainees "willingness and/or ability
to accept what a patient has to say without feeling a need to
evaluate, judge, or criticize (p. 66)." Although there were
no initial differences between groups, they found high signi-
ficant (p< .001) gains compared to the control group in the
acceptance of others with the Test of Clinical Judgment (Ash-
by, Ford, Guerney, Guerney, & Snyder, 1957).

After an extensive review of the literature, the crea-
tion of an effective interpersonal environment was postulated
by Ward and Stein (1975) to be a global skill requiring vari-
ous subskills inextricably integrated with the emotional

style of the interviewer. They concluded that learning this

35

global skill required highly individualized teaching and live
patient interviews providing an authentic interchange between
persons.

Ward and Stein incorporated these ideas into a four
month training program at the University of Wisconsin. Stu-
dents were urged to use their own affective experience as
clues and self-disclosure, questions, and confrontation as
tools for reducing the emotional distance between themselves
and their patients. Using a seminar format, one student
would interview a live patient within the group for.thirty
minutes. Then, with the patient's permission, other students
would attempt to engage with them. After the patient left
the room, first the primary interviewer and then the other
students would discuss their experience. Although no formal
evaluation was conducted, Ward and Stein observed that static,
distant interviews occurred when the interviewers themselves
were uncomfortable with the material being discussed.

Pollack and Manning (1967) have also observed the
frequency and_relevance of the students' emotional issues in
interview training. Based upon their eight years of experi-
ence training first-year students at the University of
Southern California, they highlight the principle blocks to
communication as resulting from:

1. embarassment at c0ping with a frank display of
sexuality

2. hesitancy at intruding into the patient's per-
sonal life, especially on topics which make the
students themselves uncomfortable

36

positive, negative, and mixed feelings toward
patients belonging to minority and ethnic
groups

when death is imminent, an inability to
speak easily with the patient or even per-
mit the patient to talk freely about his or
her illness

Pollack and Manning have also outlined the defensive reactions

they have observed students using to respond to their discom-

fort:

10.

early termination of interviews due to anger
or annoyance with the patient

excessive defensiveness
marked directiveness in interview style

excessive time spent collecting life history
data

an obsessive approach to certain interview
content despite the patient's attempt to
avoid these topics

almost complete avoidance of topics or.1ife
experiences of emotional significance to
the patient

detachment from the patient

overinvolvement with the patient and the
patient's life history (excessive identi-
fication)

use of the interview as an occasion to
solve their own problems

discussion of their own problems or
interests as a means of avoiding talking
with or listening to the patient

An extension of the training programs using live pa-

tients has been to train students in actual work settings.

Goroll, Stoeckle, and Lazare (1974) experimented with the

placement of first-year Harvard students in a screening clinic

.37

at Massachusetts General Hospital. These highly select
students were taught to explore the presenting concern as well
as medical, psychological and social data. After group con-
ferences of videotaped interviews, significant gains in
interviewing skill were reported. The authors advocated this
approach as a responsible and practical way to expose students
to patients and learn clinical skills.

Hastings (1968) felt that the artifical hospital envi-
ronment made it difficult for students to perceive the rele-
vance of social and interpersonal factors. Thus, first-year
students at the University of Kansas were assigned to the
hospital's home care unit as family advocates. Spending one
afternoon per week visiting home-bound patients, the students
were responsible for l) facilitating contacts between the
patient's family and the clinical staff, community profes-
sionals, and other community agencies, 2) providing emotional
support for the patient, 3) monitoring vital signs, and 4)
supervising the patient's physical therapy, diet, and use of
medications. Weekly seminars were conducted for the purposes
of providing theoretical knowledge, relieving personal
anxiety, integrating information, and reinforcing learnings.

Third-year Harvard students were trained by videotaping
their clinic work (Stoekle, Lazare, weingarten, & McGuire,
1971). Their physical examinations, history taking, diagnoses,
and development of treatment plans were recorded and discussed
in group conferences emphasizing the doctor-patient relation-

ship. In contrast to comparing their performance to the norm

38,

of a “good interview," the program.encouraged student obser»
vation that different techniques produced different outcomes.
Althbugh no empirical evaluation was conducted, the following
student reactions attest to some of the program's success:

It helped me to learn to treat.the patient as a

person rather than a disease, for I had to look

deeply into their lives to find out why they were

having their (usually) psychologically induced

complaints.

Frustration --the majority of patients were people

without organic disease whose loneliness was often

the major reason for the visit --my own helpless-

ness made this kind of encounter frustrating (p. 522).

Stoeckle, Lazare, Weingarten, and McGuire observed that
interest was greatest and self-examination was more likely
when students changed therapeutic roles. As third-year stu-
dents became more responsible for patient care, the training
helped them to enter doctor-patient relationships more suc-
cessfully. This view is consistent with Zabarenko and
Zabarenko's (1978) formulation that forming an internal ego-

ideal of physicianhood and the establishment of professional

identity are important developmental stages in the third year.

Summary and Discussion

Reports of interview training programs for medical
undergraduates have originated from a wide variety of medical
schools. All of these courses have aimed to increase the
student's interpersonal functioning within the patient-with-a
disease model. However, some programs emphasized cognitive,

theoretical understandings in classes while other provided

39
limited instruction, but considerable discussion of interview
experiences focusing upon the process of the interview and the
students' emotional reactions. The cognitive approaches have
been effective in increasing cognitive understanding of
interview principles and changing authoritarian attitudes.
However, this approach has been criticized for its failure
to provide a long term.impact on interviewing performances in
clinical settings. Although the experiential approachesidemon-
strated some gains in empathy and acceptance, most of these
studies provided descriptive, rather than empirical evalua-
tions.

These courses generally meet weekly for two to four
months. Small groups of six to twelve students were predomi-
nant. A variety of teaching methods were used, including
lecture, seminars, programmed learning films and texts, demon-
stration interviews, role-playing, group discussions, and
practice interviews with simulated and/or actual patients.
Audio or videotaping were used extensively and, together
with the actual interviewing experiences, the playbacks of
these tapes were rated most positively by students. Unfortu-
nately, few authors described the nature of their group dis-
cussions in much detail.

Most interview courses were delivered successfully to
first and second year students. However, students seemed to
become more involved in interview training when it parallels
their initial experiences with patient contact and responsi-

bility. The increasing knowledge base regarding the

40

professional and personal development of medical students may
prove useful in structuring and timing training experiences.
Empirical evidence in these studies was either lacking
or based upon poor research methodology. The research designs
reported usually lack proper control groups, make extensive
use of volunteers and lack follow-up data. The assessment
instrumentation was often self-developed and failed to report

supporting reliability and validity data.

The IPR Method, Theory, and Research
The accumulated IPR research will be discussed in three
parts. First, the research responsible for the development of
the present IPR method will be presented. Secondly, applica-
tions of IPR in nonmedical settings will be discussed. Final-
ly, the use of IPR to train specifically medical students in

the doctor-patient relationship will be reviewed.

The Development of the IPR Method

In 1962 researchers at Michigan State University began
to make observations in counselor training which led to the
development of Interpersonal Process Recall (IPR).(Kagan, 1977).
By immediately viewing a videotape of an interaction, these
researchers discovered that a person could recall thoughts,
feelings, physical reactions, and images in detail which had
gone unnoticed during the acutal interaction. This level of
self-exploration was deepened by the addition of a remote con-
trol switch for the participant and a facilitating person, or

”inquirer," who would sensitively question the participant

41

about their reactions.

The early reports of the method described its use
with.individual therapy clients (Kagan, Krathwohl, and Miller,
1963). However, the first empirical support of IPR compared
it with intensive traditional supervision as a counselor
training program.(Goldberg, 1967). Both supervision methods
used tape recall and emphasized "relationship factors" in
counseling; After ten hours of supervision, each group of
Masters level counseling students were rated pre and post on
initial interviews with tenth grade girls volunteering for
counseling. The counseling students supervised with IPR were
rated to be more effective on both the Counselor Verba1.Rating:
Scale (Kagan & Krathwohl, 1967) and the ratings of client
satisfaction on the Wisconsin Relationship Orientation Scale
(Steph, 1963).

5 With greater experience with IPR, Kagan (1977) and his
associates noticed that many clients expressed fears in recall
sessions which they would probably never be subjected to in
reality. These fears were categorized as 1) fear of the
other's hostility towards the client, 2) the client's fear of
loss of control of their own aggressive impulses, 3) fear that
the other would become too intimate or seductive, and 4) the
client's fear of their own potential seductiveness. It was
suggested that filmed vingettes of actors looking directly into
the camera while portraying these “interpersonal nightmares"
might help persons face and explore these fears.

Kagan and Schauble (1969) tested the effect of this

42

stimulated recall on client growth in therapy. Clients were
videotaped as well as having their physiology recorded on a
polygraph recorder while watching the stimulus films. IPR
recall with the aid of an inquirer followed. The results
suggested that the clients increased their ability to perceive,
differentiate, and gain insight into their reactions to others.

Danish and Brodsky (1970) proceeded to use stimulus
films successfully in helping policemen in basic training“
gain awareness of their aggressive feelings. When these
affective stimuli were incorporated into the IPR model and
used to train prepracticum counselors, Spivack and Kagan
(1972) found that this new IPR approach produced greater
gains in interviewing skills than an overview of counseling
theories and practices, group discussion, and critique of pre-
recorded audio and video tapes. Those results were replicated
by reversing the treatments during the second half of the
course. Kagan and Byers (1973, 1975) also found this model
to be effective in other cultures. Thus, affective stimulation
was made an intricate part of the IPR.method.

The next stage of the evolving IPR model was the
addition of theoretical constructs of interpersonal communi-
cation. This change resulted from the work of Rowe (1972)
who developed a 50 hour IPR training program integrating cog-
nitive and affective learnings of client dynamics. Rowe
delivered her program for 21 counseling students in a graduate-
1evel course on counseling processes. The uncontrolled study

found significant pre-post gains on the Affective Senstivity

43

Scale, the affective and specific subscales of the Counselor
Verbal Response Scale (Kagan & Krathwohl, 1967), and the
Empathic Understanding in Interpersonal Processes Scale
(Carkhuff, 1969).

Bedell (1976) assessed whether the number of instructor-
hours in IPR training could be reduced by training students
themselves in the inquirer role, then using them to supervise
each other. Bedell taught two sections of an undergraduate IPR
course using the traditional "outside“ inquirer and two sec-
tions using this new "self-contained" version. Although the
traditional group did make greater gains on the Personal Ori-
entation Inventory and expressed more satisfaction with labor-
atory sessions, there were no differences in gains of inter-
viewing skill on either the Counselor Verbal Response Scale
(CVRS) or the Discrimination Index (Carkhuff, 1969). In addi-
tion, a self-developed Inquirer Rating SCale:indi¢ated no
group differences in the skill level of this supervision tech-
nique. Thus, this self-containment model has been used as a
more efficient training mode which sacrifices nothing in terms

of skill development.

Applications of IPR in Nonmedical Settings

 

Whereas the preceeding studies have been instrumental in
the development of the IPR model, other studies have explored
the applicability of IPR training in a variety of settings.
Although much of the early work on IPR was conducted in train-

ing graduate counseling students, several studies have

44

demonstrated the utility of IPR in training paraprofessional
helpers.

Sharf (1971) compared an intensive IPR model with a
communications skills program based upon Robert Carkhuff's
work in training residence hall paraprofessionals. The IPR
program consisted of the progressive use of lectures on facili-
tative conditions, rating pre—recorded audio tapes of helping
interactions, training in helping skills, role-playing, and
client, counselor, and mutual recalls. The communications
skills model included discrimination training, empathy train-
ing, role-playing, group discussion, and interviewing practice.
Both programs were offered for five consecutive days for a
total of 40 hours.

These resident assistants (RA's) were assessed immedie
ately after training and again eight weeks later. The Affec-
tive Sensitivity Scale (Form C), four subscales of the Coun-
selor Verbal Response Scale, and audio tape ratings on the
Carkhuff Empathic Understanding in Interpersonal Processes -
Revised (Carkhuff, 1969), were used as outcome measures. Howb
ever, it appeared that this intensive training model was less
effective than weekly training sessions over time.

An extended IPR model with resident assistants was
studied by Dendy (1971). He trained 25 RA's for 19 hours
over four weeks in May, 1970 and again during the following
September. Dendy's training model included ratings of helping
interview tapes, affective sensitization using simulation

films, and to a much greater extent, IPR recall techniques.

45

Dendy's subjects were tested pre and post during each
phase of training on the same criterion measures used by
Sharf (ASS, EU, A, U, S, E, subscales of CVRS). Results indi-
cated significant gains on the combined variables for both
Phase I and Phase II. It was also found that the gains
achieved in Phase I did not deteriorate during the three month
summer recess. The study affirmed the stability of gains
in facilitative functioning over time.

The subjects from Dendy's extended training were then
compared with the intensively trained subjects from Sharf's
study. Both studies had used identical outcome measures. The
only significant differences favored Dendy's model over the
two Sharf groups on the CVRS. Thus, there is evidence that
extended training permitting time for the integration of
learning is more effective than intensive training.

Finally, Dendy's subjects were compared on these same
criterion measures with eight professional Ph.D. counselors
from the Michigan State University Counseling Center. Both
groups interviewed clients from the same client pool. When
compared to pretest scores of Dendy's subjects, there were
large differences favoring the professional counselors. How-
ever, after training, independent judges found no significant
differences between the groups. Dendy concluded that, with
IPR training, these paraprofessionals were functioning on the
criterion dimesions at levels comparable to experienced,
professionally trained counselors.

Archer (1973) designed a study to test whether

' 46

paraprofessionals could serve as IPR trainers for their peers.
Using IPR trained resident assistants from Dendy's (1971)
study as trainers, Archer conducted structured groups for
randomly selected undergraduates volunteering for a group
experience aimed at interpersonal development. The IPR groups
used affect simulation films, audio tape ratings, inquirer
training and helper, helpee, and mutual recall sessions. The
remaining undergraduates were assigned to an unstructured
encounter-developmental group and a no treatment control group.
All treatment groups met for eight sessions. .
Posttest data was collected on the Affective Sensitivi-
ty Scale (Form C), the Personal Orientation Scale (POI), the
Wisconsin Relationship Scale (WROS), and the Barrett-Lennard
Relationship Inventory (Barrett-Lennard, 1962). The analysis
revealed that the students trained in‘IPR groups had signifi-
cantly greater interpersonal skills than either those in the
encounter-developmental groups or no treatment control group.
In addition, a survey of dormitory residents revealed
that these students would prefer to discuss personal problems
with the IPR trained peers more frequently than either
enCounter trained or control group students. Archer concluded
that l) undergraduate paraprofessionals were effectove as group
trainers for their peers, 2) the increased therapeutic skills
of peer instructed students were identifiable by dormitory
residents, and 3) IPR could be adapted for non-therapy, growth-
oriented settings.

IPR was used by Hartson and Kunce (1973) as a

47

therapeutic approach in group work. These authors compared
university students in T-groups and groups using videotaped
replay and IPR recall. Criterion assessments were pre and
post measures on self-acceptance from an adaptation of Bill's
Index of Adjustment and Values (Bill, Vance, & McLean, 1951),
readiness for group interaction on Hill's Interactional Ma-
trix (Form B) (Hill, 1965), the Jourard Self-Disclosure Scale
(Jourard, 1964), and a self-developed measure of "satisfaction
with therapy."

The IPR group had significantly higher gain scores on
the self-disclosure and group readiness measures. The T-group
participants showed a significantly higher mean scores for the
satisfaction measure. The remaining measures demonstrated no
significant group differences. Further analysis revealed that
the IPR group was more effective than the T-group for socially
inactive subjects with low self-esteem. Socially active sub-
jects with high self-esteem did not respond to the two methods
differently on these measures.

Several studies have explored the applicability of IPR
within various segments of the criminal justice system. Grzegorek
(1971) compared an affective and a cognitive variation of IPR
with counselors from the Michigan Department of Corrections.
Most of the subjects had previously been guards in the prison
system. Both methods used lectures, affective sensitization,
recall and group discussion for a total of 80 hours over two
weeks. However, the affective method emphasized self-awareness

and an understanding of self-dynamics while the cognitive method

.48

focused upon client dynamics and counseling techniques.

The Affective Sensitivity Scale (Form B), Counselor
Verbal Response Scale and the Empathic Understanding in Inter-
personal Process Scale were used as criterion measures. The
affective method group demonstrated significantly greater pre-
post change on the understanding, specific, and exploratory
subscales of the CVRS and on the Empathic Understanding Scale.
No between group differences were reported regarding the sub-
jects' ability to perceive client feelings as measured by the
Affective Sensitivity Scale.

From these results, Grzegnek concluded that IPR was
effective in training prison counselors. In addition, the
experiential components of the model emphasizing affective
self-awareness and self-understanding were viewed as essential
for its effectiveness.

Heiserman (1971) used IPR to train court caseworkers who
did not perceive their role as requiring counseling skills.
She employed a reversal design with two treatment groups: IPR
using the elements of effective communication, affect simula-
tion, role-plays and recall and a cognitive teaching approach
based upon Carkhuff's Scales of Facilitative Functioning and
Kagan's Elements of Effective Communication. Each program
lasted 16 hours and was applied to two groups of subjects in
a differing order.

Pre, mid and post training measures were taken on the
Affective Sensitivity Scale (Form C), Counselor Verbal Response

Scale, the Empathic Understanding in Interpersonal Process

49

Scale, and Wisconsin Relationship Orientation Survey (WROS).
The only significant change occurred on the WROS where clients
reacted more positively to the counseling relationship provided
by IPR. Since this finding was not supported on the other
measures, Heiserman attributed no significant practical dif-
ference between the two methods perhaps due to the short expo-
sure to IPR.

The impact of IPR on prison inmates was investigated
by Singleton (1976). A group of prison inmates received IPR
training at a prison reception center prior to their assign-
ment to a prison unit. A no treatment control group was used.
Ratings by prison guards revealed that the IPR-trained inmates
were more approachable than the control group inmates. Single-
ton discussed the potential of IPR to enhance interpersonal
functioning and subsequent mental health of large communities

of people.

Applications of IPR in Medical Education

 

A number of studies have begun to assess the impact of
IPR training to enhance the medical students' effectiveness
in their interactions with patients. Benedek and Bieniek (1977)
used the IPR model with first year psychiatric residents at
Ypsilanti State Hospital. The authors indicate that the model
encouraged self-disclosures which helped students learn that
they were not alone in their anxieties related to patient con-
tacts and the role of physician. The resulting sense of

community facilitated the transition from the medical model to

50

a psychosocial approach. Benedek and Bieniek report increased
levels of empathy, self-awareness, and interviewing skill in
their observations of residents. However, no formal evalua-
tions were conducted. The following two studies offer more
complete empirical investigations of IPR in medical education.

Werner and Schneider (1974) report on a doctor-patient
relationship course for first-year students at Michigan State
University based upon IPR method. The objectives outlined for
the course focus upon the student's ability to:

1. identify interviewer-patient interactions according

to Kagan's (1967) elements of facilitative communi-

cations: exploratory-nonexploratory, affective-
cognitive, listening-ignoring, and confronting-
avoiding.

2. describe their feelings and overt behaviors to the
patient and to contrast these at various points
in the interview.

3. identify places in the interview where they were not
maximally effective owing to their concern with
"proper social behavior."

4. identify aspects of the interview situation that
cause personal concern.

5. practice interviewing and explore new ways of re-

sponding in the interview situation, especially
being aggressive without being host11e, be1ng

spontaneous, and trying out new behaviors deter-
mined mutually by the student and the instructor.
The students met in groups of four or five for 10 two
hour weekly sessions. Instructors were full-time clinical
faculty selected for their interpersonal sensitivity and
clinical experience. Each instructor received nine hours of

formal training emphasizing the review of video tapes of

interviews.

51

The first two class sessions included didactic presen-
tations providng an orientation to the course and instruction
in basic interview conCepts. The remaining eight sessions
focused upon interviews with simulated patients as described
by Jason et. a1. (1971). Each student conducted four 10
minute interviews which were then discussed for 45 minutes
using the IPR recall technique. The interview situations be-
came increasingly more difficult as the course progressed.

After each interview, the instructor and interviewer
completed a questionnaire based upon the course objectives.
The simulated patient also filled out a form indicated their
reactions to the interviewer. Together with observations
from fellow students, these materials were used as input for
group discussion.

Thirty-eight students took the Affective Sensitivity
Scale (ASS) before beginning the course while the entire class
of 76 took this instrument immediately following the course.
Thrity of each of the first and fourth interviews were rated
on Kagan's elements of effective communication. Three trained
graduate students rated the first 20 responses of each inter-
view in a random order using a double-blind design.

The students taking the ASS pre and post showed signi-
ficantly higher scores on the posttest.. The groups taking and
not taking the ASS pretest did not differ significantly on
the posttest mean scores. Werner and Schneider concluded,

therefore, that the ASS gains were probably not due to previous

52

experience with the test instrument.

The ratings of effective communication responses showed
significant gains from the first to the fourth interview on
the exploratory and affective dimensions, but not the listen-
ing dimension. Two few responses were rated on the confronting
dimension for meaningful statistical analysis. The authors
contributed the nonsignificant findings on the listening dimen-
sion to the operational definition used requiring the response
to be directly related to the previous statement of the patient.
Upon revising this definition, the authors reported a signifi-
cant increase in listening respones in the following year's
class.

From these results, Weiner and Schneider concluded that,
consistent with the course objectives, the students became
"increasingly aware of their interview behaviors and the per-
sonal and situational factors affecting their performance (p.
1236).“ In addition, they concluded that the course increased
the students' ability to empathize and demonstrate exploratory
and affective questions in interviews.

Werner and Schneider also reported that a small number
of students each year have difficulty with the course. They
attribute this drawback to 1) personal difficulties with being
open with feelings, and 2) value systems placing little
importance upon understanding and empathy and an unwillingness
to reexamine these values. The authors have provided addi-
tional supervised interviews for these students enabling all

students to meet the course objectives.

53

Novik (1978) deliverd a 32 hour IPR program to.33
first, second, and third year family medicine residents at
the Duke-watts Family Medicine Program. She sought to
enhance the psychosocial orientation of these residents through
IPR training.

Due to administrative restrictions, various groups of
subjects were trained at different times of the year. However,
all subjects were trained within the course of one year. The
training model consisted of presentations of the elements of
effective communication, affective simulation, inquirer train-
ing, and mutual recall.

