INT. REV. APP. PSYCHOL. (1975), VOL. 24, NO. 1

T H E E N C O U N T E R - S E N S I T I V I T Y T R A I N I N G G R O U P AS AN ADJUNCT TO MEDICAL

E D U C A T I O N

ALEXANDER C. R O S E N and JOSHUA S. G O L D E N Department of PsJchiatry, Unirersity of California

The first days and weeks of medical school are stimulating, confusing, and dis- turbing to the student. He has high expectations of the experience formed of his worthy but often nake ambitions. Previous contacts with physicians may have been limited and most of them have been friendly and ingratiating. The reality is quite different. Students are inundated with work beyond their most extravagant estimates. The faculty, if not hostile at least appears indifferent, preoccupied with other interests and reluctantly available for reassurance, comradeship, or counsel. In a state of mounting anxiety he turns for comfort to his classmates, mostly strangers to him, known mainly as competitors for the precious places in a medical school. Amidst a storm of rumours, threats, and anecdotes about the possible catastrophies that befall medical students, they augment one another’s fears.

Despite the rationalizations of medical educators, students tend to view these experiences as painful, dehumanizing, and embittering. Rarely do orientation programmes adequately prepare the students for what awaits them. In the cur- rently competitive market place for top applicants proselytizing interviewers don’t want to discourage a good student by ‘telling it like it is’. Paradoxically, it is only a candidate who is not very desirable who is somewhat informed of the realities of the first year of medical school. Interviewers wishing to test the strength of a student’s motivation or to discourage him tell the truth, even darkening it a bit, usually to no avail. The concerned and compassionate faculty, aware of the inevitable confrontation between student expectations and realities, often opt for postponing the disillusionment, joining in the pretence that hi forthcoming experiences will educate him, discipline him, and ennoble him for the future practice of medicine. Those of us dealing with the emotional problems of medical students have known for a long time what recent ‘activists’ among students have been saying, namely, that medical education, especially in the pre- clinical years, is not helping enough to develop or retain habits of scholarship, humanistic ideals, or emotional stability. In accord with Parkinson’s Law, medical students suffering with emotional problems identify themselves in direct proportion to the availability of psychiatric resources available to them. Where no resources exist, schools report few students with problems and vice versa. None the less, there does seem to be a significant number of medical students in trouble.

This paper describes an experimental attempt to counteract some of the emotionally stressful aspects of the students’ initiation to medical school, using group psychotherapeutic techniques. Assuming that the strews are due to un- realistic expectations, alienation from classmates and faculty, and a tendency to

62 THE ENCOUNTER-SENSITIVITY TRAINING GROUP

amplify anxieties and distort reality in an unpredictable environment, group methods offered promise of effectiveness in alleviating those stresses. Based upon abundant experience’ that ’ groups offer emotional support to their membership, and also that they can serve an effective educational function, a group experience was offered to unselected volunteers from the incoming first-year class. The authors hoped to minimize the ‘culture shock’ of entering medical school by establishing a group, which could provide an identity with fellow students and faculty, offer emotional support, information and realistic expectations, minimize anxieties and foster the retention and enhancement of ideals of scholarship, com- passion, and humanism in medicine. For a population of students who were still having vestiges of their ‘identity crises’ (Erikson), the group could provide an opportunity to explore their career choice of medicine and decide on more solid grounds if they wanted the career and were willing to make the necessary sacrifices to attain it.

M E T H O D S

Since ‘sensitivity training’ groups were familiar to many students and thought by them to be appropriate experience for ‘healthy’ people, leading to greater self- awareness and interpersonal satisfaction, our first experimental group was presented to the students at their initial orientation to medical school as ‘sensitivity training experiences’. Out of a class of 128 students, 25 volunteered. Thirteen experimental subjects were chosen at random from the volunteer group, leaving two control groups : 12 volunteers and 103 non-volunteer medical students. The authors were co-leaders of the group.

The experimental group will be referred to as Group I in the tables to follow. The first control group (referred to as Volunteer Controls of Group 11) were those persons who had volunteered for an encounter group experience but were not accepted for the group. The second group of controls, the non-volunteer controls (Group 1111, were the remaining members of the medical school class.

