Using Role Playing in teaching empathy

USING ROLE PLAYING IN TEACHING EMPATHY Adam Blatner, M.D.

(This is a revision of a paper presented as part of symposium on the Arts in Medicine at the American Psychiatric Association Annual Meeting, May 5, 1992) (Posted September 4, 2002)

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One of today's significant challenges in the training of mental health professionals and people helpers of all kinds is the development of effective interpersonal skills, and among these is the capacity for empathy. An operational definition I like to use has two components: First, empathy is an ability to imagine with some degree of accuracy what it's like to be in the predicament of the other person; and secondly, empathy entails the ability to communicate that awareness so the other person feels understood.

Empathy entails a different kind of learning. Just reading textbooks won't develop this skill. Nor is it a visual-motor skill, like getting the knack in golfing or basketball. Nor is empathy a matter of simple good will, caring, or an intention to be sensitive. Some books or papers about empathy describe it as a sensitivity to nonverbal communication, but I think this is only a small component. Rather, I view this skill as a matter mainly of focused imagination, picturing in the mind what it might be like to be in the other person's predicament. This skill also involves an integration of remembering, rational thinking, intuition, and feeling, all of which support the active imaginative process.

Empathy is teachable, but it requires experiential learning, practice. I challenge the cliche that "you either have it or you don't." Certainly there is a variable distribution of talent for this endeavor, but just about anyone can improve whatever level of innate ability with practice.

Furthermore, the natural vehicle for the experiential learning of an interpersonal skill–in this case, teaching empathy–, is role playing. It uses all of the aforementioned skill components. Role playing is a natural vehicle of learning because it's an extension of the imaginative, pretend play of childhood (Blatner & Blatner, 1997). It should be noted that this approach is often neglected in the course of traditional education, because it addresses a different type of learning than that which can be easily tested on exams. Role playing builds a deeper type of understanding and a more flexible type of thinking, qualities which will become increasingly important in the coming years. However, what most kids learn involves memorization and calculation, logical composition, and other more didactically taught skills. Role playing involves an experiential type of learning.

In teaching empathy, I have students work in dyads, with one taking a role, such as the role of one of their clients, or some vocational or social role that would challenge the imagination. The other student then simply interviews the partner-in-role. The trick is to get the knack of thinking more like an actor than like a textbook. Different sexes, ages, and educational or cultural backgrounds are also considered. We explore the psychosocial network, too: What's it like to be the parent, child, sibling, or spouse of a person with a given type of condition?

We begin with more elementary roles, and students are invited to associate to the components of the roles. Role taking is a skill that has to be built up just as playing ball begins with simply learning to throw and catch. Students are taught how to warm themselves up to the process.

Not knowing about the concept of warming-up accounts for why many teachers use role-playing incorrectly and why many students have been turned off to the technique. One cannot just assign the roles and expect a spontaneous performance. Without a warming-up process, students in role playing situations often feel subjected to an excessive degree of demand and inadequacy.

Role playing requires a build-up of spontaneity in its participants (Blatner, 2000). Now, actors know that spontaneity requires a process of warming-up, which means a gradual build-up of sense-images, associations, physical connections, and affects so that the complexity of a character can be brought to life. Another component of warming up is the establishment of a somewhat playful context which makes room for experimentation and making mistakes.

The activity of warming-up one's imagination is similar to the process of actors during the early parts of rehearsal when they are delving into the subtleties of their role. In modern theater, influenced by the work of Stanislavsky, actors seek to understand and feel into their assigned characters rather than rely on superficial gestures and artifice.

One begins to warm up by taking on the more superficial, obvious, almost clichéd parts of a role. As more associations are made, the more questions are answered, the more the person finds that unexpected ideas arise out of the subconscious--which is the essence of the creative process.

I begin the process of teaching the basic feel of role taking by using a technique I've called "the Talk Show Host Game" (Blatner & Blatner, 1991b). Most people have seen this genre of entertainment on television. The idea is for a person to imagine a role, and to be interviewed in that role. If it is a classroom, I have the students pair up: One of the pair takes the role of interviewer, a television talk show host. The other, the guest on the talk show, as I mentioned, is the person taking some role: A patient who is facing a bone marrow transplant; a spouse of a person with Alzheimer's disease; the supervisor of a program for mildly mentally retarded teenagers. The interviewer should not try to be helpful, therapeutic or diagnostic! (The interviewer in this exercise is not the one practicing the skill of empathy! Rather, it is the person being interviewed, using the dynamic of being asked questions to warm up the flow of images and ideas in the intervewee's mind.) The goal is to for the "host" to draw out the "guest" in communicating to an imagined television or studio audience some of the experiences, feelings and attitudes associated with that role.

I also use a variant of this approach when I supervise or consult with other mental health professionals individually. After warming-up by discussing the basic elements of the case and clarifying the questions, there may be a time when the person being supervised wants to understand his or her client–in that case, I'll invite the therapist to take the role of their clients, and gradually ask, at first, more general questions, and then more pointed ones. Not only do they frequently come to some enlightening insights about their clients, but they also get practice in learning the skill of role taking and empathy.

I offer cues in the form of questions which I've found to be especially effective in warming up people to a role. For example, I avoid "why" questions and work towards helping students picture specific scenes and situations rather than to use abstract generalizations. In the talk show host game, the host interviews the guest for about five minutes, and then I announce, "commercial break in one minute." After one minute, I announce "commercial break" again, and "come out of your roles; shake off your roles if you want to. Now change parts. The host will now be a guest: choose a new role. The guest becomes the talk show host. You have six minutes." After this period, I stop as before, and give the students a few minutes to process with each other how they felt about the exercise.