A pre-post, no control design was used to measure change
on the Counselor Verbal Response Scale (CVRS), Affective
Senstivity Scale (Form D) and an unobtrusive audit of patient
charts indicating the frequency of benzodiazepin (minor tran-
quilizer) prescriptions and affective words and statements.

The chart audits were limited to second and third-year resi-
dents. A second design compared residents who had completed
the IPR treatment with similar untrained residents on the CVRS.

Double blind ratings of 20 responses on audio tapes of
real patient interviews showed gains on the exploratory,
affective, and honest labeling subscales of the CVRS. The
chart audit indicated that third-year residents decreased
their prescriptions of benzodiazepin. No significant dif-
ferences were found on the Affective Senstivity Scale, listen-
ing subscale of CVRS, use of affect words in the patient

charts, or frequency of benzodiazepin prescriptions for second-

54

year residents. Significant discriminations between trained
and untrained residents were only found on the affective
dimension of CVRS.

Novik concluded that the IPR training helped to increase
the communication skills of the family medicine residents as
measured by the three subscales on CVRS. In addition, these
increased relationship skills apparently decreased the third-
year residents' perceived need for benzodiazepin medications.
Low inter-rater reliability on the tape ratings and the lack
of reliability and validity data on the chart audit method
were considered to be partially responsible for the lack of
significance on the listening subscale of CVRS and the fre-
'quency counts of affect words and second-year resident

benzodiazepin prescriptions, respectively.

Summary and Discussion

The literature indicates that IPR is an effective method
of improving interpersonal functioning for a diverse collection
of populations and settings. This review of the literature
demonstrates that the IPR model has been systematically
developed through empirical investigations of the various
components of the model. These investigations have led to the
inclusion of the elements of effective communication, recall,
affect simulation, theoretical constructs, and inquirer
training as components of the model.

The IPR method has been paricularly effective in
teaching interpersonal skills and developing affective sensi-

tivity. These gains have been noted in counselor education,

55

the training of paraprofessional helpers, the acceleration of
client growth in psychotherapy and the preparation of medical
students for doctor-patient relationships. IPR has been
demonstrated to be more effective in these areas than either
cognitive teaching methods or unstructured growth group
experiences. There is some evidence that IPR is more effec-
tive in an extended, rather than intensive format.

In medical education, IPR has helped medical students
identify elements of their interaction with patients which
create personal discomfort and decreased their interpersonal
functioning. This increased self-awareness has apparently
contributed to a greater interest and increased skill in
attending to the psychosocial aspects of medical care. There
is evidence, however, that IPR has a more limited impact with
individuals and populations who experience difficulty with
personal disclosure and/or whose value system deemphasizes the

quality of interpersonal relationships.

Social Values of Medical Students

 

This section will describe the psychosocial orientation
of the medical student population emphasizing social values.
The first section will describe assessments of the normative
levels of social characteristics of medical students. The
second section will focus upon changes which occur in social
orientation during the course of undergraduate medical educa-

tion.

56

NOrmative Levels of Social Values
fbr Medical Students

Allport, Vernon, and Lindzey (1960) reported standard-
ized norms for the Social subscale of their Study of Values
which identifies the person who "prizes other persons as ends,
and is therefore himself kind, sympathetic, and unselfish."
The authors report that 3,476 freshmen from 49 medical schools
averaged 35.7 with a standard deviation of 5.5 while 1,482
senior males from over 21 medical schools averaged 36.6 with
a standard deviation of 6.8. Compared to other male norm
groups on this scale, these medical students scored higher
than Harvard business graduate students (§'= 32.6) and Rhode

Island art students (Y = 34.4, SD 7.1), about the same as

'll

air force officers (i = 35.5, SD = 6.5), and lower than Harvard
education graduate students (2 = 43.0, SD = 7.3), counselors
(3': = 43.5, so = 7.0), and theological students (I; = 49.0, so =
5.5). Garvin (1976) found that male nurses scored significant-
ly higher than medical students on this scale at Ohio State
University. Manhold, Shatin, and Manhold (1963) found no sig-
nificant differences between dental and medical student sample
on this Social scale of the Study of Values or the Affilitation
Scale of the Edwards Personal Preference Scale (Edwards, 1959).
Similar comparisons were conducted by Gordon and Mensh
(1962) on the Benevolence scale of the Survey of Interpersonal
Values (Gordon, 1960). Benevolence is defined as "doing things
for other people, sharing with others, helping the unfortunate,

being generous (p. 48).“ Gordon and Mensh reported an average

'57

Benevolence score of 18.1, SD = 5.0, for freshman medical
students at UCLA. This scores ranks at the 70th, 75th, and
84th percentile of norms for male college undergraduates,
engineers, and middle managers, respectively.

Columbian medical students rated the concept "patient"
on 36 bipolar adjectives based upon Osgood's semantic differ-
tial by deBrabander and Leon (1968). Comparisons were made
with nonmedical students matched for size and both samples
were stratified by sex, career choice, academic standing, and
academic year at the same university. The authors found no
difference for first and second year students, but third,
fourth, fifth, and sixth year medical students rated the
"patient" significantly more postively than their nonmedical
counterparts.

Medical students' attitudes toward psychosocially
oriented specialities has also been studied. Bruhn and Parsons
(1964) had University of Oklahoma medical students rate sur-
geons, internists, psychiatrists, and general practitioners
on a list of personal traits. Psychiatrists were rated least
favorably being seen as interested in intellectual problems,
emotionally unstable, and confused in their thinking. General
practitioners were rated most favorably being described as
interested in people, aggressive, full of energy, extremely
patient, friendly, and having pleasing personalities.

Gough (1975) sent a questionnaire rating the attractive-
ness of various specialties to graduates of the University of

California, San Francisco from 1964 to 1971 as well as third-

58

year medical students. Of 40 possible specialities, psychia-
try was rated 32nd by male thsicians, let by female physi—
cians, 22nd by male students, and 24th by female students.
These rankings are somewhat inflated since surgery, which was
consistently rated below psychiatry, was subdivided and counted
as 10 separate specialties.

Kausch (1967) had first-year medical students and first-
year graduate students in social work and psychology rate a
variety of psychiatric treatments and medical specialties.
Compared to the medical students, social work students rated
psychiatric treatments and mental health-oriented specialties
more favorably. There were few differences between medical
and psychology students. Kausch attributed these differences
to variations in psychosocial emphases of these students'
undergraduate education with medical and psychology students
sharing similar backgrounds in science.

To assess the effects of larger societal effects on
the social orientation of medical students, Coe, Pepper, and
Mattis (1977) gave a questionnaire to entering students at
St. Louis area medical schools from 1970 to 1975. The question-
naire included items related to racial discrimination, poverty,
patient rights, and other issues of social concern. The study
revealed increasing liberal attitudes from 1970 to 1972 and
increasingly conservative attitudes after 1973. Coe et. a1.
felt that the students' attitudes reflected the social and
political climate of their respective eras.

Funkerstein (1977) reported a shift in the career

5.9

aspirations of medical students from 1958 to 1976. The shift
occurred from interest in scientific subspecialties to an
increasing interest in primary care. Funkenstein observed
that this shift corresponded to society's and the medical
profession's emphasis on scientific research in the 1960's and

a renewed interest in primary care delivery in the mid-1970's.

Changes in Social Values during Medical Education

In 1955, Eron observed that medical students did not
seem to have attitudes, values, and defenses consonant with
a service-oriented profession. To test out this observation,
Eron developed scales to measure humanitarianiem and cynicism
using the index of discrimination and ratings of three psy-
chologists for his item selection. Humanitarianism.was de-
fined as "a regard for the interests of mankind, benevolence,
and philanthropy (p. 561)." Cynicism was defined as ”a con-
temptuous disbelief in man's sincerity of motives or rectitude
of conduct, characterized by the conviction that human con-
duct is suggested or directed by self-interest or self-indul-
gence (p. 561)."

Eron paid 97 percent of the first and fourth-year
classes at the Yale University School of Medicine for volun-
teering to take these scales. The results showed that the
fourth-year students scored significantly higher in cynicism.
Although the fourth-year class also scored lower in humaintari-
anism, these results were not statistcally significant. Eron
concluded that medical students become more cynical and

possibly less humanitarian during the course of their medical

60

education.

Realizing the need for a longitudinal study to confirm
these results, Eron (1958) followed-up freshman medical stu-
dents at Yale by retesting them during their senior year.

Eron again used his self-developed scales of cynicism and
humanitarianism. The results showed significant decreases in
cynicism scores and a slight insignificant increase in humani-
tarianism.

The Eron studies stimulated further research exploring
the impact of medical education on student attitudes and
values. Miller and Erwin (1959) used the Eron scales to
assess differences between sophomores and seniors at the
University of Louisville Medical School. They found no signi--
ficant differences on either the humanitarianism or cynicism
scores. Similarly, Coombs (1978) did not find significant
humanitarianism or cynicism differences on Eron's scales
between any comparison of freshman, sophomore, junior or
senior medical students at an Eastern medical school.

Relationships between Eron's concepts of humanitarianism
and cynicism and performance measures were explored by Gray
and Newman (1962). The authors hypothesized that students low
in cynicism and high in humanitarianism would function more
effectively in the medical student role. The Eron scale scores
for students at a western medical school were compared with
10 performance measures, including National Board scores,
grade point averages and clerkship ratings. Highly cynical

students performed significantly lower on the medicine and

.51
public health subsections as well as overall National Board
Scores and cumulative grade point averages for the thrid

year. High humanitarians had significantly higher clerkship
ratings. No significant differences were found on the other

15 performance measures. Gray and Newman emphasized that the
clerkship ratings were one of the best indicators of later
professional performance.

Gordon and Mensh (1962) made comparisons between fresh-
man and senior medical students at UCLA on the Benevolence
scale of the Survey of Interpersonal Values (SIV). They found
seniors scoring significantly lower than freshmen on Benevo-
lence. Retests of first and third-year UCLA students after
one year indicated that Benevolence scores dropped signifi-
cantly between the first and second years, but did not change
between the third and fourth years (Gordon, 1963). Decreases
in SIV Benevolence scores over four years of training have
also been reported in crossectional studies of nurses at the
Texas women's University (WOodard, 1962) and the University
of Texas (Blune, 1963) and in a longitudinal study of Univer-
sity of Minnesota freshmen dental students after six years of
practice (Loupe, Meskin, & Mast, 1979). However, Woodard
(1962) found no differences between freshman and senior
education students at Texas women's University.

Three longitudinal studies over the four years of medical
school contradict these decreases in SIV Benevolence scores.
Juan, Paiva, Haley, and O'Keefe (1974) found no changes in

Benevolence scores of 514 freshmen entering five medical schools

62

in 1966. Haley, Huynh, Paiva, and Juan (1977) also found no
change in Benevolence for over 450 students from seven medical
schools. Coombs (1978) reported finding only a nonsignificant
trend towards a deCrease in Benevolence over four years of
training at an Eastern medical school.

Longitudinal studies assessing changes on the Social
scale of the Study of Values have generally found no differ—
ences over the course of one's medical education. Hutchins
(1964) reported a longitudinal study of 1,788 students from
a representative national sample of 28 medical schools. The
results indicated no significant change on the Social scale.

A longitudinal study of 450 students from seven medical
schools by Haley, Huynh, Paiva, and Juan (1967) also found no
change on this scale. Coombs (1978) also found no change in
Social scores over four years of medical education at an
Eastern University. Selberman (1976) reported that freshman
and senior dental students from four schools also did not
differ significantly on this Social scale.

Changes in the medical student's social orientation have
also been assessed on a variety of other dimensions. Haley,
Huynh, Paiva, and Juan (1977) gave the Cancer Attitude Scale
(CAS) (Haley, Juan, & Gogan, 1968) to 450 students from seven
medical schools at various point of their training. The CAS
was given at the beginning of the first year and at the end of
the sophomore and senior years. The first subscale of the CAS
measures are "attitude toward the patient's inner resources to
cope with serious.i11ness-like cancer" (Haley, Huynh, Paiva, &

Juan, 1977, p. 501). Haley et al. found significant increases

63

in this subscale between both the freshmen and sophomore test-
ings and the sophomore and senior assessments. The authors
concluded that throughout medical school the students developed
a greater realization of the worthiness of individual human
beings in a technology-oriented envrionment.

The ratings of Columbian medical students attitudes
towards the concept "patient" on an adjective checklist by
deBrabander and Leon (1968) also explored changes over time
using a cross-sectional design. The results showed that fifth
and sixth year students in the Columbian educational system
rated "patient" significantly less favorably than third and
fourth year students.

Perricone (1974) gave a battery of 25 attitude and value
scales to two classes of University of Kentucky medical stu-
dents. The battery was administered at the beginning of the
freshman year and at the end of their senior year. A factor
analysis of these scores led to five factors accounting for
92 percent of the variance. One of these factors was label-
led "social concern orientation" and defined as "values fellow
man above all else; views others as sincere and good; an un-
selfish and kind person; others are an end in themselves not
a means to be manipulated; happy to provide nurturance when
called for (p. 543)."

The results demonstrated that the students increased
in this social concern orientation at a significance level of
.001. In discussing the apparent contradiction between these

results and the studies showing decreases in Eron's scales,

64

Perricone concluded that his "social concern orientation"
was a much broader concept than Eron's concept of cynicism.

Kausch (1967) compared the mental health attitudes of
freshman medical students in their orientation period with
seniors during a rotating psychiatric clerkship. The criterion
measures were semantic differential ratings of a variety of
medical and psychiatric symptoms, treatments, and specialties.
Although there were few differences on the symptom ratings,
seniors rated mental hospitals, electroshock, psychological
testing, and tranquilizers higher as treatments and psychiatry
higher as a specialty than did freshmen.

Concerned that these results may have reflected differ—
ences between those particular classes, Kausch (1969) repeated
these assessments using a longitudinal design. Kausch again
found few differences in the symptoms ratings. However, 38
out of 42 comparisons for treatments and specialties showed
that seniors rated psychiatrically-oriented modes significantly
less favorably than purely medical modes. These results are
consistent with the findings of Bruhn and Parsons (1964) who
found that University of Oklahoma seniors rated psychiatrists
less favorably than freshman students.

Self-reports of reasons for choosing medicine as a career
were collected from junior and senior medical students by
Reissman and Platou (1960). The designated categories used
were Scientist (interested in science), Professional (for pres-
tige, rewards, security) and Humanitarian (desire to help

people). The results indicated that compared to juniors, the

65

attraction for seniors was based more on being a Scientist
(22.2% vs. 16.7%), more as a Professional (36.1% vs. 27.8%)
and less as a Humanitarian (41.7% vs. 55.5%). Based upon
questionnaire given to St. Louis area medical students during
their first and fourth years, Coe, Pepper, and Mattis (1977)
reported increasingly conservative stances on social issues
throughout the course of medical training.

In an unpublished study reported by Rezler (1974),

Weber assessed the differential impacts of curricular formats

on attitude change. A traditional lecture-oriented curriculum
was compared with an innovative curricula which de-emphasized
grades, provided earlier patient contact, and involved students
in course planning. Eron's cynicism and humanitarianism scales
were used as outcome measures. Weber found that cynicism
increased for students in both curricula. However, the

students in the traditional curriculum also decreased in humani-
tarianism while these scores did not significantly change for
students in the innovative curriculum.

Gray, Moody, and Newman (1965) were interested in
whether the decreases in social attitudes reported in some
studies would be recovered after the student left the medical
school environment. Eron's cynicism and humanitarianism scales
were administered to graduating medical students at a Western
university and again after four years of medical practice in a
variety of specialities. The results showed significant
decreases in cynicism and increases in humanitarianism.four

years after graduation. Gray et. a1. concluded attitude changes

66
during medical school were a response to the stressful academic
environment. Optimistic humanitarian attiudes were said to be
set aside during medical school only to return when the academic
experience was terminated.

Reinhardt and Gray (1972) explored post-graduation
changes on Eron's cynicism scale as a function of the amount
of human interaction in the physician's specialty area. "High
interaction" specialties included general practice, psychiatry,
internal medicine, pediatrics, and obstetrics-gynecology.
Surgery, radiology, anesthesiology, neurology, pathology, public
health, and rehabilitation medicine comprised the "low interac-
tion" specialties. At graduation, Reinhardt and Gray found no
differences in cynicism for students choosing these different
specialties. However, four years after graduation, physicians
in high interaction specialties had significantly lower cyni-
cism scores than physicians in low interaction specialties.

In interpreting these results, Reinhardt and Gray reported
their belief that all medical students adopt cynical attitudes
to adapt to the medical school environment. These attitudes
are retained or modified by physicians depending upon their
functional value in their medical practice.

A study by Paiwa and Haley (1971) indicated that this
differential post-graduation recovery of attitudes may also be
a reflection of differential attitudes prior to entering
medical school. The Study of Values was administered to a
national sample of 630 freshmen entering six medical schools.

Significant differences in choice of specialty indicated that

67

students scoring high on the Social scale preferred psychiatry
and general practice while low Social scores preferred surgery

as a specialty after completing medical school.

Summary and'Discussion

 

The social values and attitudes of medical students
have been widely researched. In general, medical students
score lower than students in human service professions and
higher than students in professions with no human service
component. Psychiatry is considered to have moderate to low
status as a medical specialty. There is evidence that this
social orientation of medical students is directly affected
by societal trends in this area.

The literature on attitude change during medical educa-
tion is conflicting. Several studies report decreases in
psychosocial sttitudes in medicine as well as other medical-
oriented professional training programs. However, most
studies and especially most recent studies and those employing
longitudinal designs fail to find significant attitudinal
differences. A few studies have found increases in psycho-
social orientations.

The variety of criterion variables and assessment instru-
ments to measure these varibles seems to contribute to the ap-
parently conflicting evidence. It appears that a sense of
idealism is temporarily lost throughout the course of medical
training, but that a broader concept of social concern is

either not significantly altered or possibly increases.

CHAPTER III

DESIGN AND PROCEDURES

The previous chapters have outlined the rationale,
theoretical views, and relevant literature for this study.
This chapter describes the intensive design used in the
study and planned procedures for implementing this design.

First the subject population, course format, and outcome
measures are described. The intensive case study approach
will then be explained with particular reference to its ap-
plication in this study. Finally, the data analysis proce-

dures are outlined.

Population

 

The population of this study was all first-year medical.
students in the School of Medicine at a large Midwestern
university. The School had a 5 percent selection rate. The
first-year class was 55 percent male, mostly upper middle-
class, and averaging 25 years in age. Ninety-one percent
were from the home state. Eighty percent were Caucasian with
the remainder being Black, Hispanic, and Oriental. Most of

the students had previous experience in medical settings.

Sampling

Ten subjects representing the upper and lower quartiles
of the population distribution on the Social subscale of the

68

69

Study of Values were used in this study. This instrument
was administered to 96 of the 106 members of the first year
class in two testing sessions during November, 1979.

Five students were randomly selected from both the
upper and lower quantiles. These selections were stratified
to evenly represent sex. Two students refused participation
in the study. These students were replaced with randomly
selected alternates. No more than two students were sel-
ected from the same four student lab group.

Table 3.1 (p. 70) indicates the mean scores and Z scores
on the Social subscale for the high and low social groups
compared to the total population. High social subjects
scored 1.60 standard deviations above the mean of the total
population. Low social subjects scored 1.28 standard devi-
ations below the population mean. Thus, these high and low
social groups appeared to display distinctively different
levels of social values compared to the average first-year
student in this pOpulation.

Tables 3.2 (p. 70) and 3.3 (p. 71) indicate the mean
scores and z scores on the Social subscale for the high and
low social groups compared to national normative samples.

In the high social group, males and females scored 4.40 and
3.22 standard deviations, respectively, above the mean of
the normative groups. In the low social group, males and
females scored .12 and .10 standard deviations, respectively,
above the mean of the normative groups. Thus, the high

social subjects appeared to display a distinctively higher

70

TABLE 3.1

Mean and Z Scores on the Social Subscale of the
Study of Values for High and Low Social Groups
Compared to the Population Distribution

 

 

 

Group Mean Score - Z Score
High Social (n=5) 57.00 + 1.60
Low Social (n=5) 36.80 - 1.28
Total Population (n=102)a 45.75

 

aThe standard deviation for this distribution was 7.01.

TABLE 3.2

Mean and Z Scores on the Social Subscale of the
Study of Values for Males in High and Low
Social Groups Compared to a Normative
Group of First-Year Male Medical Students

 

 

 

Group Mean Score Z Score
High Social (n=2) 60.00 + 4.40
Low Social (n=3) 36.33 + 0.12

Normative Group (n=2,492)a

 

aThis normative group consisted of 2,492 first-year
male students from 28 American medical schools. The stand-
ard deviation for this group was 5.53 (Allport, Vernon, and

Lindzey, 1960).

71
TABLE 3.3

Mean and Z Scores on the Social Subscale of the
Study of Values for Females in High and Low Social
Groups Compared to a Normative Group
of First-Year Female Medical Students

 

 

 

Group Mean Score Z Score
High Social (n=3) 55.00 + 3.22
Low Social (n=2) 37.50 + 0.10
Normative Group (n=145) .36.93

 

aThis normative group consisted of 145 first-year
female students from 28 American medical schools. The
standard deviation for this group was 5.61. (Allport,
Vernon, and Lindzey, 1960).

level of social values than the average first-year medical
student in the United States. However, the low social sub-
jects appeared to display an approximately equal level of
social values compared to the average first-year American
medical student.

All subjects signed a consent form (Appendix B) during
their first appointment. Subjects were paid five dollars per

hour of participation.
The IPR Course

Class Format
For the eleventh consecutive year, IPR training was pro-

vided as a required course during winter term, 1980. The

72

entire first-year class met in six workshop sessions. The
first three sessions presented the basic IPR method. Films
from the standard film series were used with an emphasis
upon medically-oriented vignettes. The last three sessions
consisted of lectures on loss, human sexuality and patient
education. Table 3.4 (p. 73) summarizes the training pro-
gram on a weekly basis.

All students also met as groups of four in weekly two-
hour laboratory sessions. These experiential sessions pro-
vided Opportunities to conduct interviews, receive recall
sessions and practice inquiry skills. The interviewees for
these interviews included drama students trained as patient
models, nursing home residents with chronic health concerns,
and fellow students expressing actual concerns.

These practice interviews were also used for course
evaluations. Video-tapes of these interviews were rated on
the Empathic Understanding in Interpersonal Processes Scale
(EU) and Counselor Verbal Response Scale (CVRS) to test for
minimal criteria. These criteria were a 3.0 EU rating and
a frequency of one on each of the CVRS subscales. Students
failing to meet these criteria were given opportunities to
submit additional tapes for evaluation. All students even-
tually met all criterion levels.