Testing obtained on this sample included a portion of a large battery of tests administered as a part of another research project and the Rosinski Medical Stu- dent Attitude Inventory Test. The former group of tests included the Gordon Survey of Interpersonal Values, the Minnesota Multiphasic Personality Inventory, and the Leary Interpersonal Check List.

The Medical Student Attitude Inventory (MSAI) and the Minnesota Multi- phasic Personality Inventory (MMPI), and the Gordon Study of Interpersonal Values (SIV) were all administered during the beginning weeks of the first quarter of the academic year. The SIV and the MMPI were administered during the orientation and the Leary Interpersonal Check List and the MSAI were ad- ministered in the first several weeks of the quarter. The MSAI was repeated on completion of the quarter just preceding finals.

Although there were some 13 participants in the encounter group at its onset, there were but 9 complete test batteries of before- and after-testing on the partici- pants included in the data analysis. There were a total of 9 completed tests for the volunteer controls and 93 completed repeated tests on the non-volunteer

1 Pion, R. J., Golden, J. S., and Caldwcll, A. B. (1962). ‘Prenatal care-a group psychotherapeutic approach’, Calg Med. 97,281-5.

ALEXANDER C. ROSEN AND JOSHUA S. GOLDEN 63

controls for the MSAI. It was decided to use a smaller sample for the comparisons and data analysis for the non-volunteer controls on the Gordon SIV and MMPI. For this reason, a randomly selected sample of 11 subjects were obtained from the total medical class for comparison on the Gordon SIV and the MMPI. This was necessitated by administrative strictures on the use of test materials and to have comparison samples which were approximately the same size as the experi- mental and voluntary control samples.

Shortly after the completion of the testing the experimental T-group attended an all-day intensive session’ to introduce the group members to our group pro- cesses and to begin building group identification and group spirit, as well as developing some encounter group interpersonal skills. During the quarter which followed the all-day session, the group met for one two-hour session per week, although the sessions were somewhat flexible in lengths as needs made themselves known. During the second quarter the sessions were less frequent, generally being approximately two to three hours in length. At the end of the second quarter the group met again for an all-day session, although this was largely recreational in character. During the last quarter, the group met every other week for two- to three-hour sessions, alternating group leaders each time.

It was clear that the group members were enthusiastic participants in the encounter group and were able to make use of the resources provided by other group members through identification with one another and by their identification with the leaders. They were able to gain insight into themselves and to learn something about the interpersonal dimensions of group life and to enhance and support their humanistic motivations for entering the fields of medicine. A good deal of the content of the discussions centred about academic concerns but with the primary focus on the emotional aspect of academic success in the school of medicine. There was some limited attention to the intrapersonal, historical data which might be called ‘psychotherapeutic’ in nature, but this was directed by the group leaders on topics relevant to the encounter group and, most particularly, to relationships with academic progress. The group provided a resource for the student’s review of his momentary emotional states and enabled group members to obtain help when they experienced an emotional need. I t is interesting to note that many months after the conclusion of the group, group members have expressed interest in the group, loyalty to the group and much more specifically, expressed some gratitude for the group experience and its contribution to their subsequent success in medical education.

RESULTS

Test findings reflect the process beyond the anecdotal. The Rosinski MSAT is scored on seven scales measuring professional, ethical, and intellectual attitudes of medical students. The seven scales are summarized below :

1. Respect for dignity, self-esteem, and value of man. 2. Compassion and perceptiveness in the care of patients and their families.

Future of Psychotherapy, Boston: Little, Brown & Co., International Psychiatry Clinics, vol. 6, no. 3. 1 Rosen, A. C. (1969). ‘Recent development in encounter groups’, in Calivin, Frederick (ed), 77u

64

3.

4.

5 . 6.

7.

THE ENCOUNTER-SENSITIVITY TRAINING CROUP

Understanding of the fundamental rights of the patient, professional colleagues, and community. Fundamental intellectual honesty, including complete candour in recog- nizing his own ability and limitations. Appreciation of the role of research, both basic and clinical. A willing acceptance of the responsibility for the initiation and continuing co-ordination of all of the efforts directed toward the patient’s problems as they relate to his health. Appreciation for his continued self-education whether it be in the medical school or as a practising physician.

The Gordon SIV has six scoreable scales measuring (1) support; (2), conformity ; (3) need for recognition; (4) need for independence; (5) benevolence; (6) leadership.