  The concept of role is itself a useful tool in helping students to become empathic (Blatner, 1991a). The idea of role is a powerful metaphor which suggests a familiar way of thinking about the elusive and complex world of mind and social interaction: Think in terms of the roles being played, as if in a drama, and then you can analyze the different parts, the components of those parts, and the ways those roles and sub-roles are defined. The role concept thus becomes an instrument of analysis, and it's also a value-neutral "user-friendly" language which circumvents the kinds of psychological jargon which many students find confusing.

Like a good analytical technique, the role concept breaks a holistic system, a family or the complexity of a person, into manageable parts. For example, if I ask you, "What's it like to be your mother?," there are so many facets of her being that it's impossible to know where to start, or what could be said that could capture the fullness of her existence. But if I asked, "What's it like in terms of her relation to money?" you could probably remember a number of images or things she's said or done. And, continuing the warming-up process, if I asked "What's it like in her relation to religion?" or "...in relation to housekeeping?" or "...in relation to a special hobby or interest?" you could gradually build up a composite picture which begins to have enough memories and associations so that were the interview of your mother (played by you) to continue, you'd be warmed up enough to discover some surprising new thoughts about Mom which will spring into your awareness from your subconscious.

The role concept has many advantages: It is unique in its capacity to interpret phenomena at many levels of human organization--intrapsychic, interpersonal, family, organization, and even interactions within the larger culture. Its association with drama and the arts and its roots in the play of childhood gives the exercise of this skill some of the excitement and challenge of a game, adding motivation to the learning process. And finally, its association with a technique which can be used for both education and therapy makes it especially heuristic.

Role playing is a derivative of psychodrama and utilizes a wide range of other techniques which enhance the process (Blatner, 1996). For example, if students are exploring the problem of telling family members that a patient has died, the first and most obvious technique is to role play the predicament of the family member, say, the spouse. The unspoken as well as expressed thoughts are brought out. Working from the position of what would be the best and worst things for the chaplain, therapist, or doctor to say from the point of the bereaved, the group members could take turns trying out a variety of approaches. The technique of "replay" allows participants to correct mistakes, and the technique of "mirroring" gives those who play a role some feedback as to how they were perceived by others in the group.

Another technique which can enhance the effectiveness of a role playing learning situation is to have the students read up on the psychosocial aspects of the condition(s) to be discussed in the next session. This adds an element of intellectual discipline, but it's the actual role taking which brings out the nuances and the feel of the situation which can never be gleaned from the journals or texts. That's why it's called experiential education.

The next component of empathy is that of communicating one's awareness of the other's situation so that the other person feels understood. The key here is to state the awareness in a humble, open-ended fashion, as an "I-Message." "I'm not sure if this applies to you, but if that were happening to me, I might feel (thus and so). Is that true in your case?" Derived from the psychodramatic technique of "doubling" and applied in this fashion, I call this "active empathy." It is to be contrasted with "interpretations" phrased as "I think you feel..." or "You must be feeling..."

Making "I" statements instead of "you" statements tends to allow patients more of a sense of collaborative freedom and reduces the distance between therapist and patient. It is empowering and reduces the subtle negative transference patients have with authority figures who have in the past seemed unwilling to be corrected. In other words, this more mutual way of expressing empathy, communicating a willingness to be corrected, thus enhances the treatment alliance.

Another advantage of active empathy is that it moves the interview along, being more time-efficient than the traditional non-directive techniques and yet more personal than medically-oriented directive questioning.

Finally, the activity of role playing fosters a more flexible type of thinking in the clinician. Shifting roles builds a habit of being able to move easily among different frames of reference. There's a deepening as well as a broadening of mind in this type of experiential learning. Spontaneity relies on a receptivity to the subconscious, and this in turn develops a more vibrant relationship with the creative unconscious. Remember that traditional schooling actually suppresses this relationship, but role playing re-opens channels to the "inner child" and the vitality which is associated with those complexes. As a result, practitioners become more self-aware and more enjoying of their capacity for interpersonal relations.

A basic dynamic in psychology which I've been noting is the repression and denial of activities or issues about which one feels vulnerable or inadequate. Applied to the fields of health care, one of the major reasons people aren't more interpersonally sensitive is not because professionals don't care or haven't got the potential, but because they don't know how to be empathic, they don't have the infrastructure of skills and ideas which allow them to feel competent and effective in this area. Exhortation cannot suffice. The skills of communications, emotional problem-solving, self-awarness and empathy must be learned through experiential vehicles such as role playing, and students must be given opportunities to practice until they achieve a gratifying sense of mastery. Then we will see a more personalized form of medical, nursing, and therapeutic practice.

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References

Blatner, A. (1991a). Role Dynamics: A Comprehensive Theory of Psychology. Journal of Group Psychotherapy, Psychodrama & Sociometry, 44 (1), 33-40.

Blatner, A. & Blatner, A. (1991b). Imaginative interviews: A psychodramatic warm-up for developing role-playing skills. Journal of Group Psychotherapy, Psychodrama & Sociometry, 44(3), 115-120.
    (This paper now on this website: http://www.blatner.com/adam/pdntbk/talksho.htm

Blatner, A. (1996). Acting-In: Practical applications of psychodramatic methods (3rd ed). New York: Springer.

Blatner, A. & Blatner, A. (1997). The art of play: Helping adults reclaim imagination and spontaneity. New York: Brunner-Routledge.

Blatner, A. (2000). Spontaneity. In, Foundations of psychodrama: History, theory & practice (4th ed.). New York: Springer, pp. 63-74.