Three subjects (George, Alan and Margaret) in this
study also volunteered to participate in an adjunct IPR
training program during winter term. These students re-

ceived physiological reports of their heart rate, skin

73

TABLE 3.4

Summary of Training Program and Interview
Assessment Schedule

 

 

Interview
Assessment

Week

Training Session

 

#1

#2

#3

#4

 

Week

Workshop: Presentation, practice and
small group discussion of
elements of communication;
Affective simulation (two
full days).

Lab: Interview of a patient model with
private recall by lab instructor.

 

Week

Lab: Continuation of week 1 lab.

 

Week

Workshop: Presentation of theory and
techniques of the inquirer
role; Inquirer practice with
individual and mutual recalls
of peers discussing genuine
concerns (full day).

Lab: Interview of a patient model with
peer recall in the group.

 

Week

Lab: Comfimuation of week 3 lab.

 

Week

Workshop: Lecture and discussion on
loss and the grief process
(half day).

Lab: Mutual recall in group of peers
discussing a personal loss.

 

Week

WorkshOp: Lecture and discussion on
sexual physiology and dys-
function (half day).

Lab: Interview of a patient model with
a sexual dysfunction with recall
in group.

 

Week

Lab: Continuation of week 6 lab.

 

74

TABLE 3.4 (Continued)

 

Week 8 WorkshOp: Lecture and video-tape model
on patient education with
discussion (half day).

Lab: Interview of genuine geriatric
patient with private mutual recall.

 

week 9 Lab: Continuation of week 8 lab.

 

Week U) Lab: Optional private review of all
tapes.

 

#5

 

75

conductance and respiration while viewing affective stimulus
vignettes. Each subject attended two training sessions show—
ing approximately ten vignettes. Recall sessions immediately

followed the viewing of the vignettes.

The IPR Staff

Two Ph.D. counselors conducted the IPR workshop sessions.
Both instructors had extensive experience as IPR trainers
with both medical students and a variety of other popula-
tions. These instructors were assisted by faculty physici-
ans. The primary role of these physicians was to support
the IPR model and make direct medical applications. Ph.D.
phychological consultants presented the loss and patient
education workshops.

The laboratory sections were facilitated by second-year
medical students, medical faculty, and a doctoral counseling
student. These laboratory instructors were selected for
their previous IPR training and small group facilitation

skills.
Instrumentation

Study of Values

 

Allport, Vernon, and Lindzey (1960) developed the Study

of Values to measure the relative prominence of six basic

 

values orientations outlined in Spranger's (1928) Types of
Men. These values are classified as theoretical, economical,

aesthetic, social, political, and religious.

76

The Social subscale measures the altruistic and philan-
thropic nature of the person. The social person "prizes
other persons as ends and is therefore himself kind, sympa-
thetic and selfless (Allport, 23.21-r1960r p. 5)."

Allport, gE_al. report a split-half reliability of .90
for the homogeneity of the Social subscale. As a measure of
stability, they cite a test-retest reliability of .88 over
two months.

The validity of the Social subscale can be examined in
terms of occupational and sex differences. Allport, 2E.El-
report the highest normative scores for clergymen, nurses,
social workers, personnel and guidance workers, and graduate
students in education. The lowest scores are reported for
engineers, business students, laboratory technicians, and
dieticians. College females score .71 S.D. above college

males on the Allport,e§ pl. normative group.

Attitudes Toward Social Issues in Medicine (ATSIM)

This scale was developed by Parlow and Rothman (1974) to
assess psychosocial attitudes and values in medicine. The
instrument consists of 63 items using Likert-type scaling.
The subscale to be used in this study, Doctor-Patient Rela-
tions, is defined as "recognizes importance of emotional
factors and interpersonal relations between health profes-
sional and patient in effective patient care (p. 386)."

Parlow and Rothman reported that the internal consis-

tency of this subscale for first-year medical students was

77

.71. They also report that high reliabilities have been
obtained for second- and third-year students.

Two construct validity studies at the University of
Toronto were described by the authors. In the first study
the ATSIM scale was administered to 750 students in dentis-
try, medicine, nursing, pharmacy, and social work. As pre-
dicted, nursing and social work students scored highest on
Social Factors, Para-medical C00peration, Preventive Medicine,
Doctor-Patient Relations and Total score. Social work stu-
dents also scored highest on Government Role and General
Liberalism as predicted. In a second study involving third-
year medical students, peer ratings of "attentiveness to the
psychosocial aspects of patient care" correlated significant-

ly at .43 with Total score on ATSIM.

Affective Sensitivity Scale (ASS)

The Affective Sensitivity Scale (Kagan and Schneider,
1978) is an empathy measure designed to assess one's ability
to detect and describe affective states. The instrument re-
quires the testee to view a film segment of an interview
situation (counseling, medical, school, family) then identi-
fy a participant's feeling towards self, their concern, or
the other person.

The ASS version used in this study (Form E) consists
of 55 multiple choice items presenting one correct and two
distracting choices. The correct responses were determined

by clinical judges and recall sessions.

78

Schneider, Kagan, and Werner (1977) report a Cronbach's
alpha of .75 on an earlier version of the ASS. These authors
also found a test-retest reliability of .63 for medical and
nursing students in less than one week.

Validity data has also been gathered using earlier ver-
sions of the ASS. In a concurrent validity study with M.A.
counselor training groups, Kagan and Krathwohl (1967) re-
ported a correlation of .63 between counselor ratings of
affective sensitivity and ASS scores. Schneider, 23 gl.
(1977) found that the instrument discriminated significantly
between nominated high and low empathizers. Numerous studies
(Spivack, 1970; Grzegorek, 1971; Rowe, 1972) have reported
that the ASS is sensitive to pre- and post—differences due
.to IPR training. Due to the considerable similarities be-
tween earlier forms and Form E, it was assumed that this

reliability and validity data also applies to Form E.

The Relationship Inventory (RI)

Barrett-Lennard (1960) developed the Relationship Invens
tory (Appendix E) to assess client perceptions of the quality
of a helping relationship. The instrument is based upon the
proposition that therapeutic personality change results from
the client perceiving certain qualities in the therapist.
Based upon Roger's (1957) conception of the necessary condi-
tions for therapeutic change, the subscales reflect these
qualities as level of regard, unconditionality of regard,
empathic understanding, congruence and willingness to be

known.

79

The original instrument consists of 92 statements regard-
ing the therapist's attitudes and feelings towards the client.
The client rates their agreement with these statements on a
six-point scale. A modified version Empathic Understanding
subscale of the Relationship Inventory was used in this study
consisting of 15 items relevant to short-term medical inter-
views. The total subscale score was the only measure con-
sidered.

Barrett-Lennard reportedaisplit-half reliability on the
Empathic Understanding subscale of .86 for psychotherapy
clients. In a concurrent validity study, Berlin (1960) found
that this subscale differentiated "good" relationships and
"poor" relationships within a sorority. Barrett-Lennard
found that the Empathic Understanding subscale discriminated
between integrated ratings of expert and nonexpert therapists

and changed and unchanged clients after psychotherapy.

Counselor Verbal Response Scale (CVRS)

The Counselor Verbal Responsestale (Kagan, gp‘al.,l967)
(Appendix G) is a rating scale designed to measure helping
responses. The current scale used in this study consisted
of four dichotomous dimensions: 1) exploratory and non-
exploratory, 2) listening and non-listening, 3) affective and
cognitive, and 4) honest labeling and distorting. Since
these scales reflect the elements of communication taught in
the IPR training, this outcome measure assessed both the

level of helping effectiveness and mastery of course concepts.

80

This scale has been validated as a discriminator of
effective and non-effective helping. In a study by Kagan,
epigl.,(l967), Ph.D. candidates scores higher than M.A.
trainees on every subscale of the CVRS at the .01 level of
significance. Later studies showed that the CVRS can be
used to measure changes due to training procedures for para-
professionals (Sharf, 1971; Dendy, 1971) and prison counsel-
ors (Grzegorek, 1971) and to differentiate among supervision
methods for counselors (Goldberg, 1967).

The initial research on the CVRS (Kagan, eE_gl., 1967)
indicated interrated reliabilities ranging from .80 to .96
for the various subscales. Other reports of inter-rated
reliability have ranged from .81 to .96 for Goldberg (1967),
from .93 to .99 by Spivack (1970), from .93 to .99 by
Grzegorek (1971), and from .73 to .91 by Rowe (1971), while
Sharf (1971) averaged .75.

The Empathic Understanding in Interpersonal Process Scale (EU)
This scale was derived by Carkhuff (1969, v. II)
(Appendix F) from Truax's "A Scale for the Measurement of
Accurate Empathy (AE)." Truax's nine-point scale was refined
into a five-point scale measuring empathy in helping rela-
tionships.
In contrast to the conception of empathy as a trait,
the EU levels assess empathic responses to others in inter-
personal situations. At Level 1, the helper's response does
not attend to or significantly distract from the affective

expression of the helpee. At Level 2, the helper responds

81

to the other's feelings, but subtracts noticeably from the
total affect expressed. At Level 3, the minimal level of
facilitative interpersonal functioning, the response is essen-
tially interchangeable with the meaning and intensity of the
expressed feelings. At Level 4, the helper's response ex-
pressed feelings at a level deeper than the helpee actually
expressed. At Level 5, the helper adds significantly to the
feeling and meaning expressed to be with the other person in
their deepest moments.

Raters are trained to use these operational definitions
as criteria for evaluating the level of empathic responding
of either a particular response or an interview segment. In
this study, trained raters independently provided ratings of
the entire student interview.

Truax and Mitchell (1971) summarized l4 predictive vali-
dity studies of AE ratings involving over 1,000 clients.

They reported that 29 out of 80 outcome measures supported
the predictive validity of the AE ratings with statistical
significance. Other studies (Bachrack, Mintz, and Luborsky,
1971; Hefele and Hurst, 1972; Beutler, Johnson, Neville, and
workman, 1973) have also supported the validity of AE and

EU ratings.

Carkhuff, Kratochvil and Friel (1968) reported the inter-
rater reliabilities of three experienced raters to be .88,
.87, and .85. The inter-rater reliabilities of EU ratings in
IPR studies have averaged .94 for Spivack (1970), .48 for
Scharf (1971), .98 for Grzegorek (1971), and .79 for Rowe
(1972).

82

Tape Ratings

 

Selection of Raters

 

Five doctoral students in counseling and a master's
level clinical psychologist independently rated interviewing
responses on the Counselor Verbal Response Scale (CVRS) and
Empathic Understanding Scale (EU). These raters were experi-
enced with interpersonal skill training and had no previous

contact with any subject.

Rating Procedures

 

Two separate rating procedures were used in this study.
First, two doctoral counseling students and the clinical
psychologist rated pre- and post-training video-tapes of
actor patient interviews conducted by all 106 students.
These raters received ten hours of training from a Ph.D.
psychologist. In addition, three doctoral counseling stu-
dents rated audio—tapes of psychologist patient interviews
conducted throughout training by the ten students in this
study. These raters received six hours of training from a
doctoral counseling student.

Both rating procedure employed similar methods. All
tapes were randomly assigned and rated blindly by two of
the three raters. For both procedures, CVRSratings were
given for each student-to-patient response. A response was
defined as at least one complete sentence preceeded and
followed by a patient statement. All raters gave an EU

rating to the entire interview. The raters of the

83

psychologist patient interviews rated the first fifteen
student-to-patient responses. The raters of the actor pati-
ent interviews rated only the first ten student-to-patient
responses, but these ratings have been prorated in this study
to fifteen responses for purposes of comparison.

Overall, the ratings of actor patient interviews (Table
4.2, p. 98) were higher than the ratings of psychologist
patient interviews (see graphs in Chapter 4 case studies).
This difference may result from several factors. First, the
raters for psychologist patient interviews were trained with
a more conservative interpretation of the rating scales.
Secondly, the raters of actor patient interviews were aware
that their ratings would be used as course evaluations.
These raters may have protected the students by assigning
higher ratings.

Inter-rated reliabilities for both rating procedures
were computed using the Pearson Product-Moment Correlation.
Tables 3.5 and 3.6 (p. 84) summarize the computed reliabili-
ties for actor patient and psychologist patient interviews,

respectively.

Design

Intensive Case Study

 

Although a variety of research methodologies exist, ex-
perimental orthodoxy has contributed to a continued reliance
upon comparative group designs in the behavioral sciences.

Homans (1962) reminded us that research methodology is "a

84

TABLE 3 . 5

Reliabilities of the Average Ratings Between
Two Judges on the CVRS and EU Scales for
Actor Patient Interviews

 

 

 

 

Measure Reliability Coefficient
CVRS - Exploratory .49
CVRS - Listening .48
CVRS - Affective .82
Empathic Understanding (EU) .72
VTABLE 3.6

Reliabilities of the Average Ratings Across Pairs
of Judges on the CVRS and EU Scales for
Psychologist Patient Interviews

 

 

 

Judges Judges Judges

Measure 1&2 1&3 2&3
CVRS - Exploratory .78 .61 .59
CVRS - Listening .89 .87 .44
CVRS - Affective .70 .77 .85

Empathic Understanding .18 .35 .32

 

85

matter of strategy, not of morals (p. 257)." The intensive
case study approach has been acknowledged as the most appro-
priate design for exploring what variables cause a particular
person's behavior and what treatments might be most appro-
priate for influencing that type of person (Kiesler, 1971;
Miller and Warner, 1975).

An examination of the differences between comparative
group and intensive case study designs provides the basis for
wise decision-making in the selection of a method. Compara-
tive group designs use group means as an ideal representative
of a single variable while intensive designs focus upon the
complexity of the individual. Between-group designs view
individual variability as chance events while case studies
consider individual variability as lawful, subject to the
control of environmental events. Between group analyses pro-
vide statistical significance based upon probability while
descriptive analyses provide real significance oriented
towards practicality. Finally, comparative group designs
are based upon statistical inference to a general population
while intensive designs systematically replicate individual
phenomena.

Anton (1978) contended that since most counseling prac-
tice focuses upon the growth and development of the individ-
ual, intensive designs are particularly advantageous for
counseling research. Thoreson (1972) has outlined several

advantages as:

86

1. The specific actions of individuals are the unit
of focus rather than average comparisons of groups
of individuals.

2. The frequency, magnitude and/or variability of the
individual's actions can be examined continuously
during the process of the investigation.

3. The investigator can alter the treatment if nec-
essary based upon observations during the process
of the investigation.

4. Past experience and individual differences are
fully controlled by the subject serving as its own
control using an initial baseline.

5. The interaction effects of treatments administered
simultaneously on one or more client behaviors can
be examined over time for a particular individual
using multiple baselines.

6. The untenable assumption of random sampling is
avoided since generalizations are based upon repli—
cations of specific results by means of interven-
tion techniques across individuals.

7. -An intimate method is provided for controlled in-

quiry of the covert processes which are often of
interest to humanists.

The intensive care study design will be used in this
study for several reasons. First, pre-post comparative group
designs have not been well-suited for identifying where learn-
ing gains occur during the training process. Second, the
intensive design provides for a highly controlled study of
the progressive development of helping skills within the
individual. Third, in reality IPR training is a collection
of learning stimuli which interact simultaneously. Fourth,
this study is exploratory in nature stressing the generation
rather than confirmation of hypotheses. Finally, learning
during IPR is basically a covert process which can be most

easily studied with this intensive design.

87

Summary of the Design

 

In this study a modified case study design was used
(Thoreson, 1972). Interview skills were assessed over the
course of different treatments (class sessions). The sub-
jects were studied both as individuals and as comparison
groups on social values, curriculum preference and partici-
pation in experiential sessions providing physiological feed-
back.

To assess the overall impact of the training, pre— and
post-measures were made of affective sensitivity, attitudes
towards the doctor-patient relationships, and interview
functioning with patient models. The subjects also conducted
five interviews interspersed throughout training. Doctoral
counseling students expressing actual health concerns were
the interviewees for these interviews. In addition, a semi-
structured format (Appendix D) was used in five face-to—face
interviews of each subject assessing their personal reactions

to training experiences.

Data Analysis

 

The data for each subject is presented and analyzed in
a case study format. Graphs for each subject depict changes
in how students interview during training on each measure.
This data is analyzed in conjunction with biographical data,
expressed reactions to training experiences, and the litera-
ture on medical student development. Secondly, group trends

of expressed reactions to training and interview skill

88

development for high versus low social subjects, Track I
versus Track II students, and participants versus nonparti-
cipants of additional experiential sessions providing physio-

logical feedback are reported and discussed.

Summary

Ten first-year medical students, five high and five low
in social values, participated in IPR training as part of
their medical curricula. The class involved six workshop
sessions and ten weekly two-hour laborabory sessions based
upon the standard IPR method. The instructors consisted of
Ph.D. counseling psychologists, medical faculty, doctoral
counseling students, and second-year medical students.

The study employed a modified time series design to
assess the growth of interpersonal functioning throughout the
course, Pre- and post-data was collected on the Affective
Sensitivity Scale and Attitudes Toward Social Issues in Medi-
cine Scale and medical interviews of actor patients. Each
subject also conducted five medical interviews of actual
health concerns expressed by a doctoral psychology student.
All interviews were rated on the Relationship Inventory by
the interviewee and on the Empathic Understanding in Inter-
personal Processes Scale and four subscales of the Counselor
Verbal Response Scale by independent judges. In addition,
biographical data and reactions to class sessions were col-

lected.

CHAPTER IV

RESULTS, DISCUSSION AND CONCLUSIONS

The previous chapters have contained the rationale,
theoretical views, relevant literature and design of the
study. This chapter will include the results of the study,
discussion of the meaning of the results and conclusions of
the study. .

This chapter will begin with the presentation and dis-
cussion of pre-post changes in affective sensitivity and
attitudes towards the doctor-patient relationship. Then,
individual case studies will be presented for each subject.
These case studies will use pseudonyms identifying only the
sex of the subject.

The cast studies will begin with a biographical descrip-
tion of each subject. Self-reported perceptions of changes
in interview functioning and training experiences stimulating
these changes will then be included. Ratings of five inter-
views with psychologist patients will then be presented
graphically to illustrate behavioral changes in how students
interview. Post-interview comments by interviewees will be
added to clarify the meaning of these changes. These re-
sults of interviews with psychologist patients will be com-
pared with pre-post changes in the ratings of each subject's

use of interview skills with actor patients. Finally, the

89

90

literature on medical student development will be cited to
offer theoretical perspectives on these perceptual and be-
havioral changes during interview training.

Group comparisons of high and low social subjects,
Track I and Track II students, and participants and non-
participants in an adjunct IPR training program offering
physiological feedback will then be presented. These presen-
tations will summarize group trends of self-reported reactions
to the training program and behavioral ratings of skill
development. Each presentation will include a discussion of
the possible meaning of these trends and conclusions of the
group comparison.

This chapter will conclude with implications for future

training and research based upon the findings of the study.

Deletions of Data

 

Too few honest labeling responses were used by students
in both the psychologist and actor patient interviews to
permit meaningful analyses. Therefore, this skill will not
be presented in this chapter. Honest labeling responses in-
volve a high level of interpersonal risk. Possibly, students
receiving an initial exposure to interview training did not
develop the necessary comfort to take these risks in ten
weeks. In addition, the effectiveness of honest labeling is
facilitated by the amount of trust developed in the relation-
ship. Thus, these responses may have been less appropriate

in fifteen minute initial medical interviews.

91

The inter-rater reliabilities between raters on The
Empathic Understanding Scale (EU) ratings of psychologist
patient ratings ranged from .18 to .35 (Table 3.6, p. 84).
Therefore, these EU ratings have not been included in the
presentation and discussion of the results of this study.
These low reliabilities may result from several factors.
First, the conservative interpretation of this scale used to
train these raters led raters to generally use only the
first three levels of this scale. The reduced range of the
distribution of these ratings scores also reduced the reli-
ability coefficients. Secondly, only six hours of training
was provided for these raters with the majority of that time
devoted to the Counselor Verbal Response Scale. Finally,
although the doctoral student conducting the training was
experienced as an EU rater, this training was his first ex-
perience as a trainer.

Pre-Post Changes in Affective Sensitivity and
Attitudes towards the Doctor-Patient Relationship

As indicated in Table 4.1 (p. 92), the pre-test mean for
all subjects on the Affective Sensitivity Scale was 31.0.
The post-test mean was 31.3. The pre-test mean for all sub-
jects on the Doctor-Patient Relations subscale of the Atti-
tudes toward Social Issues in Medicine Scale was 37.0. The
post-test mean was 37.1. Thus, pre-post changes of practical
significance were not found on these measures. Furthermore,
Table 4.1 also shows minimal pre-post changes on these

measures for the various comparison groups.

592

TABLE 4.1

Pre— and Post-Test Mean Scores by Subject
and Comparison Groups

 

m
Affective Sensitivity Doctor-Patient Relations

 

 

 

saw smxamcmtmaxmna
nnsdoannmp mm ent me set
nflbdmnlsmfiexs
George 34 33 40 38
Mary 27 26 37 41
Fred 28 26 41 41
Claire 33 38 37 36
Carolyn 24 30 '32 37
Adan 34 29 39 35
We 28 30 37 36
Mark 35 25 32 ’ 34
Brian 32 38 34 35
Susan 35 38 41 38
Social Values
High (n-S) 29.20 30.60 37.40 38.60
Low (n-S) 32.80 32.00 36.60 35.60
auricular! Track
I (n94) 30.00 30.75 34.50 35.80
II (n.5, 31.67 31.67 38.67 38.00
HerflhflqnauPnnnm
Participants (n93) 32.00 30.67 38.67 36.33
Nonparticdpants (n97) 30.57 31.57 36.29 37.43
All Subjects (rt-10) 31.00 31.30 37.00 37.00

Total Population (II-74) 29.26 30.47

 

93

Significant pre-post changes on these scales will be
discussed within the cast studies of each individual.

Several factors might explain the overall lack of pre-
post changes on these measures. First, Werner (1980) re-
ported that the pOpulation mean scores on the ASS ranked at
the 87th percentile of the general norm group's distribution.
The pre-test mean score of subjects in this study on the
Doctor-Patient Relations Subscale ranked at the 93rd percen-
tile of a normative group of entering medical students
(Rothman, 1979). Thus, a ceiling effect may have limited
the ability of these scales to measure further growth on
these dimensions. Secondly, affective sensitivity and atti-
tudes towards the doctor-patient relationship may represent
trait rather than state characteristics. These traits may
not be subject to short term change. Follow-up studies after
further clinical training and experience would test this
hypothesis. Finally, the post-test of the ASS was given with
short notice during final exam week. Several students ex-
pressed resentment that they had learned on Thursday that
the post-test was to be administered on the following Monday.
Twenty-five of the 106 students did not report for this test
administration. Since the ASS requires sustained concentra-
tion, these feelings of resentment may have inhibited the
students' concentration, resulting in reduced post-test

scores .