TABLE 1

MEANS AND STANDARD DEVIATlONS BY MSAI SCALE FOR THE THREE GROUPS, TWO ADMINISTRATIONS

UCLA freshmen, December 1968 1 2

T-;T-~~ou~, N = 9 8 27.40 28-40 SX 4-50 3.43

8 28-10 29.00 SX 5-56 1-58

;P 27-10 28.60 SX 3-94 3.25

T-group, controls .N = 9

Non-volunteers, JV = 93

UCLA freshmen, May 1969 ?-group, .N = 9

R 28.60 30.30 S X 3.40 3.04

x 25.60 25.40 S X 5.08 6.88

R 26.70 28.80 S X 3.94 3.10

T-group, controls N = 9

Non-volunteers, N = 93

3

2 7 -00 2 -00

28.10 3-78

27.80 3 -02

27-80 1 -79

26.90 6.56

27-70 3-13

4

27.80 4.32

26-40 3 -78

27-30 4.07

30-00 1.11

24.60 5.98

27.60 3.26

5

21-30 2.78

21.10 3 -22

2 1 a 0 0 2.88

20.20 3 -63

20.10 3.62

20.50 2.93

6

29.30 3 -46

26.10 4 -89

28.80 3 -46

3 1 -20 2.54

23.40 9.86

30.20 3 -20

7

30.00 2 -50

28.30 4.06

29.10 4-46

28.10 2.76

25.90 6.75

28-90 3.34

Tables 1-3 represent the pretesting on the MSAI, the SIV, and the MMPI for the three indicated groups. It is important to note that in the pretest con- dition, that there were no unusually high or low scores for any of the three groups. The findings compare quite favourably with those reported by Rosinski in his original paper and with findings informally provided for us on students attend- ing a nearby school of medicine. The students appear to share the same attitudes

ALEXANDER C. ROSEN AND JOSHUA S. GOLDEN

TABLE 2 SUMMARY OF MEDICAL STUDENTS’ SIV PROFILES

Means Group I Group 2

Per- PU- R a w centile Raw centile score score SD score score SD

1. Support 16.8 62 5.2 14-4 40 3.4 2. Conformity 5.1 12 4-0 7.1 21 3.7 3. Recognition 11.1 37 4.5 10.1 30 4.1 4. Independence 21.9 60 4.7 21.1 55 9.1 5. Benevolence 20.0 78 4.5 18.2 70 4.8 6. Leadership 15.1 35 6-4 18.0 50 5.1

65

Group 3 Per-

Raw centile score score SD 17.8 68 3.2

7.7 26 5.4 9.7 30 3.3

23.4 70 3-4 17.6 65 6.6 13.7 31 5.6

Percentile scores Jv1= 9 94-99-Very high 8-3 1-Low Jv, = 9 70-93-High 1-7-Very low N , = 11 32-69-Average

and belief systems as do other freshmen students in other schools of medicine. The repeat testing on the MSAI is also summarized on Table 1. The conclusions to be drawn from this data are covered under the discussion of Table 7.

1. L 2. F 3. K 4. Hs 5. D 6. Hy 7. Pd 8. Mf 9. Pa

10. Pt 11. sc 12. Ma 13. Si 14. Es

TABLE 3 SUMMARY OF MEDICAL STUDENTS’ MMPI PROFILES

Means Group I Group 2

8 SD s SD 48-4 6.3 46.3 5.8 56.5 6.5 55.1 8-1 51.9 13.1 60.9 6.4 54.5 5.9 52.7 7 -5 60-0 13.1 54.2 6 -6 58.2 6.0 58.6 6.5 65.6 9 -3 61 -2 6.7 67.8 10.3 69.3 15.5 59 *5 6.6 59.6 9.1 60.9 9.4 57.6 7-6 61.2 10.1 63.0 10.2 56.1 9.6 57.8 12.9 50.8 11.5 46.1 7.5 60.6 2.8 64.8 7.0

Group 3 8

46.6 51.5 59.7 51.6 56.8 57.2 57.2 61.7 54.4 54.2 54.6 56.3 48.9 63.0

SD 4.4. 5.2 6.3 5.6 6.9 6.3

10.5 8.9 9.1 6-2 5.9 9.2 6.7 7.0

XI= 8 = Experimental I-group. N2 = 9 -= I-group control. N, = 11 = Non-volunteer sample.