94

Case Studies of Students Who Scored in the Upper
Quartile on Social Subscale of Study of Values
George (High Social)

George was a 28-year-old married student in Track II.
After completing a 8.8. in chemistry and M.S. in biochemistry,
he taught chemistry for two years at a small college. His
hobbies included photography, reading and outdoor recreation.
He chose medicine as a career in order to combine his inter—
ests in the basic sciences with a helping profession.

During the interviews assessing his reactions to train-
ing, George reported that his contact with students as a
teacher had increased his awareness of the value of inter-
personal skills. However, he stated that he had no formal
training to develop these skills. During these interviews,
George expressed that the training was "one of the most sig-
nificant courses I've taken." George added further positive
reactions through his reports of sharing his learnings with
his wife, listening more effectively to friends and working
through the loss of an infant child during the course. These
self-reports suggest a high level of personal involvement in
the course.

George reported after the initial workshops that he had
become aware of his deficiencies in listening and attending
to feelings. His first interview with a psychologist patient
confirmed his failure to exhibit these skills. The ratings
of this first interview reported in Figure 4.1 (p. 95), indi-

cate low frequencies of listening ( 0 ) and affective ( 0 )

95
FIGURE 4.1

Graphs of Changes in Interview Skills
During Training for George

°-Enmmaury

 

10—
8 9" ‘ <9-Ibnufim;
3 8- . A-nMHamhm

7%
g 6
8 -
£325—

,4

m
Eg‘ ~

fifaP
$5"
¢ 1

 

l l l I l _| I l I

0 1 2 3 4 s 6 7 a 9 10
Tuxamlnmiwaflnhsmfnmlmunhq

Cumawm:Wuuulhqnmn£bflmIwws)aumgmcmifiwsnmuwnms
mthqphflqnm:amnmusnmfigtmeomnncfilmnnmg

'é
r

80 "
70 /
60

40"
30"
20L

10—

annaaaflnlutmiuufllwfimMnmbun

 

l l I l l l l i I I

o 1 ‘2 3 4 s 6 7 a 9 10
fimcbmnmmfiefiaasofImvnammn

 

Ruaunmmuanwammq<mn mmnnsofF m muavums
wfithpflflqnmzmmflmusunhg1me0mmxufi1ntmnw

96

responses and low ratings on the Relationship Inventory (61).
In addition, the early interviewee feedback indicated that
George focused upon "figuring out"3 the patient's concern.
Thus, George may have understood the purpose of medical
interviews to be cognitive problemrsolving. However, his
self-reports support the notion that the data reflects defi-
cits in facilitation skills. The second and third interviews
indicated increases in affective responses (0 to 7.5) and
listening responses (0 to 9.0) and on the Relationship Inven-
tory (61 to 77). The basis for these changes might be found
in George's reports that mutual recalls had led him to see
that ”what was significant to me was not necessarily import-
ant to the other person." George also stated that the inquir-
er role helped him to focus more upon what was important for
the patient.

Several factors appear to have contributed to these early
gains in interview skills. Due to his initial low scores,
these_gains could be artifacts of a regression towards the
mean. However, George's teaching experience may have created
a readiness for improving his interpersonal effectiveness.
His status as a high social subject and the incorporation of
his learnings into his personal life might indicate a ten-
dency to generalize his gains in training to other social
settings. This motivation would increase the value of train-

ing. Whereas the interviewee feedback suggests that George

 

3All quotations used in this chapter are verbatim state-
ments made by students and interviewees.

97

found affective and listening responses and the inquirer role
to be useful tools for becoming more facilitative. This in-
tegration of objective problem-solving and empathic under-
standing has been cited by Zabarenko and Zabarenko (1978) as
one of the primary developmental tasks for first-year medical
students.

Figure 4.1 also indicates significant decreases in ex-
ploratory (6 to 3), listening (9.0 to 2.0) and affective (2.0
to 0) responses over the last few interviews. In addition,
Table 4.2 (p. 98) shows little pre-post change in interviews
with actor patients. However, ratings on the Relationship
Inventory continued to increase for psychologist patients
(74 to 84) and actor patients (44 to 70). George reported
that he felt distracted in this fifth interview because he
overidentified with the patient's concern.

This data might suggest less motivation after early suc-
cess in training. On the other hand, these decreases might
also suggest that George began to integrate his new skills
into his natural problemrsolving style. His continued high
scores on the Relationship Inventory may indicate the success
of this integration. This latter hypothesis is congruent
with Ward and Stein's (1975) conception of medical interview-
ing as a global skill consisting of subskills integrated into
one's personal style. In addition, the patient education
seminar was presented prior to the fifth interview. This
session may have influenced George to practice an educational

rather than facilitative approach on the final interview.

98

.Nh. an: manuuau ammunuuoa ham huaawnauaou uwuuuuuwucu on»
.Hoozo- auowpoa was flouu unfimoHO£Ohom .o.:m a an uncanny can pond: uuouou an once one) nocwuou amazes

 

 

 

2. ma 9. 3” 9e 9: 92 93 93 mi. :83.
8 2. 9m 9m 9“ 9... 9o 92 9a 9a :38
2. 2. 9n 9~ 9. 9H 92 9... 3. m4. fin. .
2. a... 9n 9~ 9. m; m.» 9e 9o 9. 6629!
2 2.. 9.. m4 9o m4 9a 9m 9s 9s 52
4.... 3 9n 9... 9. 9... 92 92 . ms 92 .588
S G. 9n 9H 9a 92 9.350
3 z. 9a 9m 93 9a 68m
3 5 9m 9m 9m 9m 92 9a 3. m... E
2. 3 9... 9w 9m 9m 9o 95 9a 92 8.88
amen flfim anon mum amen can ”Eon mum amen can uuQTEG
E52: “Signage; a 38m 93834 . wen. gfiumfl . 95o ~93ng u mEO

 

£23369: 35%

 

 

 

muommnsm an mucmwumm Houo< nuwz w3mw>umucH How noncommmm
:mmumwm How pmumuoum mmuoom com: umwulumom can Imam

N . w Hands

99

Finally, George's report of his overidentification might indi-
cate that emotional responding can be more difficult when the
student personally identifies with the patient's concern.

Emotional detachment has often been cited as a defense against
emotional identification with patient concerns (Parsons, 1951;

Pollack and Manning, 1967; Zabarenko and Zabarenko, 1978).

Mary (High Social)

Mary was a 28-year-old, single student in Track II. She
attained a 3.8. for a multidisciplinary program in chemistry,
zoology, sociology, and psychology. Her hobbies include
reading, skiing and gymnastics. She chose a medical career
to work with people and pursue her interests in psychosomatic
medicine.

Mary was described by several interviewr's as "sweet",
"spontaneous", "genuine" and "inquisitive”. In contrast to
these impressions, Mary indicated that her early training ex-
periences made her aware of her tendencies to be dominating
and opinionated in social interactions. One interviewee con-
firmed this view by stating that "Mary did not stay with
feelings without checking her own frame of reference". These
self-references may relate to Mary's reported realization
through her recall sessions that she used patient interaction
to feel helpful and liked by others. Both self-reports and
interview feedback appear to suggest that Mary gratified
important personal needs during her interviews. This moti-
vation may have influenced Mary's choice of a medical career,

consistent with Knight's (1973) "conceived purposes" for

100

becoming a physician. Thus, high social orientations may
prove to be counterproductive to effective interviewing if
the satisfaction of the student physician's needs becomes a
central focus of the interview.

Mary reported that vignettes of egalitarian doctor-
patient interactions were helpful models to assuming a more
objective interviewing style. In addition, she reported that
her use of exploratory responses helped her to objectively
focus upon the patient. As indicated on Figure 4.2 (FL 101),
her second and third interviews with psychologist patients
showed increases in these exploratory responses (0.5 to 6.0)
as well as listening responses (1.5 to 3.5) and Relationship
Inventory (72 to 86) ratings.

These results appear to indicate that immediate gains in
a more patient-centered focus. The presentation of model
vignettes of doctor-patient interactions and the exploratory
response immediately prior to these interviews may indeed
have accounted for these gains.

However, the later interviews indicate decreases in ex-
ploratory (6.0 to 1.0), listening (3.5 to 1.0) and affective
(3.0 to 0) responses and on the Relationship Inventory (85
to 56). These last two interviewees commented that they
"felt criticized and defensive" and that Mary "jumped ahead
of what I was saying". Mary stated that she felt these
interviewees were "malingering" and "evaluating my use of

the interview skills".

101

FIGURE 4.2

Graphs of Change in Interview Skills
During Training for Mary

 

10- 0—blploratory
9- (3-5HBUmhn
8- A -Aflhflhm
7...

36%-

S—

3

“'4:-

3 q

531‘

322i.

1' ._ ~ .3

kwxqplkupachncmtwusanhn

 

 

1 n . 1 l ' I I I I

012345678910
ENnOauunumaunhsdEnmlmnmmg

GmnnMr\mnnlnupman&nuemws)nnbgsofrhn1mmmdam
tubRudnkgnmpmnumsnxhqthaauneoftnmnm;

§
1

 

40"
30-
20)-
10—

annaaauelflzmiuudtylwmndmna

 

L .L I I I J I I I I

0 1 2 3 4 5 6 7 8 9 10
finihmnmtflmibdmcfiJmRTnummg

 

lhhmkmmfipImManruu)Rnhwsoffiwelmwndam
uuhpmphmqnmzmmhmuanmngImeOamaaanmhdm;

102

This data may reflect the patients' failure to meet
Mary's needs to be helpful and liked. These interviewees may
have been less willing to reSpond to her needs. Although
Mary became more patient-centered in the second and third
interviews, the failure to have her needs met in these inter-
views may have elicited hostile feelings towards later pati-
ents. Recall sessions are designed in part to resolve hidden
agendas for assuming helping roles. However, more severe
"conceived purposes” may require additional training and/or
a psychotherapeutic intervention.

As indicated in Table 4.2 (p. 98), Mary achieved signi-
ficent pre-post gains using exploratory (4.7 to 7.5) and
listening (9.0 to 13.5) responses with actor patients. Thus,
she maintained these gains throughout training while her
gains with psychologist patients tended to decrease. These
former interviews were conducted within a course with an
educational purpose. Hence, Mary may have had fewer expecta-
tions that her personal needs would be met in these inter-
views. In addition, the psychologists tended to engage in
more social conversation prior to the interview. These
interactions may have raised Mary's expectations for having

her needs met in these interviews.

Fred (High Social)

Fred was a 24-year-old single student in Track II. He
held a 3.8. and was completing a M.S. in nutrition. In his
leisure time, Fred enjoyed printing, photography and music.

His helping experiences included being a nutrition educator

103

for migrant farm workers, an emergency room orderly, and a

hospital aide and volunteer on a variety of wards. Fred felt
that a medical career would provide an opportunity to facili-
tate both the personal growth and physical health of others.

During the interviews of his class reactions, the author
observed that Fred attributed positive comments to himself
and negative comments to other students. Fred also responded
positively to authority with his early statements that the
instructor's comments, Opinions of respected students and
the theoretical constructs were the most useful components
of his training. Later, he reported that inquirer training
was helpful for focusing upon affective material. Fred
commented upon his own affect in recall sessions that he
"worries too much about what others perceive in me". He re-
ported that viewing the awkwardness of follow students and
receiving emotional support during lab sessions relieved this
self-consciousness.

These observations suggest concerns with performance ex-
pectations and needs for approval. These concerns could re-
flect a tendency to defer to authority. They may also have
been based upon anxieties related to academic success.
Regarless, emotional support and a sense of commonality in
his lab group appeared to relieve these concerns.

Following intensive skill training, Fred's second inter-
view with a psychologist revealed increases in listening
(0.5 to 6.5) and affective (0.5 to 5.0) responses (Figure 4.3,

EL 104. However, his Relationship Inventory rating from the

P
O

ILUIGNQW

firrhmtfifiunnnnnmmm

HNN

 

Amnqplkapachmcmcwmsanhn

104

FIGURE 4.3

Graphs of Changes in Interview Skills
During Training for Fred

-Bmkmnmy
(lsnnmmmg
L-Ififlcfime

 

 

nmlhmnamhmvbdmcfiIGRTanng

ammnkx\mflilnugmns&zueEWS)mmngsothmlhumdam

H
8

amnaanflninasRMnihynmaNunn

 

uuhPmphnqfim:HmhmusnmkgImeOQKaimEnmflum;

 

I I I I J I I I I I

l 2 3 4 5 6 7. .8 9 10
TanxmnamhmvbasofImknammg

RuddGEMpImnmnqruu)mnhgsoanmeurwe§
thPmphflqnmzmmhmusnmhgtmeOamaedPnzhnm;

105

interviewee decreased from 84 to 43. This low rating was
supported by the interviewee's comment that Fred "seemed to
want to be helpful, but was tense and not in command of himr
self or the interview." This data indicates significantly
increased skill usage, but with considerable personal dis-
comfort. These findings may indicate performance anxiety
with applying these new skills. Also, Fred may have intro-
jected these skills into his behavioral repertoire without
developing a sense of timing or fully understanding the pur-
pose of these skills.

During the third and fourth interviews, Fred increased
his rating on the Relationship Inventory from 43 to 80. How-
ever, these interviews indicate decreases in exploratory
(3.0 to 2.0), listening (6.5 to 0) and affective (5.0 to 1.5)
responses. These reductions in his efforts to encourage
self-exploration were also evidenced by Fred's statement
that ”I gave my opinion of what I thought he had" immediately
following the third interview. During this time Fred reported
that he was working through the deaths of both parents. He
indicated that he had discussed these losses in his lab
group. He also reported difficulties becoming aware of his
feelings in recall sessions. While discussing a personal con-
cern related to his training, he responded that "it's no main:
personality problem or anything."

These observations appear to indicate emotional vulner-
ability and defensiveness. These findings suggest that the

training had been emotionally impactful for Fred. Fred's

106

personal concerns may have precluded his ability to emotion-
ally reSpond to patients. However, he may not have fully
developed these skills. As previously discussed, the skill
gains in the second interview may have represented behavioral
manifestations lacking personal meaning. This data also sug-
gest a reliance upon an advice-giving role. The high Rela-
tionship Inventory score may have resulted from the patient
finding this advice helpful. His non-verbal expressions of
interest and warmth may also have contributed to this score.

During the fifth interview, Fred demonstrated increases
in exploratory (2.0 to 4.0), listening (0 to 4.5), and affec-
tive (1.5 to 5.0) resPonses. He maintained a moderate Rela-
tionship Inventory score of 64. Further improvements were
indicated by the interviewee's comment that Fred "seemed
genuinely concerned" and “Opened up as the interview pro-
gressed." Fred reported that he felt more confident in his
interview skills and was more aware of his own feelings
during this interview.

These findings suggest that Fred may have made progress
with his grieving and/or performance concerns. This data
also indicates a successful integration of Fred's skill usage
and his own personal comfort and satisfaction in interview-
ing. It appears that his lab group was instrumental in facil-
itating this growth. Also, it appears that the entire ten

weeks of training was necessary to achieve these changes.

107

Claire (High Social)

Claire was a 22-year-old, single student in Track 1.

She had a B.A. in biology and enjoyed dancing, roller skating
and reading. Claire worked as an interpreter and volunteer
in urban hospitals and as a counselor in a poverty program.
She reported choosing a medical career to work at improving
the quality of health care for lower-income persons. Claire
was the only non-Caucasian subject in the study.

Claire did not attend the initial workshop session, and
stated "I didn't miss much." She was also the only subject
who missed an appointment for this study, stating that she
"completely forgot." In addition, Claire was the only sub-
ject who refused the offer for a debriefing session for feed-
back on her participation in this study. These facts may
suggest a lack of interest and personal involvement in the
training program or perhaps a high state of anxiety or defen-
siveness.

After the first workshop she attended, Claire expressed
satisfaction with a vignette of a physican modeling the ef-
fective use of interview skills. She stated that this film
made the elements of communication appear "more real" for
medical settings. Claire also reported that the small groups
during the workshop and lab groups provided for interesting
discussions related to patient concerns. However, Claire
criticized the lack of racial minorities in the film series
even though one-fourth of the vignettes actually included

non-Caucasians. Finally, she cited a vignette of a girl

108

tryong out for a men's swim team as the most interesting
vignette.

The first of these observations might suggest an initial
skepticism for the relevance of the training material. Her
comments related to racism and sexism appear to indicate a
greater interest in social issues rather than the content of
the training program. It is possible Claire perceived the
training as less relevant for the lower class, minority
settings in which she intended to practice. If this hypo-
thesis is true, this factor might also account for her appar-
ent lack of involvement throughout the training program. On
the other hand, these observations may simply represent the
strength of her interest in social issues relative to her
interests in interviewing. Having missed the first workshop
session, Claire's racial remarks may have been the result of
limited exposure to the film series.

The results from Figure 4.4 (pa 109) indicate decreases
in listening responses (3.5 to 1.0), affective responses
(2.0 to 1.0) and on the Relationship Inventory (65 to 52) for
the second interview with a psychologist. These results
show only minimal gains for exploratory responses (4.0 to
4.5). These results were consistent with the interviewee's
remark that "she seemed to be telling me that it (the inter-
viewee's concern) was no big deal." These results are not
consistent with Claire's self-report that ”I was able to

apply the skills."

p
O

OU‘OQQU

RthmtfiKuanRupmum

HNU

Aurqptkapanhacmcwmianhn

H
8

TWT

smnaaIueFEasRflnihrnwaMhua

109

FIGURE 4.4

Graphs of Changes in Interview Skills
During Training for Claire

O-EquMnfiI

 

 

 

 

_ (D-InmwMQ
F A-Aflhnhm
F
L.
.r’
I 1 L I I I I I
l 2 3 4 5 6 8 9 10

Tuuxmnamnnfiuksafnmlmunmg

ammnkrIMnnlnugmaefiaueMWS)angsofrnelmumdam
uuthpumqnm:nmnmusaruythaaxnncuumwmhg

 

I I I I I I I I I I

2 3 4 5 6 7 8 10
Taiamannhehhasofrmunamhg

Ibhmnmmuprmnmnqrflu)RmhgsofRWeImznuam
wuthphnqnm:amnmusnmhgImecamaemfnahum;

110

The inconsistency between Claire's self-perceptions and
the ratings suggest a lack of understanding of the interview
skills or a defensiveness attitude towards the training.
This failure to exhibit gains in interview skills may be due
to Claire's failure to attend the first workshOp session.
Her failure to focus upon the intended content of the train-
ing program may also have contributed to these findings.

.Claire reported that she personally shared the health
concern expressed by the third interviewee. She stated that
this fact "made me want to avoid the t0pic." Claire also
stated that she "felt betrayed and angry" when a tape of her
expressing a personal problem was shared with three other
students during the inquirer training. She had assumed that
confidentiality would be maintained.

The results of this third interview indicate decreases
in exploratory (4.5 to 3.0) and listening (1.0 to 0) respon-
ses, but increases in affective responses (1.0 to 3.0) and
her Relationship Inventory score (52 to 77). These gains in
affective responding may be due to Claire's identification
with the patient's feelings. Since her initial scores on
these measures were quite low, these gains might also indi-
cate regression to the mean. The decreases in exploratory
and listening responses may be the result of her desire to
avoid the topic. Her emotional identification may have been
a barrier to her objective exploration of the patient's con-
cern. These decreases could also be the effect of a gener-
alization of her anger from the confidentiality issue to the

IPR skills.

111

The CVRS results of the fourth interview indicate de-
creased exploratory (3.0 to 0) and affective (3.0 to 0)
responses and a continued low level of listening responses
(0 to 0.5). Her Relationship Inventory Score also decreased
from 77 to 71. These results are consistent with the inter-
viewee's feedback that Claire "did little to explore my con-
cern." Claire reported sharing a personal experience during
this interview ”to convey my understanding of the situation."
Claire also indicated that she was "feeling out of touch with
things.” She mentioned that this stress was related to the
recent workshop on loss, stating that discussions of loss
"get me depressed a lot.”

These findings suggest that the loss worksh0p may have
induced emotional stress for Claire. Since she had recently
moved from a lower-class environment in a large Eastern
metropolis to a middle-class, smaller Midwestern city, the
loss of her support system and familiar living environment
may have accounted for this stress. These personal concerns
may have interfered with her effective use of interview
skills. Her self-reports suggest that she attempted to cope
with her anxiety in the interview through identification
with the patient. Like Mary, the interview ratings indicate
that this identification did not produce an effective inter-
view.

Claire reported feeling more emotionally stable at the
end of the term. The results of the fifth interview indi-

cated increases in exploratory (0 to 4.5), listening

112

(.5 to 2.5) and affective (0 to 4.0) responses. However,
immediately following the interview Claire reported that the
interview was "a complete disaster . . . I broke all the
rules. I couldn't resist sharing my personal experience."
Consistent with these self-perceptions, the interviewee come
mented that Claire "jumped to some conclusions which did not
apply to me.'

This data appear to indicate that Claire resolved her
emotional concerns to some extent. The resulting emotional
stability may have enabled her to increase her skill usage
in the interview. However, these skill gains may be inflated
by the low scores of her fourth interview. The self-reports
and interviewee feedback suggest the continued use of iden-
tification to convey understanding. These comments indicate
that her identification was again ineffective for developing
rapport. However, the skill increases suggest that Claire
may have modified her identifying responses somewhat to make

them more facilitative.

Carolyn (High Social)

Carolyn was a 22-year-old, single student in Track I.
She had worked as a volunteer in a nursing home and enjoyed
biking, swimming, photography and tennis. Having a 3.8. in
biology, she chose a medical career based upon her interest
in science and her enjoyment of pe0ple.

carolyn initially stated that interpersonal skill train-
ing was only relevant for physicians treating patients

explicitly presenting emotional concerns. However, Carolyn

113-

reported later in training that the course seemed “real
relevant." She stated that all physicians "have to be able
to talk to people." Carolyn disclosed her earlier attitudes
towards the course may have been influenced by family con-
flicts. Carolyn had recently seen her father, a psychologist,
for the first time in seven years. This separation had re-
sulted from her parent's divorce. Consistent with these self-
reports, her pre-post scores on the Doctor-Patient Relations
Subscale of the Attitudes towards Social Issues in Medicine
Scale increased from 24 to 30 (Table 4.1, p. 92).

Thus, Carolyn's initial low esteem for psychological
training appears to have been based upon associations to her
father. Her increased valuing of the doctor-patient relation-
ship might be due to her exposure to models of patients pre-
senting emotional concerns and receiving effective psychologi-
cal interventions in general medical settings. Since Carolyn
had the lowest pre-test score on the Attitudes towards Social
Issues in Medicine Scale, her gains may also be the result
of regression to the mean.

Carolyn reported developing an awareness through recall
sessions of her discomfort in listening to the emotional con-
cerns of others. She stated that this discomfort was some-
what relieved by observing similar anxieties in her fellow
students during labs. Carolyn reported that mutual recalls
were particularly useful for learning more of the affective
experience of patients. This self-report was confirmed by

her pre-post gains (24 to 30) on the Affective Sensitivity

114

Scale (Table 4.1, p. 92). However, her pre-post scores for
.interviews with psychologists decreased on the Relationship
Inventory (85 to 61) (Figure 4.5, p. 115).

These findings suggest increases in Carolyn's affective
sensitivity. Self-reports indicate that these gains may be
due to mutual recall experiences. Again, regression towards
the mean may have been a causal factor due to her low ASS pre-
test score. However, these gains in her affective understand-
ing were not reflected in her emotional responding. Her
self-reports suggest that these deficits reflected anxiety
related to affect. As in the cases of Fred and Claire, emo-
tional conflicts (i.e., with her father) may have impeded her
ability to improve her responding to other's emotions.

The results of the second interview with a psychologist
indicate decreases in exploratory (1.0 to 0), listening
(4.0 to 0), and affective (4.0 to 2.5) responses. These
skill reductions were also evident on the Relationship In-
ventory (85 to 73). This data is consistent with the inter-
viewee's comment that Carolynappeared "nervous and ill-at-
ease.” In addition, the interviewee noted "when I stopped
tandng and left it to her to take the lead, she faltered and
seemed lost." This last remark is consistent with Carolyn's
report that silent patients were her most difficult inter-
viewees.

Since this interview immediately followed intensive
skill training, these findings might reflect performance

anxiety. This anxiety may have been exacerbated by the

115

FIGURE 4.5

Graphs of Changes in Interview Skills
During Training for Carolyn

 

 

10— 0 -Ennmaury
3 9- GIfLHMmhg
3 8- a-ummm
E 7"
8 6
jigs

h

a
£3!

 

I L I

0 1 2 3 ’ 4 5 6 7 8, 9 10
nmlhmnanhnihdmcfiJuananum;

ammnkn‘mnnlnupamQSGHe(0mm mmhgsoffimeImnndam
wfimlwmeofimtnnflmM3nmhgthaaunnoftnmum;

1a)-

annaaIuBIUamluufltylmmndaee
8
I

 

I I I I I . I I I I I

o 1 2 3 4 5 6 7 "8 9 10
TunxmxmmbmibdmcfilminaHMn

lhhmnmmupImManrfiu)Ruhnsoffimelmzndam
mthnpumqnm:mmnmusumhgtmeOomaedfnmhfim;

116

interviewee's silence. However, these reductions in inter-
view skills might also reflect her perceptions of the lack
of relevance of psychological training.

The results of the third interview with a psychologist
reveals increases in exploratory (0 to 4.5), listening (0 to
1.5), and affective (2.5 to 5.0) responses. Her Relationship
Inventory score remained virtually unchanged (86 to 85). The
interviewee again observed her nervousness, but also cited
Carolyn's warmth as a strength. Carolyn indicated that she
enjoyed the inquirer training which preceeded this interview
because it was consistent with her nondirective style.

These gains may be due to a greater use of Carolyn's
natural warmth and attentiveness to others. Earlier skill
training may have been novel for Carolyn, eliciting perfor-
mance expectations. Being more congruent with her personal
style, inquirer training may have given her permission to be
herself in interviews. These gains might also indicate that
psychological training was appearing more relevant to I
Carolyn.

The fourth and fifth interview ratings indicate de-
creases in exploratory (4.5 to 1.0) and affective (5.0 to
.5) responses and on the Relationship Inventory (69 to 61).
Listening responses (1.5 to 1.0) remained relatively un-
changed. Interviewees described Carolyn as "reserved and
controlled" and ”lost for words." Carolyn commented that
the fifth interviewee "seemed like he just wanted some infor-

mation.”

117

This data indicates that the skill gains observed on
the third interview were not sustained. Earlier successes
may have been based upon performance anxiety towards academic
success. Partially achieving this success may have reduced
the anxiety motivating her skill development. The data may
also suggest that these gains were never firmly established.
The patient education workshop preceeding the fifth inter-
view may have provided Carolyn a reason to disengage from
the more threatening use of facilitation skills. This work-
shop may also have confused the purpose of these interviews.

As indicated in Table 4.1 (p. 92), pre-post ratings of
actor patient interviews indicate decreases in exploratory
(10.5 to 7.5) and affective (6.0 to 4.5) responses. Her
Relationship Inventory score (58 to 67) increased. The level
of listening responses (10.5 to 10.5) remained unchanged.
Although the actor patient for the post-test interview was
trained to present a sexual dysfunction as a concern, Carolyn
commented that "sex never came up” in the interview. This
comment suggests a denial of sexual cues in the interview.
Anxiety related to sex may have contributed to her apparent

overall decrease in interviewing effectiveness.

Case Studies of Students Who Scored in the Lower
Quartile on Social Subscale of Study of Values

 

Alan (Low Social)
Alan was a 23-year-old, single student in Track II. He

held a 3.8. in zoology and had seven years of experience as

118

an orderly. Alan enjoyed music, reading and horseback riding.
He chose medicine to integrate his interests in science and
helping relationships.

Alan cited recall sessions as his most valuable training
experiences. He reported that these sessions helped him to
identify his tendency to focus upon symptoms while missing
underlying affects. Alan similarly reported that he "felt
pressured to uncover the problem in the time limit" during
his interviews. Thus, these self-reports suggest a problem-
solving style of interviewing focusing upon traditional diag-
nosis and treatment of the physical symptom. This urgency
to problemesolve might suggest that Alan was struggling with
Zabarenko's and Zabarenko's (1978) develogmental task of
"controlling needs for omnipotence."

Alan also stated a preference for affect simulation
vignettes used in the initial training workshops. He indi-
cated that these vignettes helped him to become more aware
of hiw own feelings and to identify patients he found most
difficult to treat. Alan's comment that he was "totally com-
fortable with sex" may suggest a need for greater affective
awareness. Alan's pre- and post-scores on the Affective
Sensitivity Scale, however, indicated a decrease (34 to 29)
on this dimension (Table 4.1, p. 92).

Thus, Alan's interest in affect simulation and comment
regarding sex suggest a need for affective awareness. Although
Alan reported growth in his affective sensitivity, the ASS

results seem to indicate that growth in this area did not

119

occur. Several authors have noted that physicians motivated
by needs for omnipotence tend to mask their own affect
(Parsons, 1951; Fox, 1957; Zabarenko and Zabarenko, 1978).
Thus, Alan's need to maintain a sense of omnipotence may have
inhibited his growth in affective sensitivity. However,
,Alan's post-test score on the ASS may also have been deflated
by the resentment towards the post-test administration proce-
dures as previously discuSsed (p. 93).

As indicated in Figure 4.6 (p. 120), Alan demonstrated
increases in exploratory (1.0 to 4.0), listening (2.5 to 3.0)
and affeCtive (1.5 to 3.5) responses during his second inter-
view with a psychologist. His interview effectiveness de-
creased, however, on the Relationship Inventory (87 to 47)
rating. Consistent with this RI decrease, the interviewee
commented that Alan "gave the general appearance of uncer-
tainty and anxiety." Alan supported this observation by
stating that he was "more nervous than the previous inter-
view." The interviewee also stated that Alan "projected his
own feelings several times and was uneasy when I told him I
felt differently."

This data indicates that Alan was able to apply the
elements of communication immediately following the exten-
sive skill training. However, performance anxiety related
to the use of these skills may have interfered with his
development of rapport with the patient. In addition,

Alan's enthusiasm for gaining a greater awareness of his own

feelings through affective stimulations may have led to a

120

FIGURE 4.6

Graphs of Changes in Interview Skills
During Training for Alan

 

 

 

 

10- o-—a@kmnmy
3 9— Gl-LEUmhg
ags- A-Affective
E 7"
8 5"
3§s—
:4r-
E333 ”
33:!
Il- .
e "

I I; I I I II I I I I
0 1 2 3 4 s a 7 a 9 10

hmlhmnamhnihdmcfiJWRTnmum;

CumumxwmnnlnugmaaézkzmW6)mmhgaofRWQImanmam
unthnmmnunlhdamsnrtgtheanuaoanmfimI

amn3atfleinasnnnimrnmuxuun

 

L I I I I l I I I I

0 1 2 37 4 S 6 7 8 9 10
TauxmnmmhmwuksofImUHEMbg

lhhmnnflfipImManrGu)mnrnsomeeImnndam
wfihPmphflqfimzfimhmusumflyImeOmmaedEnahfim;

121

dysfunctional projection of these feelings onto the patient.
Furthermore, the apparent insignificance of the patient's
presenting concern (chapped lips) may have frustrated Alan's
efforts to solve a significant medical problem. This frus-
tration could also have led to the resulting anxiety.

The ratings of the third and fourth interviews indicate
increases in exploratory responses (4.0 to 6.5). These find-
ings are consistent with the third interviewee's observation
that Alan was "much warmer than other interviewers." How-
ever, these results reflect lower frequencies of listening
(1.0 to 0.5) and affective (3.5 to 2.0) responses. These
ratings are consistent with Alan's remark that he "felt
phoney" using listening and affective responses. The Rela-
tionship Inventory scores increased (47 to 67) for the third
interview, but decreased (67 to 44) on the fourth interview.

These findings suggest that Alan began to discriminate
between which of the elements of communication to employ.
The exploratory nature of inquirer training may have influ-
enced his greater use of exploratory responses. Consistent
with his tendency to objectively problemesolve, Alan's
failure to use more affective and listening responses may
also have been an avoidance of emotional contact with his
patients. As in the case of Fred, Alan's preference for ex-
ploratory responses might indicate the integration of inter-
viewing skills with one's personal style as described by
Ward and Stein (1975). This phenomenon may have freed Alan

to express more warmth and empathy to his patients. The

122

fourth interviewee presented a chronic medical concern
(herpes) with few treatment possibilities to problem solve.
The low RI rating on the fourth interview might indicate that
Alan's problemrsolving style of interviewing was less effec-
tive with this type of medical concern.

Alan's fifth interview reflected an increased Relation-
ship Inventory score (44 to 66). However, this interview
indicated decreased exploratory (6.5 to 1.5) and affective
(3.5 to 1.0) responses. Alan's post-test interview with an
actor patient indicated more consistent gains in interview
skills (Table 4.2, p. 98). These interview ratings indicate
increases in exploratory (6.75 to 9.75), listening (5.25 to
9.00) and affective (1.50 to 8.25) responses. Ratings on the
Empathic Understanding Scale (1.5 to 4.0) and Relationship
Inventory (50 to 70) also increased.

These differences in post-test results may be due to the
nature of the interviewee's presenting concern. The students
knew that the actor patient would present a specific sexual
dysfunction during the post-test interview. Thus, Alan's
problemrsolving style may have been more effective for iden-
tifying and responding to this concern. In addition, the
patient education workshop followed the post-test patient
model interview, but preceeded the final psychologist patient
interview. Thus, this psychologist patient interview may
have been confounded by a more educational approach requiring

fewer facilitation skills.

123

Margaret (Low Social)

 

Margaret was a 27-year-old, single student in Track I.
She had a 3.8. and M.S. degree in biology and enjoyed athle-
tics, handicrafts, movies and horseback riding. Margaret's
enjoyment of having been a hospital volunteer and phlebotomist
led her to choose a career in medicine.

During the initial training sessions, Margaret reported
difficulties integrating the physical and emotional concerns
of patients. She attributed this dilemma to the fact that
her past hospital experiences focused solely upon physical
concerns. Margaret stated that the presentation and small
group discussions of vignettes of patients discussing emotion-
al concerns increased her awareness of psychological problems
with patients. In addition, Margaret reported that the loss
and sexuality sessions enhanced her awareness of these speci-
fic psychological issues in medical settings.

Margaret's past work settings apparently used the tra-
ditional disease model of medical care. Her academic train-
ing in biology likely reinforced this view. Thus, a
transition was necessary to integrate psychological concerns
into her conceptualizations of patient cases. Filmed models
of patients presenting emotional concerns and educational
workshops on loss and sexuality appeared to facilitate this
integration.

Margaret also expressed dissatisfactions with the loss
and sexuality worksh0ps. She regretted that the loss session

”did not explain how to break the news (of a death) to the

124

family." She also stated that the sexuality session "didn't
give enough guidelines." However, at the end of training
Margaret reflected that earlier she "tried too hard to do it
(use interview skills) the right way." Margaret's remarks
seem to indicate a preference for structure in her learning.
Structured learning situations may have been sought to relieve
anxieties concerning academic success. This preference may
also be related to difficulties tolering ambiguity, a char-
acteristic identified by several authors as a prerequisite
for effective functioning as a physician (Fox, 1957;
Zabarenko and Zabarenko, 1978). However, Margaret's comments
indicate that she apparently achieved greater conceptual
flexibility during the course of training.

The results of Margaret's second interview with a psy-
chologist indicate increases in exploratory (1.0 to 4.0) and
listening (1.0 to 3.5) responses and on the Relationship
Inventory (44 to 68) (Figure 4.7, p. 125). However, her fre-
quency of affective responses (0 to 0.5) remained virtually
unchanged. The interviewee stated that Margaret's "nervous-
ness seemed to impede her ability to express the warmth
which flashed through occasionally." The interviewee also
observed that Margaret "mostly asked questions and jumped
around."

This data suggest that Margaret was able to exhibit
exploratory and listening responses immediately after inten-
sive skill training. However, she seemed to have greater

difficulties exhibiting affective responses. These findings

Average Weiss on CVRS Scales

SooremtheRIaslhtedbyInterviewee

for First Fifteen Msponses

PM“

125

FIGURE 4.7

Graphs of Changes in Interview Skills

p
O

hUIQNIQW

'3‘

90
80

7O

60
SO
40

.30

20
10

 

 

During Training for Margaret

L‘ 0 - Dcploratory
— O fastening
F A - Affective

 

 

 

Owneelor Verbal msponse Scale (CVIG) Ratings of Five Interviews
with Psychologist Patients bring the Course of Training

I I I I I I I I I |

l 2 3 4 5 6 7 8 9 10
Ten Consecutive Weeks of IPR Draining

MatiaIship Inventory (RI) Ratings of Five Interviews
with Psycl'ologist Patients airing the Curse of Training

126

may indicate her failure to include affective material in her
conceptualizations of patients at the beginning of training.
Since affective expressions are often ambiguous, her reported
anxiety and failure to respond emotionally may reflect her
intolerance for ambiguity. Margaret's nervousness also sug-
gests performance anxiety in a novel learning situation.

Margaret's affective responses (0.5 to 2.0) increased
during her third interview with a psychologist. However, her
exploratory (4.0 to 2.0) and listening (3.5 to 1.5) responses
and Relationship Inventory score (68 to 52) decreased. The
interviewee remarked that Margaret was "the most'anxious and
least skilled" of four interviewers. Margaret reported
after the interview that "I tried to focus on feelings, but
he seemed to just want to talk about his knees." Margaret
also indicated that she had difficulty integrating the ele-
ments of communication with the inquirer role and "tried to
keep the two separate."

These results suggest that Margaret reversed the trend
she demonstrated on the second interview by increasing affec-
tive responses and decreasing exploratory and listening re-
sponses. This trend is consistent with Margaret's stated
attempts to structure aspects of interviewing. In this
interview, she apparently tried to focus upon affects to the
exclusion of the physical concern. The low RI score, nega-
tive interviewee feedback and Margaret's anxiety may indi-
cate an attempt to prematurely explore the patient's affect.

This attempt may have been influenced by the inquirer

127

training which focused upon affective experience through
recall sessions. These findings suggest that Margaret had
yet to integrate exploration of physical concerns with affec-
tive reaponding.

The fourth interview reveals increases in affective
(2.0 to 4.5) and listening (1.5 to 3.0) responses and on the
Relationship Inventory (52 to 75). These ratings demonstrate
a minimal decrease in exploratory responses (2.0 to 1.0).

The interviewee stated that he "felt a great deal of empathy
from her." He also observed that she "has a very easy way
abOut her." Margaret also observed her improvement by stat-
ing that she was "getting the hang of finding the underlying
cause of the physical illness." The post-test interview with
an actor also reflected increased skill develOpment (Table
4.2, p. 98). Exploratory (4.5 to 6.0), listening (6.0 to
7.5) and affective (1.5 to 4.5) responses all increased. In
addition, the rating on the Empathic Understanding Scale (2
to 3) and Relationship Inventory (59 to 73) increased.

These findings suggest less anxiety and a greater inte-
gration in attending to both physical and emotional concerns.
The loss and sexuality workshops emphasizing medical concerns
with psychosocial implications were presented prior to this
interview. These sessions may have facilitated these changes.
Additional interview experience during the preceeding three
lab sessions and/or the additional sessions providing physio-
logical feedback may also have been instrumental to this

growth.

128

Margaret's frequencies of exploratory (1.0 to .5),
listening (3.0 to 2.0) and affective (4.5 to 1.0) responses
decreased on the fifth interview. However, the interviewee
remarked that Margaret was ”informal, relaxed and communi-
cated her ideas with warmth and understanding.” When the
interviewee requested advice for lifestyle improvements con-
sistent with the holistic model of health, Margaret stated
"Luckily, I knew enough about it to talk about it." This
last comment might be further evidence of an attitude change
incorporating both physical and emotional aspects of health.
These observations also suggest that the skill decreases may
have been due to a more educational focus following the

patient education workshop.

Mark (Low Social)

Mark was a 33-year-old, married student in Track I. He
held a B.S.E. in science engineering, M.A. in experimental
psychology, and M.S. and Ph.D. in biomedical engineering.
His previous helping experiences included teaching amputees
to ski and serving as a Scoutmaster. Mark reported interests
in electronics, computers and reading. He chose a medical
career based upon his desires to help others, solve problems
and guide children.

Mark reported that he found the loss and sexuality work-
shops to be valuable because they presented models indicating
stages of grieving and sexual dysfunction. He indicated that
these models allowed him to make a diagnosis and develop a

treatment plan for the appropriate stage. Mark also stated

129

that he valued the elements of communication because they
represented "the proper ways of interviewing." Mark expressed
dissatisfaction with the inquirer role because it "just leaves
a person hanging."’ He indicated that he preferred to be
"more active and helpful." These self-reports suggest that
Mark preferred structured learning formats which taught prac-
tical and concrete skills. As with Margaret this preference
for structure may be due to difficulties tolerating ambiguity
or an attempt to reduce performance anxiety.

Immediately following his second interview with a psy-
chologist, Mark stated that he had used the elements of com-
munication frequently, but requested immediate feedback on
his interview functioning. This self-observation was discon-
firmed by the interviewee who stated that "this interviewer
often missed what I was saying." She added "we never got
below the surface. I wasn't getting a chance to get across
what my feelings were." The opportunities for affective ex-
pression may have been limited due to Mark's reported inter-
est in collecting facts first "to geta sense of what's going
on." The results of this interview indicate decreased fre-
quencies of exploratory (2.5 to 1.0) and listening (3.0 to
.5) responses (Figure 4.8, p. 130). Mark maintained low
scores on affective responses ((1 to 0) and on the Relation-
ship Inventory (44 to 54).

These findings suggest that Mark was unable to apply
interview skills immediately following training. His request

for feedback suggests anxiety related to his competence in

130

FIGURE 4.8

Graphs of Changes in Interview Skills
During Training for Mark

 

10- "EKPloratory
3 9— 05mm
3 8" . . A-Affective
5%”
8 6
32%:
E“

53
II”
‘ 1

 

 

 

TenOmeeaItiveVbeksofIPRminiI-Ig

WVerbalmieeScale (CV16) RatingsofFiveIntervim
with Psycinlogist Patients wringthecmrae of Raining

H
8
1

 

Scoremtl'neRIasRatedbyInt-erviewee

 

I I I I I I I I I I

0 l 2 3 4 5 6 7 8 9 10
Ten Ccnsermtive Weeks of IPR Training

mlaticnship Inventory (RI) Ratings of Five Interviews
with Psyclnlogist Patients airing the Course of Training

131

interviewing. His emphasis upon data collection apparently
prevented encouragement of affective expression or effective
listening to material the patient desired to discuss. Mark
may have emphasized data collection to avoid close emotional
contact.

The third interview reflected increases in exploratory
(1.0 to 5.5), listening (.5 to 1.0) and affective (0 to 2.5)
responses. The already low Relationship Inventory score
(54 to 29) decreased even further. While discussing his in-
terview style at this time, Mark indicated that he "prefers
to fire questions and make you think." However, following
this interview Mark expressed frustration by stating "I
couldn't get her to listen to logic." The interviewees only
written comments were "pissed me off."

These interview ratings suggest that inquirer training
may have influenced Mark to use more exploratory leads and
begin to respond to affect. However, his rational approach
to feelings appeared to alienate his patient. Another poten-
tial cause of this alienation may have been Mark's active
and challenging interviewing style.

During his debriefing session, Mark reflected that the
lab session on loss using mutual recalls was the turning
point in his training experience. After this lab, Mark re-
ported that the interviewing skills felt more natural. The
ratings of his fourth and fifth interviews confirm these
self-perceptions. These interviews indicate increases in

listening (1.0 to 5.5) and affective (2.5 to 5.0) responses

132

as well as on the Relationship Inventory (29 to 74) ratings.
In addition, the pre-post ratings of interviews with actor
patients revealed increases in listening (9.75 to 12.00) and
affective (1.5 to 4.5) responses. The only decrease during
these last two interviews occurred on listening responses
(5.5 to .5) during the fifth interview. The interviewee com-
mented after this interview that Mark "made several useful
suggestions and provided me with technical information that
I found useful." Considering Mark's interview style, he may
have assumed an active educational role requiring less need
for listening skills after the patient education workshop.
These results on the later interviews seem to indicate
significant gains in Mark's effective use of interviewing
skills. The lab session dealing with loss appeared instru-
mental to this process. The mutual recalls may have provided
an opportunity for Mark to reality test his perceptions of
the inner experience of fellow students. The identification
of misinterpretations may have led Mark to become more facil-
itative and less presumptuous in his approach. This session
on loss likely included considerable affective sharing with-
in a supportive environment. This experience may have en-
couraged an increase in Mark's affective sensitivity. This
hypothesis was not supported by Mark's pre-post decrease
(34 to 29) on the Affective Sensitivity Scale (Table 4.1,
p. 92). However, Mark had a final exam on the day of the
post-test. In addition, he expressed resentment for receiv-

ing three days notice of the post-test administration. Thus,

133
these factors may have deflated his post-test score.

Brian (Low Social)

Brian was a 27-year-old, married student in Track II.
Having received a B.S. in medicine, Brian worked as a
physician's assistant in a prison. He enjoyed stamp col-
lecting and photography as hobbies. Brian's attraction to
medicine was based upon his interests in problem solving,
biology and helping others.

Brian stated that affective stimulation vignettes were
helpful for imagining himself in clinical situations. He
reported using these opportunities to practice identifying
the patient's feeling, becoming more aware of his own feel-
ings towards the patient and then making a response to the
patient. Brian identified the small group discussions of
these vignettes as useful for hearing other students' assess-
ments of the patient's affect. In addition, he indicated
that these discussions helped "to desensitize myself to my
own fears.” These self-reports are consistent with Brian's
pre-post gains (32 to 38) on the Affective Sensitivity
Scale (Table 4.1, p. 92). Thus, these findings suggest that
Brian did learn to more accurately assess feeling states.

Brian reported that the training program could be im-
proved with more detailed explanations of "what to do."

For instance, he indicated that the presentation on sexual
dysfunctions could have included "what areas to explore,
what therapeutic approach to use and when to refer patients."

Brian also expressed a desire for more written handouts for

134

future reference. These observations suggest that Brian
displayed a concrete, practical approach towards learning.
These observations may also indicate concerns with his com-
petence in patient care. More specific skills and informa-
tion may have been desired to reassure himself of his
competence.

Following intensive skill training, Brian demonstrated
skill increases in exploratory (1.0 to 5.0) and affective
(.5 to 7.5) responses in his second interview with a psycho-
logist (Figure 4.9, p. 135). However, his frequency of
listening responses (6.0 to 3.0) and his Relationship Inven-
tory score (86 to 76) from the interviewee decreased. The
interviewee commented that Brian "seemed uncomfortable with
the role . . . I felt he was mechanical at times." Brian
also reported after this interview that "I felt like I was
role-playing."

These results reflect significant skill gains. However,
these new skills do not appear well-integrated with Brian's
personal style of responding. In fact, his natural atten-
tiveness as indicated by his high pre-test level of listen-
ing responses seemed to be impaired. Brian may have felt
pressure to assume an idealized role of a physician, rather
than to simply improve upon his own personal style of inter-
acting. Strong role expectations have often been identified
as part of the socialization process in medical schools
(Becker, 1961; Coombs, 1978). This tendency to role-play

may also be due to anxieties related to competence.

135
FIGURE 4 . 9

Graphs of Changes in Interview Skills
During Training for Brian

O-Dcploratm-y

 

 

 

10-
8 9- O-Iistening
3 8- . A-Affective
E 7"
8 6
3.33»
E‘_ A
6
II“-
I‘E’z' ‘
a 1H

0 1 2 3 ’4. s 6 7 a 9 1o
ImmuvemeksofIPRTramm

annular Verbal Expense Scale (CVRS) Ratings of Five Interviews
with Psyclnlogist Patients wring the Course of Training

100—

SooremtheRIasmtedbyInterviaIee
~l
O
I.

 

l J I I I I J I I I

O 1 2 3 4 5 6 7 8 9 10
Ten Consecutive Weeks of IPR Training

mlatimship Inventory (RI) ratings of Five Interviews
with Psychologist Patients airing the Course of Training

136

Unfortunately, Brian's reactions to these performance expec-
tations seem to discount his natural competencies for inter-
viewing.

Brian's remaining interviews indicated progressive de-
creases in his Relationship Inventory (76 to 64) scores.
Skill decreases also occurred for exploratory (4.5 to 3.0),
listening (3.0 to 1.5) and affective (7.5 to 1.0) responses
although listening responses did increase again on the fifth
interview (1.5 to 6.0). Brian's pre-post scores for inter-
views with actor patients also indicated decreases in listen-
ing responses (12.0 to 6.0) and on the Relationship Inventory
(73 to 60) (Table 4.2, p. 98). These decreases may be re-
lated to Brian's reports of problems with his lab experience.
An administrative error caused him to change groups after
two weeks of training. He described his fellow students as
unmotivated "to take the training seriously." He also
questioned the commitment of his lab instructor who "usually
came late and left early."

These findings confirm that Brian's early skill gains
were not well integrated with his personal style. His in-
creased use of listening responses and decreases on all other
scales during the fifth interview resembles Brian's pre-
training level of interview skills. Thus, Brian may have
attempted to return to his pre-training style of interaction.
This attempt suggests frustration and disillusionment with
his training experience. Brian's comments about his lab

group could have been projections of his own lack of

137

investment in the training. However, Brian's positive feed-
back on the initial training workshops and gains in affective
sensitivity contraindicate this explanation. Thus, Brian's
placement in a less effective lab group apparently inhibited
his development of interviewing skill. A well-functioning
lab group may have offered a supportive environment for Brian
to explore his competence issues and develop an identity as

a physician consistent with his personal attributes.

Susan (Low Social)

Susan was a 26-year-old, married student in Track II.
She held B.A. degrees in Spanish and Chemistry and enjoyed
photography, athletics and fashion design as hobbies. Medi-
cine was seen as an opportunity to combine her interests in
the humanities and science in an interpersonal setting.
Susan had worked as a counselor in an adolescent psychiatric
facility and a family planning center. She served as an
interpersonal skills training consultant using the Human
Resource DevelOpment (HRD) model developed by Robert Carkhuff.

Susan reported that the theoretical constructs of IPR
provided useful understandings of human behavior. In addi-
tion, she stated that this theoretical rationale for IPR
training facilitated her acceptance of a different training
model. She stated that she learned through that affect simu-
lations how feelings could become barriers to communication.
She explained that her HRD training attended to only the
facilitative value of affects- Thus, Susan displayed a ten-

dency throughout training to compare IPR with her previous

138

HRD training. Her comments suggest that the IPR model
covered several gaps in her previous training experiences.

Susan's second interview with a psychologist indicated
a decrease in her previously high listening score (5.0 to
4.0), but increases in her previously low levels of explora-
tory (2.0 to 3.0) and affective (2.0 to 5.5) responses
(Figure 4.10, p. 139). Her Relationship Inventory scores
were consistently high (87 to 95) on all interviews with
psychologist patients. The second interviewee commented that
Susan "helped me to look at the source of my stress in a way
that was nonthreatening and showed real concern for my
dilemma."

These findings support an initial high level of inter-
personal functioning perhaps due to her previous training.
Since the HRD model emphasizes responding to the helpee's
remarks, the decrease in listening may signify less emphasis
upon her previous training. This observation is confirmed
with an increase in exploratory responses which are incon-
sistent with the HRD model. Thus, it appears that Susan was
becoming involved in a new approach to interviewing.

This increase in exploratory responses continued through-
out Susan's remaining psychologist patient interviews (2.5 to
5.5). Her pre-post interviews with actors also indicate
gains in exploratory responses (7.5 to 10.5) (Table 4.2, p.
98). Whereas she reported feeling punished in her HRD train-
ing for using questions, Susan stated that she realized

through IPR training the appropriateness of using questions

139

FIGURE 4 . 10

Graphs of Changes in Interview Skills
During Training for Susan

I"
O

bungee»

 

for First Fifteen lbsponses

HMO.»

Average Requencies on onus Scales

 

I I I I I I I I I I

0 1 2 3 4 5 6 7 8 9 1o
mmdvevbeksofIPRTrairdng

annular Vertel lieponse Scale (cvm) Ratings of Five Interviews
withPsycI'plogistPatimtsmringtheCoirseofW

3.:
8
I

ScoremtheRIasmtsdbyLnterviewee

 

I I I I I I I I I I

0 1 2 3 4 5 6 7 8 9 10
Ten Consecutive Weeks of IPR Training

lblat'ionship Inventory (RI) Ratings of Five Interviews

with Psycl'nlogist Patients During the Course of Taking

140

in certain situations. She cited patients presenting little
affect as an example.

The third and fourth interviews also demonstrated in-
creases in her listening responses (4.0 to 8.0). The third
interviewee simply commented "excellent." The fourth inter-
viewee stated that Susan was "very responsive to my concern
and was able to uncover the residual angry feelings I had
about my concern."

These results reflect further modifications in Susan's
interviewing style. Inquirer training appeared to provide
the rationale and skills for using an exploratory questioning
mode. These changes may also have been due to Susan conform-
ing to the interviewing philosophy purported by her peers and
the general medical school environment. The reappearance of
a frequent listening response suggests that Susan was also
employment more of her previous HRD training. Thus, it
appears that Susan was integrating both her previous and
current training experiences. The interview comments and
RI and EU ratings suggest that this integration was achieved
without a disruptive impact upon her interviewing effective-
ness.

The fifth interview indicated decreases in listening
responses (8.0 to 4.5) and affective responses (4.0 to 3.0).
However, these skill levels were still high compared to other
subjects. Susan also reported at this time that the loss

workshop had had a significant personal impact for her. She

141

tearfully discussed her husband's recent leaving for a pro-
longed work assignment on the West coast.

The findings appear to be due to Susan's recent loss of
a significant other. Her grief likely inhibited her ability
to emotionally respond to patients. The patient education
session may also have encouraged a more educational approach.
This approach would still require exploratory responses, but
necessitate less listening, affective and empathic responses

than more a facilitative approach.

Group,Comparisons

High Social vs. Low Social

The high and low social groups reported different reac-
tions related to the components of the IPR method. The high
social subjects4 tended to cite the lab groups, recall ses-
sions and inquirer training as the most impactful training
components. Mary, Fred, Claire and Carolyn reported that
lab groups offered personal contact, emotional support and
a diversity of perspectives. Fred and Carolyn expressed that
seeing their fears and anxieties being shared by other group
members was relieving. Mutual recall sessions were cited
by Carolyn for providing a greater understanding of other's
affective experience. In addition, George and Fred shared
that recall sessions helped them identify perSonal dynamics

which inhibited their interview functioning. George and

 

4These students included George, Mary, Fred, Claire and
Carolyn.

142

Carolyn stated that the inquirer role was useful in their
efforts to maintain the focus of the interview upon the
patients' concern.

This feedback suggests that high social subjects pre-
ferred training experiences which involved social interaction.
These experiences appeared to be used to achieve a better
understanding of themselves and others. These findings are
consistent with this group's high level of social values.

During interviews with psychologist patients, Mary,
Claire and George often shared personal identifications with
the presenting concern in their interviewees. These identi-
fications correlated with advice giving, avoidance of the
patient's feelings and reduced interview skill ratings. Thus,
the expression of these identifications appear dysfunctional
to interviewing effectiveness.

These observations suggest that high social subjects
view frequent personal disclosures as a means to develop
rapport with a patient. These students may have difficulty
differentiating between social and professional roles. The
need to share one's own experience may also result from "con-
ceived purposes” for being a physician whereby personal need
gratification becomes a professional goal.

The most impactful training components for low social
subjects5 were affective simulation exercises, recall ses-

sions and theoretical models. Alan, Brian and Susan reported

 

5These students included Alan, Margaret, Mark, Brian
and Susan.

143

that affective stimulus vignettes helped them to achieve an
awareness and desensitization to feelings which blocked their
communication with patients. Alan stated that recall sessions
demonstrated his failure to attend to patient's affects.

Mark added that mutual recalls provided opportunities for
him to check out his assumptions of what the patient was ex-
periencing. Brian, Mark and Margaret indicated that the
models of grieving and sexual dysfunction facilitated their
understanding of "what to do" to diagnose and recommend
treatments for these concerns. Margaret also reported that
these models helped her to understand the psychosocial impli-
cations of physical illness. Brian, Mark and Margaret also
expressed a need for more practical explanations of all
training material.

These findings suggest that affective awareness and a
greater understanding of the psychological nature of patients
were training needs for low social subjects. Having a low
level of social values, these subjects may have experienced
less emotional depth in their past interpersonal relation-
ships. This fact would account for less self-awareness and
less understanding of other persons. The intolerance for
the ambiguity inherent in human interaction may also have
contributed to this lack of understanding. The preference
for models and pragmatic explanations may have been an attempt
to clarify and master this ambiguity.

During the pre-post actor patient interviews conducted

by all 106 students, low social students demonstrated

144

increased exploratory (6.90 to 8.55), affective (3.30 to
4.95) and empathic (2.20 to 3.40) responses compared to the
decreased exploratory (8.50 to 8.00), affective (4.25 to
3.50) and empathic (2.83 to 2.67) responses of high social
subjects (Table 4.3, p. 145). However, the high social sub-
jects made gains on the Relationship Inventory (58.8 to

66.4) and Affective Sensitivity Scale (29.2 to 30.6) (Table
4.1, p. 92). The mean scores for low social subjects on the
Affective Sensitivity Scale (32.8 to 32.0) decreased, while
their Relationship Inventory (68.4 to 69.4) mean score re-
mained virtually unchanged. The levels of listening responses
of high (9.00 to 10.00) and low (9.60 to 9.30) social subjects
also showed little change.

These results indicate gains for low social subjects in
specific skill areas. These skill gains reflect the appar-
ent pragmatic orientation of low social subjects. Further
training and/or clinical applications of the present gains
may be necessary to achieve more internalized gains in affec-
tive sensitivity and relationship functions. Gains in affec-
tive sensitivity and higher empathy ratings from interviewees
(RI) may result from the high social subjects' attention to
interpersonal training experiences. Greater involvement with
interpersonal processes may have increased their awareness
of others feelings and development of effective responses to
these feelings. Another possible explanation is that the
low social subjects felt more anxious interviewing a highly

sensitive concern (sex) due to less interpersonal experience.

145

TABLE 4.3

Pre- and Post-test Mean Scores Prorated for
Fifteen Responses for Interviews with Actor
Patients by Comparison Groups

 

 

(NEE-Eumxmnqt GmS-Idmnggi (NEE-Afiexha

 

GmgumnnGnmp m2 pan pa pan an. out
$xflu\mhes
High (n-3) 8.50 3.00 9.00 10.00 4.25 3.50
low (II-'5) 5.90 8.55 9.60 9.30 3.30 4.95

omnmnmuuum

1 (n94) 7.50 7.00 8.75 10.00 3.00 4.50
11 (n-4) 7.50 9.15 9.75 9.30 4.05 4.35
Humemkskalnmman
participants (n93) 7.25 8.25 6.25 7.50 5.00 5.25
Nonparticipants (n=5) 7.65 8.40 11.25 10.80 4.65 3.90
All Subjects (n-B) 7.50 8.34 9.37 9.56 3.66 4.41

mm Regulation (11- 99) 7.56 7.56 10.00 9.60 3.59 3.60

 

146

TABLE 4.3 (Continued)

Pre- and Post-test Mean Scores Prorated for
Fifteen Responses for Interviews with Actor
Patients by Comparison Groups

 

 

Ehpathic understanding

 

 

 

Scalea Relationship Inventory
Cbnperison Group pre post pre post
Social values
High (2.0., n=3) 2.83 2.67 58.80 66.40
(R.I., n85)
Low (H's) 2.20 3.40 68.40 69.40
Curriculum Track
I (8.0., u-4) 2.50 3.00 60.75 70.75
(Role 1 “-5)
II (8.0., n-4) 2.40 3.20 65.50 66.00
(R010, “.5) '
IPR Physiological Program
Participants (n-3) 1.83 3.00 51.00 71.00
Nonparticipants (EU, u-5)2.80 3.20 69.00 64.90
(RI, "-7)
All Subjects (8.0.. n=8) 2.44 3.12 63.60 67.90
(R.I., nFIOI
Tatal Population (3.0.. n-99 I 2.68 3.16 67.46 67.72

(R.I., n-103)

 

"Theaa ratings were:made by'raters hired and trained by’a Ph.D. psychologist fnun
the medical school. The inter-rater reliability for

E
I
I
I
E

147

These subjects may have responded to their anxiety by being
more skill-oriented.

Tables 3.2 (p. 70) and 3.3 (p. 71) indicate that "low
social" students in this population exhibited a level of
social values comparable to the average American medical
student. Thus, the findings in this study for "low social"
students may actually be applicable to "average social" stu-

dents in other medical schools.

Track I vs. Track II

All four subjects in Track I6 cited film vignettes
modeling effective doctor-patient interaction as valuable
training experiences. Margaret reported these vignettes in-
creased her awareness of the emotional concerns of patients
and helped her to visualize an integration of the emotional
and physical aspects of patient care. Although she initially
valued the psychosocial aspects of medical care, Margaret
stated that these films enabled her to perceive applications
of IPR skills in medical settings. Carolyn reported less
anxiety and demonstrated more effective interview skills
after viewing model physicians consistent with her nondirec-
tive style. Compared to these role models, Mark said that
he realized his own attempts to intellectualize the patients'

concern and control the interview process.

 

6
Mark.

These students included Claire, Carolyn, Margaret and

148

Ratings of psychologist patient interviews for these
subjects (Figures 4.4, p. 109; 4.5, p. 115; 4.7, p. 125; 4.8,
p. 130) indicate that significant gains in interview skills
did not occur until the third and fourth interviews. Since
these interviews followed inquirer training which used several
models of effective doctor-patient interactions, these results
support the subjects' self-reports. These ratings also indi-
cate these students were able to apply exploratory and listen-
ing responses considerably sooner than affective responses.
Finally, these results demonstrate that the full ten weeks
of training were necessary to master most of the skills.

These findings suggest students choosing a cognitively-
based lecture style curriculum need to make an adjustment to
incorporate affective elements into their learning style.
Zabarenko and Zabarenko's (1978) developmental task of
“balancing objectivity and empathy” may be particularly re-
levant during training for students choosing these curriculun.
Initially, the IPR model may appear irrelevant to these
students' conception of physician functioning. The interview
skills presented may also threaten the students' established
interpersonal style. However, role models appear particular-
ly effective for transmitting the relevance of IPR training
and facilitating an integration of the training concepts
with one's own personal style.

In spite of extremely high pre-test scores, Track I
subjects exhibited pre-post gains (34.5 to 35.8) on the

Doctor-Patient Relations subscale of the Attitudes towards

149

Social Issues in Medicine Scale (Table 4.1, p. 92). The pre-
post scores of Track 11 students decreased (36.6 to 35.6).
This data confirms that Track I subjects did modify their
image of physicianhood by placing greater emphasis upon their
relationships with patients.

The course feedback from Track II7 students reflected
considerable emphasis upon their own personal growth. Alan,
Brian and Susan, in particular, described affect simulations
as Opportunities to learn about their own emotional reactions
to particular types of patients. George, Mary, Fred and Alan
cited their use of recall sessions to explore the meaning of
these reactions within the supportive environment of a lab
group.

Thus, Track II students integrated their interview skill
development with their own personal development. Several
examples can be cited from the case studies of these sub-
jects. For instance, George curtailed his urge to problems
solve to become a more effective listener. Mary was able to
attribute her dominance in interviews to her own needs to
feel helpful and be accepted by others. After realizing the
extent of his self-criticism, Fred's developing self-
acceptance allowed him to be more empathic with patients.

The ratings of psychologist patient interviews for these
students (Figures 4.1, p. 95; 4.2, p. 101; 4.6, p. 120; 4.9,

p. 135; 4.10, p. 139) often indicated increases in the

 

7These students included George, Mary, Fred, Alan, Brian
and Susan.

150

elements of communication during the second interview. How-
ever, the Relationship Inventory scores often decreased.
Apparently, Track II students perceived the relevance of the
training immediately and were able to make applications of
their extensive skill training. However, reports of inter-
viewer anxiety, particularly for Fred, Alan and Brian, appar-
ently led to low RI ratings. This anxiety was typically
related to the personal issues explored through affective
simulations and recall sessions.

Although these results indicate generally increasing
gains through the fourth interview, significant declines in
skill usage and mixed results on the Relationship Inventory
are revealed on the fifth interview. These results might in-
dicate that the students completed their training goals prior
to the tenth week of training. Confidence in their interview
skills may have reduced their motivation in the fifth inter-
view. The patient education workshop which preceeded this
interview may also have elicited greater attention to patient
education skills.

Track II subjects scored higher gains in exploratory
responses (7.50 to 9.15) for pre-post interviews with actor
patients than Track I subjects (7.50 to 6.70) (Table 4.3,

p. 145). However, the Track I subjects demonstrated higher
gains for listening responses (8.75 to 10.00), affective

responses (3.0 to 4.5) and the Relationship Inventory (60.75
to 70.75) compared to the listening responses(9.75 to 9.30),

affective responses (4.05 to 4.35) and Relationship

151

Inventory (65.5 to 66.0) mean scores of Track II students.

These results indicate that Track I students made greater
gains in interview skill development than Track II students.
The novelty of psychosocial issues and affective learning
may have increased the motivation of Track I students to
achieve greater skill gains. However, the necessary initial
adjustment to effectively learning about psychosocial issues
may have led Track I students to make their gains in inter-
view skills later in training. Thus, their gains reported
on the post-test may simply represent the timing of these
gains. A review of Table 4.2 (p. 98), indicates that signi-
ficant pre-post skill decreases for Fred, Susan and Brian
contributed to the lower gains for Track II students. All
three students were experiencing emotional distress during
the post-test administration (6th week). The loss workshOp
had stimulated grief reactions for Fred and Susan. Brian was
struggling with role expectations without the support of an
effective lab group. The gain in exploratory responses may
be explained by the decreased emotional investment involved
with this response. These findings might also suggest stu-
dents using training experiences to foster personal develop-
ment do not demonstrate immediate gains in interview skills.
Follow-up studies might investigate whether this personal
_growth actually leads to later improvements in interview
effectiveness.

Several conclusions seem appropriate in viewing these

results. Having chosen a curriculum exploring psychosocial

152

issues using an affective learning mode, Track II students
already exhibit an appreciation for these factors of medical
training. The training experience of these students seems
to involve earlier skill gains and greater self-exploration
of personal issues involved in their patient care. Within
the developmental model purported by Zabarenko and Zabarenko
(1978), Track II students were apparently involved in a

greater variety of developmental tasks.

Physiological Feedback vs. No Physiological Feedback

Three subjects8 volunteered for additional experiential
sessions. During these sessions, physiological feedback was
provided while the subject viewed affective stimulus vignettes,
followed by a recall session.

These participating subjects reported that affective
simulation and recall sessions were the most impactful train-
ing components. Alan and Margaret reported that affect
simulation heightened both their cognitive awareness of psy-
chosocial concerns in medicine and their affective awareness
of their own emotional reactions to particular types of
patients. In addition to increasing affective awareness,
George and Alan stated that recall sessions helped them to
appreciate individual differences in emotional responding.
Furthermore, Alan and George were the only subjects in the

study to request additional practice interviews.

 

8These students included George, Margaret and Alan.

153

Compared to nonparticipants, the participants in these
additional sessions achieved greater pre-post gains on every
measure for interviews of actor patients (Table 4.3, p. 145).
The participant's ratings for exploratory (7.25 to 8.25),
listening (6.25 to 7.50), affective (5.00 to 5.25) and empa-
thic (1.83 to 3.00) responses and on the Relationship Inven-
tory (51.0 to 71.0) increased. The nonparticipants' ratings
of listening (11.25 to 10.80) and affective (4.65 to 3.90)
and on the Relationship Inventory (69.0 to 64.9) decreased.
Their ratings of exploratory (7.65 to 8.40) and empathic (2.8
to 3.2) responses increased, but not as much as the increases
for participants.

These results indicate that additional exposure to affect
simulation and recall, combined with physiological feedback,
enhanced the development of interview skills. These findings
may have partially been the effect of the high motivation of
volunteers. However, the near perfect attendance of non-
participants at training and research sessions suggests that
they were also highly motivated. These results were likely
the effect of physiological feedback providing additional
evidence of emotional responding. To reduce the cognitive
dissonance created by this evidence, the student may have
used recall to learn a meaning of these responses consistent
with their self-perceptions. Of course, this data could also
be the result of additional affect simulation and recall
sessions regardless of physiological feedback. Finally, the

requests for additional practice suggest that continued

154

experiences with IPR reveal its usefulness as a supervisory

technique beyond the realm of initial interview training.

Summary and Discussion

 

The subjects in this study displayed an initial high re-
gard for the doctor-patient relationship as evidenced by their
high scores on the Doctor-Patient Relations subscale of the
Attitudes towards Social Issues in Medicine Scale. A ceiling
effect and the stability of this trait were cited as possible
causes for a lack of pre-post change on this measure. These
high scores may have resulted from the selection process of
the School of Medicine which emphasizes psychosocial medical
training. Since the subjects knew that this study involved
medical interviewing, these scores may also represent social
desirability. Track I students, particularly Margaret and
Carolyn, perceived restricted applications of the training
initially. However, film models of medical interaction in
affect simulation and inquirer training broadened these views,
making the training appear more relevant to their training
needs.

The subjects also displayed high pre-test and little
pre-post change on the Affective Sensitivity Scale. In addi-
tion to the possibilities of a ceiling effect and trait
stability, post-test administration problems were hypothe-
sized to have accounted for this lack of gains.

Whereas previous research had relied only upon pre- and

post-test measures of interview skills, this study described

155

learning curves of the entire training process. These curves
often showed mid-training gains which were not maintained in
post-test results. The individual case studies revealed

that conscious experimentation with skills often occurred
during mid-training. Success with that experimentation usu-
ally led to an integration of these skills with the student's
personal style, often resulting in less actual skill use in
the final interview. These decreases in the final interview
may also be attributed to the patient education session which
influenced several subjects to practice a more educational
than facilitative role. The Counselor Verbal Response Scale
ratings appeared to vary with the subject's practice of the
elements of communication. However, the Relationship Inven-
tory ratings appeared to reflect more stable indications of
effective doctor-patient relationships.

This study provided substantial evidence that the devel-
opment of interviewing skills interrelated with medical
student development in general. In order to become emotion-
ally involved in their interviews, most students choosing a
more traditional, lecture-based curriculum needed to relin-
quish their tendency to mask their affect as they had ”trained
for uncertainty” in Fox's (1957) terms. For instance, Mark
was able to modify his role as a detached observer who intel-
lectualized the patient's presenting concern. Students
choosing a less traditional, issue-oriented curriculum.focused
upon individual issues of personal development. For example,

Mary discovered "conceived purposes" for being a physician

156

which led her to uncover her own hidden agendas in interviews
(Knight, 1973). All subjects appeared to manifest some of
the developmental tasks presented by Zabarenko and Zabarenko
(1978), including balancing objectivity and empathy, managing
nurturance and executive necessities, and controlling needs
for omnipotence.

The lab group experience proved to be an Opportunity to
resolve developmental issues while actually engaged in doctorb
patient interactions. These groups were cited for their
emotional support, confrontation, diversity of ideas, and
demonstration of the universality Of fears and anxieties
related to interviewing. As an example of the value of these
groups, Fred and Brian both exhibited considerable performance
anxiety related to role expectations for being a competent
physician. A "rich” lab experience facilitated Fred's over-
coming this anxiety to deve10p effective interviewing skills,
while a "poor" lab experience significantly curtailed
Brian's progress.

Several group differences were indicated in this study.
High social students preferred the interpersonal experience
of lab groups and recall sessions. These students often mani—
fested a tendency to overidentify with patients which was
moderated by inquirer training. Low social students found
affect simulation and recalls helpful in gaining an appreci-
ation for the relevance and complexity of human interaction
in medical care. Students choosing a more traditional curri-

culum (Track I) required an adjustment to affective learning

157

which was facilitated by filmed role models in doctor-patient

interactions. These students made the greatest skill gains

later in training. Students choosing an issue-oriented cur-

riculum involving small group learning made fairly rapid I

gains in skill development. These students focused upon

personal growth during their training.

Implications for Training

 

The results of the pilot study suggested greater overall
dissatisfaction with the IPR course among 1979 first-year
students compared to the current study of 1980 first-year
students. During 1979, the IPR film series was presented
and discussed in weekly two-hour class meetings instead
of the workshop sessions used in the present study. Thus,
it is recommended that the workshoP format be maintained
as a delivery system of IPR to medical students. The
intensive skill training provides the necessary stimuli
to initiate interview skill development. The weekly lab
experience provides supportive environments for students
to resolve developmental issues at their own pace.

This study indicated that students choosing a more tradi-
tional curriculum required the entire ten weeks of train-
ing to achieve significant gains in interviewing skills.
However, students choosing a curriculum which focused
upon medical toPics in small groups made more rapid.gains.
Thus, short-term training designs may be more appropri-

ate for trainees with previous experience in affective

learning and small groups.

158

Gains in skill develOpment for students choosing the
traditional curriculum were accelerated by viewing vig-
nettes of patients with emotional concerns and models of
effective doctor-patient interactions. Thus, training
designs for trainees experienced primarily with theore-
tical instruction should make maximal use of audio-visual
models demonstrating approPriate situations and applica-
tions related to medical interviewing.

The results of this study indicated that students volun-
teering for additional lab sessions made greater gains

in their development of interviewing skills. Thus, it

is recommended that future IPR trainees be offered addi-
tional Optional lab experiences. These lab sessions
might include additional practice interviews and/or addi4
tional affect simulation with physiological feedback,

followed by recall.

 

Implications for Research

Counselor Verbal Response Scale (CVRS) ratings fluctuated
considerably in this study with the practice of the ele-
ments of communication. Since trainees integrate the
elements of communication with their personal style during
the course of training, the CVRS must be used with cau-
tion as a pre-post outcome measure. More accurate CVRS
results might be attained using mid-training assessments
when these skills are actually being practiced. Since

Relationship Inventory ratings proved to be more stable

159

indicators of overall interviewing effectiveness, this
measure is recommended for pre-post assessments. Future
research should continue to use multiple outcome measures.
The presentation of a patient education workshop appeared
to confound the final psychologist patient interview re-
sults in this study. To attain more accurate pre-pOst
assessments, future research should complete post-test
interviews prior to the patient education session.
Follow-up studies of IPR training would serve several pur-
poses. First, affective sensitivity and attitudes towards
the doctor-patient relationship remained relatively un-
changed in this study. Follow-up studies could explore
whether these traits change as students apply their trahr-
ing in clinical settings. These studies would also re-
veal the extent to which personal growth during training
actually leads to increased interview effectiveness in
the future. Finally, these studies could assess whether
continued applications of the training in clinical set-
tings leads to increased interviewing effectiveness.
Several subjects demonstrated differential effectiveness
when interviewing psychologist patients compared to actor
patients and visa versa. Further research is needed to
assess the comparative training value of actual patients
and simulated patient models.

This study made several tentative conclusions regarding
the training needs and skill development of high versus

low social students, students choosing more traditional

160

versus less traditional curricula, and participants
versus nonparticipants of experiential sessions provid-
ing physiological feedback. Before extensive training
modifications are developed, studies using larger sample
sizes with group comparison designs should be conducted
to confirm these conclusions.

The decline in the use of interpersonal skills for some
students might suggest that these students exceed an
appropriate level of emotional responding during train-
ing. High levels of affective responsiveness may actually
be dysfunctional in medical interviews. Future research
might attempt to identify an Optimal level of emotional
responding in medical interviews after which increased
training produces diminishing returns.

The use of two separate rating.procedures in this study
confounded comparisons between psychologist patient and
actor patient interviews. In the future, it is recomr

mended that a single rating procedure be employed.

BIBLIOGRAPHY

- BIBLIOGRAPHY _

Adler, L. M., & Enelow, A. J. Instrument to measure skill in
diagnostic interviewing: A teaching and evaluation
tool. JOurnal of Medical Education, 1966, 41, 281-288.

Adler, L. M., Ware, J. E., & Enelow, A. J. Changes in medical
interviewing style after instruction with two closed-
circuit television techniques. Journal of Medical
Education, 1970, 45, 21-28.

 

Allport, G. W., Vernon, P. E., & Lindzey, G. Study of values
(3rd. ed.). Boston: Houghton Mifflin, 1960.

 

Anton, J. L. Intensive experimental designs: A model for the

counselor/researcher. Personnel and Guidance Journal
1978, 56, 273-278.

 

Archer, J., Jr. Undergraduates aspparaprofessional leaders of
interpersonal training groups using an integratedfilPR
TInterpersonal Process Recall) videotape feedback/affect
simulation training model. Unpublishedfdoctoraldisser-
tation, Michigan State University, 1971.

Bachrack, M., Mintz, J., 8 Luborsky, L. On rating empathy and
other psychological variables: An experience with the
effects of training. Journal of Counseling and Clinical
Psyphology, 1971, 36, 445.

 

Bales, R. F. Interaction process analysis. Cambridge, Mass.:
Addison-Wesley Press, 1950.

Barbatsis, G. S., & Wong, M. R. Production feedback question-
naire. International Journal of Instructional Media,

Barrett-Lennard, G. T. Dimensions of therapist response as
causal factors in therapeutic change. Psychological
Monographs, 1962, 16, 1-36.

Becker, H. 8. Boys in White. Chicago: University of Chicago
Press, 1961.

Becker, H. S., 8 Geer, B. The fate of idealism in medical
school. American Sociological Review, 1958, 23, 50-56.

 

Bedell, W. P. A comparison of two approaches to peer supervision
in the training of communication skills using a videotape
recall model. Unpublished doctoral dissertation, Michigan

State University, 1971.
161

162

Benedek, E. P., & Bieniek, C. M. Interpersonal process recall:
An innovative technique. Journal of Medical Education,
1977, 52, 939-941.

 

Beutler, L. E., Johnson, D. T., Neville, Jr., C. W., & WOrkman,
S. N. "Accurate empathy" and the A-B dichotomy. Jour-
gal of Consulting and Clinical PsychQIOgy,_1972, 38, 372-
375.

Bernstein, L., Headlee, R., & Jackson, B. Changes in "Accep-
tance of Others" resulting from a course in the physi-
cian-patient relationship. British Journal of Medical
Education, 1970, 4, 65-66.

 

Bill, R. E., Vance, E. L., & McLean, O. S. An index of adjust-
ment and values. JOurnal of Consulting Psychology, 1951,
12, 257-261.

Bracht, G. H. Experimental factors related to aptitude-treat-
ment interactions. Review of Educational Research,
1970, 49, 627-645.

 

Bruhn, J. G., & Parsons, O. A. Medical student attitudes
toward four medical specialties. Journal of Medical
Education, 1964, 39, 40-49.

 

 

 

Carkhuff, R. R. Helping and human relationships (Vol. I and II).
New York: Ho t, Rinehart and Winston, 1969.

Carkhuff, R. R., Kratochvil, D., & Friel, T. Effects of pro-
fessional training: Communication and discrimination
of facilitative conditions. Journal of Counseling
Psychology, 1968, 15, 68-74.

 

Carpenter, C. R. A theoretical orientation for instructional
film research. Audiovisual Communication Review, 1953,
1, 38-52.

Charney, E., Bynum, R., Eldredge, D., Frank, D., MacWhinney,
J. B., McNabb, N., Scheiner, A., Sumpter, E. A., &
Iker, H. How well do patients take oral penicillin?:
Collaborative study in private practice. Pediatrics,
1967, 49, 188-195.

 

Cline, D. W., & Garrard, J. N. A medical interviewing course:
Objectives, techniques and assessment. American Journal
of Psychiatry, 1973, 130, 574-578.

 

 

Clyne, M. B. The doctor-patient relationship as a diagnostic
tool. Psychiatry in Medicine, 1972, 3, 343-355.

 

Coe, R. M., Pepper, M., & Mattis, M. The 'new' medical stu-
dent: Another view. Journal of Medical Education,
1977' -5_2' 89-98.

163

Coher, A. M., Trent, J., T., & Rose, C. Evaluation of teach-
ing. In R. M. Travers (Ed.), Second handbook of re-
search on teachiyg.. Chicago: Rand McNally, 1973.

 

 

Coombs, R. H. Mastering socialization in medical school. New
York: The Free Press, 1978.

 

Danish, S. J., & Brodsky, S. L. Training of policemen in
emotional control and awareness. American Psycholo-
‘gist, 1970, 33, 368-369.

Davis, M. S. Attitudinal and behavioral aspects of the doctor-
patient relationship as expressed and exhibited by
medical students and their mentors. Journal of Medical
Education, 1968, 33, 337-343.

Davis, M. S. Variations in patients' compliance with doctors'
advice: An empirical analysis of patterns of communica-
tion. American Journal of Public Health, 1968, 33,
274-288. i

Davis, M. S., & Eichhorn, R. L. Compliance with medical regi-
mens: Panel study. Journal of Health and Human Behav-

deBrabander, B., & Leon, C. A. A comparative study of atti-
tudes among Columbian medical and nonmedical students.
Journal of Medical Education, 1968, 43, 912-915.

Dendy, R. F. A model for the training of undergraduate resi-
dence hall assistants as paraprofessional counselors
using video-tape techniques and interpersonal process
recall (1233. Unpublished doctoral dissertation,
Michigan State University, 1971.

 

Echt, R., & Sui-Wah, C. A new problem-oriented and student-
centered curriculum at Michigan State University.

Journal of Medical Education, 1977, 33, 681-683.

Edling, J. V. A study of the effectiveness of audio-visual
teaching materials when prepared according to the
principals of motivational research. Monmouth, Oregon:
Oregon State System of Higher Education, 1963.

Edwards, A. L. Edward's personal preference schedule. New
York: The Psychological Corporation, 1959.

Enelow, A. J., Adler, L. M., & Wexler, M. Programmed instruc-
tion in interviewing: An experiment in medical educa-
tion.’ Journal of the American Medical Association,
1970, 333, 1843-1846.

Eron, L. D.' The effect of medical education on medical stu-
dents' attitudes. Journal of Medical Eeucation, 1955,
32, 559-565.

164

Evans, L. The crisis ‘in’ medical education. Ann Arbor: The
University of Michigan Press, 1964.

 

Fine, V. K., & Therrien, M. E. Empathy in the doctor-patient
relationship: Skill training for medical students.
‘Journal of Medical Education, 1977,33, 752-757.

Francis, V., Korsch, B. M., & Morris, M. J. Gaps in doctor-v
patient communication. New England Journal of Medicine,
l969,‘280, 535-540.

Franzwa, D. Influence of meaningfulness, picture detail and
presentation mode on visual retention.’ Audiovisual
Communication Review, 1973, 33, 209-223.

 

 

Freeman, 8., Negrete, V. R., Davis, M., & Korsch, B. M. Gaps
in doctor-patient communication: Doctor-patient inter-
action analysis. ‘Pediatric Research, 1971, 3, 298-311

Froelich, R. C. A course in medical interviewing. Journal of
Medical Education, 1969, 31, 1165-1169.

 

Funkenstein, D. H. A prospective study of factors which influ-
enced thecareers o rmedical students and3physicians
from 1958 to 1976. Boston: Robert WOod Johnson Founda-
tion, 1977.

 

Gagne, R. M. Learning theory, educational media, and individu-
alized instruction. In S. G. Tickton (Ed.), To improve
learning: An evaluation of instructional technology
(Vol. 2). New York: R. R. Bowker, 1971.

 

 

Garvin, B. J. Values of male nursing students. Nursinnge-

Gold, R. D. Analysis of a cognitively oriented self-management
weight control program using an intensive case study
withdrawal design. Unpublished doctoral dissertation,
Michigan State University, 1976.

Goldberg, A. P. A sequential program for supervising counselors
using the Interpersonal Process Recall technique. Un-
‘ published doctoral dissertation, Michigan State Univer-
sity, 1967.

Gordan, L. V. SRA manual for surVey of interpersonal Values.
Chicago: Science Research Associaties, 1960.

Gordon, L. V., & Mensh,_I. N.. Values of medical students at
different leVels ofitraining.mflJourna1_of Educational
Psychology, 1962,_33;“48-51.' '

 

165

Goroll, A., Stoecle, J. D., & Lazarre, A. Teaching the clincial
interview: An.experiment with first-year students.
Journal of Medical Education, 1974, 33, 957-962.

Gray, R. M., Moody, P. M., & NeWman, W. R. E. An analysis
of physicians' attitudes of cynicism and humanitari-
anism before and after entering medical practice.
Journal'of Medical Education, 1965, 33, 760-766.

 

Gray, R. M., & Newman, E. The relationship of medical students'
attitudes of cynicism-and humanitarianism to performance
in medical school. JOurnal of Health and Human Behavior,
1962, 3, 147-151.

Grezgorek, A. E. A study of the effects of two trpes of
emphasis in counselor training used in coniunction with
simulation and videotaping. Unpublished doctoral dis-
sertation, Michigan State University, 1971.

 

 

Gough, H. G. Specialty preferences of physicians and medical
students. Journal of Medical Education, 1975, 39, 581-588.

Haley, H. B., Huynh, H., Paiva, R. E., & Juan, I. R. Student's
attituedes toward cancer: Changes in medical school.
Journal of Medical Education, 1977, 33, 500-507.

 

Hammarskjold, D. Markings. New York: Alfred A. KnOpf, 1965.

 

Hastings, G. E. Teaching psychiatry 'in vivo.‘ Journal of
Medical Education, 1968, 33, 741-744.

 

Hayes, D. M., Hutaff, L. W. & Mace, D. R. Preparation of medical
students for patient interviewing. Journal of Medical
Education, 1971, 33, 863-868.

 

Hefele, T., & Hurst, M. W. Interpersonal skill measurement:
Prediction, validity and utility. The Counseling Psychol-

gist, 1972, _3_, 62-69.

Heidt, E. Instructional media and the individual learner. New
York: Nichols Publishing, 1978.

Heiserman, M. S. The effects of experimental-videotape training
procedures compared to cognitive-classroom teaching
methods on the interpersonal communications skills of
juvenile court caseworkers. Unpublished doctoral dis-
sertation, Michigan State University, 1971.

Helder, H., Verbrugh, H. S., & deVries, M. J. Toward a holistic
education in pathology and medicine. Journal of Medical
Education, 1977, 33, 648-653.

 

Hill, W. F. Hill interaction matrix. Los Angeles: University
of Southern California, Youth Studies Center, 1965.

166

Hollifield, G., Rousell, C. T., Bachrach, A. S. & Pattishall,
E. G. A method of evaluating student-patient inter-
views.‘ Journal of‘Medical Education, 1957, 33, 853-
857.

 

Homans, G. C. §§ntiments‘and'activities. New York: Free
Press of Glencoe,’1962-

 

Hutchins, E. B. The AAMC longitudinal study: Implications
for medical education. Journal of Medical Education,

Jarrett, F. J., Weldron, J. J., Bura, P. & Handforth, J. R.
Measuring interviewing skill. The Queen's University
Interviewer Rating Scale (QUIRS). Canadian Psychiatric
Association Journal, 1972, 31, 183-188.

 

 

Jason, H., Kagan, N., Werner, A., Elstein, A., & Thomas, J. B.
New approaches to teaching basic interview skills to
medical students. gmerican Journal of Psychiatry,
1971, 333, 1404-1407.

Jourard, S. The transparent self:_'Se1f-disclosure ang
well being. Princeton, N. J.: Van Nostrand, 1964.

 

Juan, I. R., Paiva, R. E., Haley, H. B., & O'Keefe, R. D.
High and low levels of dogmatism in relation to
personality characteristics of medical students: A
follow-up study. Psychological Reporps, 1974, 31, 303-
315.

Kagan, N. Influencing human interaction - Fifteen years with
IPR. Unpublished manuscript, Michigan State University,
1977.

Kagan, N., & Byers, J. Assignment reports: IPR workshop
conducted for the United Nations World Health Organiza-
tion in New Guinea and Australia. World Health Organi-
zation, Manila, Phillipines, 1973 and 1975.

Kagan, N., & Krathwohl, D. R. Studies in Human Interaction:
Interpersonal Process Recai; Stimulated by Videotape.
ERIC Document Reproduction Service, ED 017 946, 1967.

 

 

Kagan, N., Krathwohl, D. R., & Miller, R. Stimulated recall in
therapy using videotape--A case study. Journal of
Counseling Psychology, 1963, 33, 237-243.

 

 

Kagan, N., & Schauble, P. G. Affect simulation in Interperso-
nal Process Recall. Journal of Counseling Psychology,

167

Kahn, G. S., Cohen, 8., & Jason, H. The teaching of inter-
personal skills in United States medical schools.
’ Journal of Medical Education, l979,j33, 29-35.

Kausch, D. F. Attitudes of medical students and graduate
students toward emotional illness and psychiatric
practice. JOurnal of Medical Education, 1967, 33
207-212.

Kausch, D. F. Medical students' attitudes toward the mental
health field: A longitudinal study. Journal of Medical
Education, 1969, 33, 1051-1055.

 

Keisler, D. J. Experimental designs in psychotherapy research.
In A. E. Bergin and S. L. Garfield (Eds.), Handbook of
Ps chotherapy and Behavior Change. New York: Wiley,
Iggl, 36-74.

Kimball, C. P. Techniques of interviewing: Interviewing and
the meaning of the symptom. Annals of Internal Medicine,
1969, 33, 147-153.

Kimball, C. P. Techniques of interviewing: Setting up an
interviewing course. Psychiatry in Medicine, 1970, 3
167-170.

Knight, J. A. Medical student: 'Doctor in the making. New York:
Appleton-Century-Crofts, 1973.

 

Koos, E. Metropolis: What city people think of their medical
services. American Journal of Public Health, 1955, 33
1551-1557.

Korman, M., Stubblefield, R. L., & Martin, L. W. Patterns of
success in medical school and their correlates. Journal
of Medical Education, 1968, 33, 405-409.

Leserman, J. The professional values and expectations of medi-
cal schools. Journal of Medical Education, 1978, 33, 330-
336.

Loupe, M. J., Meskin, L. H., & Mast, T. A. Changes in values
of dental students and dentist over a ten-year period.
Journal of Dental Education, 1979, 33, 170-175.

Marshall, J. C., & Feeney, S. Structured vs. intuitive intake
interview. Nursing Research, 1972, 33, 269-272.

Meadow, R., & Hewitt, C. Teaching communication skills with
the help of actresses and videotape simulation. British
Journal of Medical Education, 1972, 3, 317-322.

Mensh, I. N. Orientations of social values in medical student
assessment.’ Social Science and Medicine, 1970, 3, 339-
348.

168

Menzel, H., Coleman, J., & Katz, E. Dimensions of being "mod-
ern" in medical practice. JOurnal of Chronic Disease,_
1959' a, 20-40. -

Merton, R. K. some preliminaries to a sociology of medical
education. In R. K. Merton, G. G. Reader, & P. L.
Kendall (Eds.), The student-physician: Introductory
studies in the sociology of‘medical educatiog. Cam-
bridge, Mass.: Harvard University Press, 1957.

Miller, E., & warner, R. W. Single subject research and eval-
uation. Personnel and Guidance Journal, 1975, 33, 130-
133.

Miller, L. B., & Erwin, E. F. A study of attitudes and anxi-
eity in medical students. 'Journal of Medical Education,

1959, 33, 1089-1092.

Novik, B. R. The effects of teaching interviewing skills and,
affective sensitivity to family medicine residents: A
pilot study. Unpublished doctoral dissertation, Michigan
State University, 1978.

 

Pacoe, L., Naar, R., Guyett, I, & Wells, R. Training medical
students in interpersonal skills. Journal of Medical

 

Paiwa, R. E., & Haley, H. B. Intellectual, personality, and
environmental factors in career speciality preferences.
Journal of Medical EducatiOn, 1971, 33, 281-289.

Palmer, J. W. Staff-patient communications in a chest hospital.
British Journal of Preventive and Social Medicine, 1966,

—' - .

Parker, S. P. Personality factors among medical students as
related to their disposition to view the patient as a
”Whole Man." Journal of Medical Education, 1958, 33

Parlow, J., & Rothman, A. ATSIM: A scale to measure attitudes
toward psychsocial factors in health care. Journal of
Medical Education, 1974, 33, 385-387.

Pellegrino, E. P. 'Educating the humanist physician. Journal
of the American Medical Association, 1974, 227, 1288-

1294.

Pellegrino, E. P. Human values and the medical curriculum.
JOurna339f the American Medical Association, 1969, 209,
1349-1353}

Perricone, P. A social concern in medical students: A recon-
struction of the Eron assumption. Journal of Medical
Education, 1974, 33, 541-546.

 

169

Pollack, S., & Manning, P. R. An experience in teaching.the
doctor-patient relationship to first-year medical stu-
dents. Journal of Medical Education, 1967, 4_2, 770-774.

Rasche, L. M., Bernstein, L. & Veenhuis, P. E. Evaluation of
a systematic approach to teaching interviewing. Jour-
nal of Medical Education, 1974, 33, 589-595.

 

Reinhardt, A. M., & Gray, R. M. A social psychological study
of attitude change in physicians. Journal of Medical
Education, 1972, 33, 112-117.

 

 

Reissman, L. & Platov, P. The motivation and socialization
of medical students. Journal of Health and Human Be-
havior, 1960, 3, 174-182.

Rezler, A. G. Attitude changes during medical changes: A re-
view of the literature. Journal of Medical Education,
1974, 33, 1023-1030.

 

Rogers, C. R. The necessary and sufficient conditions of
therapeutic personality change. Journal of Counsult—
ing Psychology, 1957, 33, 95-103.

 

 

Rosenhan, D. L. On being sane in insane places. Science,
1973, 179, 250-258.

Rosinski, E. F. Human values and curriculum design: A view
for the future. Journal of the American Medical Asso-
ciation, 1969, 209, 1346-1348.

Rothman, A. Personal communication, 1979.

Rowe, K. A 50-hour intensified IPR training program for
counselors. Unpublished doctoral diSsertation.
Michigan State University, 1972.

 

Secundy, M. F. & Katz, V. Factors in patient/doctor commu-
nication: A communication skills elective. Journal of
Medical Education, 1975, 33, 689-691.

 

Sharf, K. R. Training of resident assistant and peer mem-
bers in the communication interactional process skills
of empathetic understanding of student feeling and
student depth Of’self-exploration. Unpublished doc-
toral dissertation, Michigan State University, 1971.

Shostrom, E. L. Manual: Personal Orientation Inventory. San
Diego, Educational and Industrial Testing Service,
1966.

Silberman, S. L. Standardization of value profiles of den-
tal students and dental faculty. Journal of Dental
Research, 1976, 33, 939-950.

 

170

Singleton, N. Training incarcerated felons in communication
skills using an integrated IPR (Interpersonal Process
Recall) videotape feedback/affect simulation training
model. Unpublished doctoral dissertation, Michigan
State University, 1976.

 

 

Snow, R. E. Representative and quasi-representative designs
for research on teaching. Review of Educational Re-
search, 1974, 33, 265-293.

Spivack, J. D. The use of developmental tasks for training
counselors using interpersonal process recall. Unpub-
lished doctoral dissertation, Michigan State University,
1970.

Spranger, E. gypes of men. Translated from the 5th German
edition y Le ens ormen by P. J. Pigors. Halle: Max

Niemeyer Verlag, 1928. New York: Stechert-Hafner.

Steele, T. E. Evaluation of first-year medical students'
ability to recognize suicidal potential. ‘Journal of
Medical Education, 1975, 33, 203-205.

 

Steph, W. Responses to hypothetical counseling situations as
a predictor of relationship orientation in school
counselors. Unpublished doctoral disseration, Univer-
sity of Wisconsin, 1963.

Stoeckle, J. D., Lazare, A., Weingarten, C., & McGuire, M. T.
Learning medicine by videotaped recordings. Journal of
Medical Education, 1971, 33, 518-524.

 

Strayhorn, J. Aspects of motivation in preclinical medical
training: A student's viewpoint. Journal of Medical
Education, 1973, 33, 1104-1110.

 

Taylor, M. K., & Berven, D. M. An evaluation for teaching
interviewing in multiple settings. Journal of Medical
Education, 1974, 33, 609-612.

 

Thoresen, C. E. The intensive design: An intimate approach
to counseling research. Paper presented at the meeting
of the American Educational Research Association,
Chicago, April, 1972.

 

Tournier, P. To resist or surrender. Richmond, Va.: John
Knox Press, 1964.

Truax, C. B. Toward a tentative measurement of central thera-
eutic ingredients. Arkansas Rehabilitation ReSearch
and TraininglCenter, University of Arkansas, 1961.

 

171

Truax, C. B., & Mitchell, K. M. Research on certain therapist
interpersonal skills in relation to process and out-
come. In Bergin, A. E.,_& Garfield, S. L. (Eds.),
Handbook of psychotherapy and benavior change:_An
empiricdlanalysis. New York: John Wiley and Sons,
1971, 229-344.

 

 

Wager, W. Media selection in the affective domain: A further
interpretation of Dale's cone of experience for cogni-
tive and affective learning. Educational Technology,
1975, 15(3), 9-13.

Waldon, J. Teaching communication skills in medical school.
American Journal of Psychiatgy, 1973, 130, 579-581.

 

Ward, N. G., & Stein, L. Reducing emotional distance: A new
method to teach interviewing skills. JOurnal of Medical
Education, 1975, 33, 605-614.

 

Ware, J. E., & Strassman, H. D. A negative relationship be-
tween understanding interviewing principles and inter-
view performance. Journal of Medical Education, 1971
4_6.,. 620-622. -

 

Werner, A., & Schneider, J. Teaching medical students inter-
actional skills. New England Journal of Medicine, 1974,
290, 1232-1237.

Werner, D. Personal communication, 1980.

Younge, K. A. The use of closed circuit television for the
teaching of psychotherapeutic interviewing to medical

students. Canadian Medical Association Journal, 1965,
33, 747-751.

Zabarenko, R. N., & Zabarenko, L. M. The doctor tree: Develop-
mental stages in the growth of physicians. Pittsburgh,
Pa.: University of Pittsburgh Press, 1978.

 

Zakus, G. E., Hutter, M. J., Dungy, C. 1., Moore, V. M., &
Ott, I. E. Teachinginterviewing for pediatrics.
Journal of Medical Education, 19 , __, - .

Zucker, H. D. Medical education: Undergraduate trends. Bul-

3etin of the New York District Board of the American
Psychiatric Association, 1968, 33, 1-71

 

APPENDIX A

ROLE AND FUNCTION OF THE INQUIRER

172

APPENDIX A

ROLE AND FUNCTION OF THE INQUIRER

Ideally, the inquirer should remain as neutral as
possible and avoid forming a new relationship with the per-
son experiencing the recall. The inquirer's function is to
help the person discover for himself some of his feelings
and thoughts which interfered with effective communication.
Often he will gain insight before the person being questiomaL
but the inquirer should lead the person to discover for him-
self what was happening. He should avoid making judgments
and interpretations for the other person. Rather, he should
gently probe and push for more material with a direct line
of questioning and only accasional use of reflective state-
ments. I takes time for the person to gain insight, so the
inquirer should be wary of a need to get the job done
quickly.

The inquirer should focus on the feelings of the person
experiencing reca11--i.e., the feelings the person was hav-
ing about himself and the other person during the video-taped
interaction.

A suggested line of questioning might be the following:

1. What do you think he was trying to say?

2. What do you think he was feeling at this point?

3. Can you pick up any clues from his non-verbal

behavior?

4. What was running through your mine when he said
that?

5. Can you recall some of the feelings you were hav-
ing then?

6. Was there anything that prevented you from shar-
ing some of your feelings and concerns about the
person?

7. What kind of risk would there have been if you
had said what you really wanted to say?

8. What do you think his perceptions are of you?

The inquirer should encourage the person to stop the
machine as often as he wants.

APPENDIX B

CONSENT FORM FOR IPR RESEARCH PROJECT

173

APPENDIX B

CONSENT FORM FOR IPR RESEARCH PROJECT

I have been informed to my satisfaction of the nature of
Mr. Ron May's research and agree to participate in ten
lO-minute helping interviews and ten lO-minute telephone

interviews regarding my reactions to IPR training.

I consent to this participation freely and realize that
there are no consequences for failing to participate. I
am aware that I am free to discontinue my participation

at any time.

I have been assured that all data collected in this study
is strictly confidential and that I will remain anonymous
in any research report. However, I am aware of my right
to a full debriefing and report of my individual results

following winter term, 1980.

Signed: Date:

 

APPENDIX C

BIOGRAPHICAL INFORMATION

174

APPENDIX C

BIOGRAPHICAL INFORMATION

Student Number

 

Age Marital Status

 

 

Sex Present living situation

Avg. Hours per Week
Spent Studying

 

 

 

Curricular Track

 

Past Educational History (degree, school, major):

Current Hobbies/Interests:

Past Experience in Helping Relationships and/or Helping
Skills Training (briefly describe the nature of the position/
training):

Briefly describe why you chose medicine for a career:

APPENDIX D

REACTIONS TO IPR CLASS

175

APPENDIX D

REACTIONS T0 IPR CLASS

Student Number

Date

 

How relevant was today's class to your work with
patients?

1 2 3 4 5 6 7

Not Moderately Extremely
relevant relevant relevant

What did you give that rating?

How much did you feel that you learned today?

1 2 3 4 5 6 7

Nothing Some A great
at all things deal

Why did you give that rating?

What did you find most helpful in today's class?

What did you find least helpful in today's class?

176

APPENDIX D (Continued)

What changes would you recommend for today's class?

Has anything significant happened in your life during
the past week which affected your involvement in today's
class?

Have you noticed any differences in your interactions
with peOple during the last week which you would attri-
bute to this course? If yes, please describe briefly:

APPENDIX E:

RELATIONSHIP INVENTORY

177

APPENDIX E

RELATIONSHIP INVENTORY

Below are listed a variety of ways that one person could
feel or behave in relation to another person. Please con-
sider each statement with respect to whether you think it
true or not true during your interview with your inter-
viewer. Mark each statement in the left margin according
to how strongly you feel it is true or not true. Please
mark every one. Write in +1, +2, +3; or -1, -2, -3, to
stand for the following answers:

 

+1: I feel that it is probably true, or more true
than untrue.

+2: I feel it is true.
: I strongly feel that it is true.

I +
r- w

I feel that it is probably untrue, or more untrue
than true.

I feel it is not true.

I strongly feel that it is not true.

-3:
l. S/He tried to see things through my eyes.
2. S/He understood my words but not the way I felt.
3. S/He was interested in knowing what my experiences
meant-to‘mg.
4. S/He seemed to know exactly what I meant.
5. At times s/he jumped to conclusions that I felt

more strongly or more concerned about something
than I actually did.

6. Sometimes s/he thought that I felt a certain way,
because s/he felt that way.

S/He understood me.

His/her own attitudes toward some of the things I
said stopped him/her from really understanding me.

9. S/He understood what I said, from a detached, ob-
jective point of view.

10. S/He appreciated what my experiences felt like to
me.

11. S/He did not realize how strongly I felt about some
of the things we discussed.

12. S/He responded to me mechanically.

13. When I did not say what I meant at all clearly

s/he still understood me.

178

APPENDIX E (Continued)

l4. S/He tried to understand me from his/her own
point of view.

15. S/He was deeply and fully aware of my most pain-
ful feelings without being distressed or burdened
by them.

 

APPENDIX F

COUNSELOR VERBAL RESPONSE SCALE

 

179

APPENDIX F

COUNSELOR VERBAL RESPONSE SCALE,

EXPLORATORY RESPONSE

 

When a patient or colleague is trying to tell you what is

of concern, oftentimes, they do not know exactly how to put
the concern in words; or are not fully aware of what it is
that is bothering them; or if ypp are to be trusted with an
intimate, personal statement. Exploratory responses encour-
age patients to get more deeply involved with the communica-
tion with you. An exploratory response prompts the patient
to assume greater responsibility for the direction of the
conversation. Often, an exploratory response is as simple
as: "Tell me about that." "Go on." “Could you tell more?"
Your response, whatever words are used, should make the
other feel free to explore more fully, expand, give more
detail, discover new levels of what may be complex territory.

In essence, the exploratory response is like asking an essay
question, Instead of you being judgemental or authoritative
or the problem-solver, you seek to have the other describe
the concern with greater detail, to paint in the picture for
you. You respond more as a facilitator that as an advisor.

Non-exploratory responses tend, on the other hand, to be
limiting of the other; to tie them down with specific alter-
natives. Non-exploratory reSponses are often in the form

of multiple choice or true/false statements. Non-exploratory
responses are often lengthy, highly intellectual and com-
plex. They usually result in the other letting you carry
the burden of the conversation.

LISTENING RESPONSES

 

People who are telling you their concerns want to feel that
you are actively and carefully listening to them. Effec-
tive communicators meet this need by periodically paraphras-
ing or "checking out" with the patient if they have truly
understood the communication. For instance, "what you say
is . . . have I got that right?" In addition, what you
don't understand, you ask the patient to help you. That is,
instead of pretending to understand what you didn't, you
ask for clarification. For instance, "As I listen to you
talk, I am not sure I understand what it is you are saying

. . . could you tell me again please?"

 

 

180

Effective interviewers spend more of their energy listening
to patients than trying to figure out what to say next.
Listening responses allow you to understand a patient's
communication, but listening responses also communicate to
patients that they are being taken very seriously, and that
often encourages patients to listen to themselves more
closely.

AFFECTIVE RESPONSE

By the term affective, we refer to the ”feelings" component
in a statement. Cognitive refers to the content or intel-
lectual outline of the statement. While the cognitive,
story-line, of a statement is important, equally important
in medicine is the affective quality or feeling tone of a
statement. Affective responses are about emotions, bodily
states, feelings, moods.

When you give an affective response you help the other focus
on feelings. You encourage the other to look at underlying
attitudes, "gut-level" reactions and implied values. The
interesting thing about feelings is that we all recognize
them, but rarely do we name them or deal with them directly.
Yet, most of us act more on our feelings than on logic or
rational strategies. Therefore, it may be helpful to pati-
ents to respond to their affect by naming what you sense in
their emotional tone. "You sound depressed" or else you
may ask them to describe their feelings, "How do you feel
about yourself, given your health problems?", or "What about
your health worries you the most?" Many times such a re-
sponse makes it possible for patients to recognize and put
into words for the first time, that they are experiencing
certain chronic emotional stress.

HONEST LABELING RESPONSE

 

"Honest labeling" are responses which are unusually frank.
They are meant to encourage patients to be honest and
direct with themselves and with you. Here you may need to
be able to face squarely your own reactions, feelings and
attitudes because sometimes honest labeling is perceived by
us as dangerous or, at least, not polite.

When you label honestly what you feel and hear, then the
other person may risk being as honest with you. Likewise,
if you consistently "clean up" a message, then the result
will likely be that patients will do the same. Honest
lables let the other person know that you hear and are will-
ing to listen to whatever is the concern. When people come
to us for help, much of their energy is focused on our re-
actions to them. Honest labeling responses are therefore

181

often about our relationship with the patient, "I sense you
are concerned that I may reject you if you tell me what
happened."

There four response modes have been described as distinct
entities, for the purposes of clarity and ease of conceptu-
alization. However, in most cases, combinations of these
responses are used.

 

APPENDIX G

EMPATHIC UNDERSTANDING IN
INTERPERSONAL PROCESS SCALE

 

182

APPENDIX G

EMPATHIC UNDERSTANDING IN
INTERPERSONAL PROCESS SCALE

Scale 1

Empathic Understanding in Interpersonal
Processes, 11‘

A Scale for Measurement1

Robert R. Carkhuff

Level 1
The verbal and behavioral expressions of the first person
either do not attend to or detract Significantly from the
verbal and behavioral expressions of the second person(s)
in that they communicate significantly less of the second
person's feelings than the second person has communicated
himself.

Examples: The first person communicates no awareness of.
even the most obvious, expressed surface feel-
ings of the second person. The first person
may be bored or disinterested or simply Oper-
ating from a preconceived frame of reference
which totally excludes that of the other
person(s).

In summary, the first person does everything but express

that he is listening, understanding or being sensitive to

even the feelings of the other person in such a way as to
detract significantly from the communications of the
second person.

 

1The present scale ”Empathic understanding in
interpersonal processes" has been derived in part from
“A Scale for the measurement of accurate empathy" by
C. B. Truax which has been validated in extensive process
and outcome research_on counseling and psychotherapy (sum-
marized in Truax and Carkhuff, 1967) and in part from an
earlier version which has been validated in extensive pro-
cess and outcome research on counseling and psychotherapy
(summarized in Carkhuff & Berenson, 1967). In addition,
similar measures of similar constructs have received ex-
tensive support in the literature of counseling and therapy
and education. The present scale was written to reduce

 

 

183

Level 2

While the first person responds to the expressed feelings

of the second person(s), he does so in such a way that he

subtracts noticeable affect from the communications of

the second person. .

Examples: The first person may communicate some awareness
of obvious surface feelings of the second person
but his communications drain off a level of the
affect and distort the level of meaning. The
first person may communicate his own ideas of
what may be going on but these are not congruent
with the expressions Of the second person.

In summary, the first person tends to respond to other than

what the second person is expressing or indicating.

Level 3 ; .
The expressions of the first person in response to the
expressed feelings of the second person(s) are essentially
interchangeable with those of the second person in that
they express essentially the same affect and meaning.
Example: The first person responds with accurate under-
standing of the surface feelings of the second
person but may not respond to or may misinter-
pret the deeper feelings.
In summary, the first person is responding so as to neither
subtract from nor add to the expreSsions of the second per-
son; but he does not respond accurately to how that person.
really feels beneath the surface feelings. Level 3 consti-
tutes the minimal level of facilitative interpersonal
functioning.

Level 4

The responses of the first person add noticeably to the
expressions of the second person(s) in such a way as to
express feelings a level deeper than the second person
was able to express himself.

 

the ambiguity and increase the reliability of the scale.
In the process many important delineations and additions
have been made, including in particular the change to a
systematic focus upon the additive, subtractive or inter-
changeable aspects of the levels of communication of
understanding. For comparative purposes, Level 1 of the
present scale is approximately equal to Stage 1 of the
Truax scale. The remaining levels are approximately
correspondent: Level 2 and Stages 2 and 3 of the earlier
version; Level 3 and Stages 4 and 5; Level 4 and Stages

6 and 7; Level 5 and Stages 8 and 9. The levels of the
present scale are approximately equal to the levels of
the earlier version of this scale.

 

184

Example: The facilitator communicates his understanding
of the expressions of the second person at a
level deeper than they were expressed, and thus
enables the second person to experience and/or
express feelings which he was unable to express
previously. '

In summary, the facilitator's responses add deeper feeling

and meaning to the expressions of the second person.

Level 5

The first person's responses add significantly to the

feeling and meaning of the expreséions of the second

person(s) in such a way as to (1) accurately express feel-
ing levels below what the person himself was able to ex-
press or (2) in the event of ongoing deep self-exploration
on the second person's part to be fully with him in his
deepestymoments.

Examples: The facilitator responds with accuracy to all
of the person's deeper as well as surface feel-
ings. He is "together" with the second person
or "tuned in” on his wavelength. The facili-
tator and the other person might proceed to--
gether to explore previously unexplored areas
of human existence.

In summary, the facilitator is responding with a full

awareness of who the other person is and a comprehensive

and accurate empathic understanding of his most deep feel-
ings.