On Table 3 it is relevant to note that there were some minor differences on the SIV for the three groups. The volunteer T-group appeared primarily to be low on conformity and high on benevolence, as were the volunteer controls who were, as well, low on need for recognition. The non-volunteer controls were E

66 THE ENCOUNTER-SENSITIVITY TRAINING GROUP

similarly low on the need for conformity but were also high on the need for independence and leadership. It would appear, therefore, that those students who voluntarily applied for participation in the encounter group were not only low on the need for conformity, but also more visibly benevolent and more visibly in need of support and recognition than were the non-volunteer controls. I t is also relevant to note that the non-volunteer controls, as would be expected on a common-sense basis, are those who describe themselves as having greater need for independence, but at this point seemingly not dominated by the need for control and leadership.

TABLE 4

SUMMARY OF COMPARlSONS OF SN BETWEEN GROUPS ( t 0.025=2*12; t 0*005=2*92)

Scale 1 2 3 4 5 T-group us. volunteer controls t 1.14 -1.10 0.48 0.23 0.81

(NS) (NS) (NS) (NS) (NS)

T-group us. Non-volunteer controls t -0.48 -1.25 0.76 -0.83 0.95

(NS) (NS) (NS) (NS) (NS)

Volunteer control us. Non-volunteer controls t -2.22 -0.30 0.22 -0.74 0.23

(NS) (NS) (NS) (NS) * NS = non-significant. * = significant beyond 5 per cent level.

Table 4 shows a summary of significance of differences between the means of the T-groups and the means of the volunteer controls, the T-groups and the non- volunteer controls, and the volunteer controls versus the non-volunteer controls on the SIV. Of the 18 comparisons, there was only one significant difference (two-tailed T-test) and that was on Scale 1. Need for Support, between the con- trols and the non-voluntary controls. Although this appears to have some reIavence and is in the appropriate direction, it would be wise to view the result with scepticism since one significant difference at the 5 per cent level out of 18 paired comparisons may well be a fortuitous finding.

Table 5 summarizes comparisons on the MMPI between the various groups as indicated and it is relevant to note that in those measures of personality as reflected in the fourteen listed scales of the MMPI, there are no significant differ- ences between the experimental and two control groups. In the examination of the MMPI profiles it would appear generally that the medical students are rela- tively high on measures of control and ego strength, and despite the situational character of the test atmosphere, i.e. during the first week of medical school, show- ing little evidence of visible or excessive distress or disturbance as measured by such sub-scales as the depression scale or the psychasthenic scale of the MMPI. There were no startling elevations on test protocols.

Scale 1. L 2. F 3. K 4. Hs 5. D 6. Hy 7. Pd 8. Mf 9. Pa

10. Pt 11. sc 12. M a 13. Si 14. Es

Scale

ALEXANDER C. ROSEN AND JOSHUA S. GOLDEN 67 TABLE 5

SUMMARY OF COMPARISONS ON MMPI BETWEEN GROUPS

(t-tets, t 0.025=2.13; t 0.005=2*95) Group 1 us. Group 2 Group I us. Group 3

0.70 NS 0-67 NS -0.01 NS 0.39 NS 1.77 NS 1.14 NS 1 -76 NS -1.57 NS 0.40 NS 0.56 NS 1 *07 NS 0.34 NS 1.13 NS 0.63 NS -0.86 NS

-0.10 NS 0.38 NS 0.48 NS 1.11 NS 1 -85 NS 0.78 NS 0.25 NS 1.33 NS 1 -48 NS

-0.02 NS 1 -43 NS 1 *27 NS 0.80 NS 1.77 NS 1 -08 NS

-0.36 NS 1 -66 NS 2-18 * -0.33 NS -0.0342 NS 0.32 NS

0.97 NS 0-404 NS -0.87 NS - 1 -64 NS - 1 *02 NS 0.57 NS

Group 2 us. Group 3

Group 1 = I-group. Group 2 = Volunteer controls. Group 3 = Non-volunteer controls.

NS = nonsignificant. * = significant beyond 5 per cent level.

TABLE 6 COMPARISON OF THREE GROUPS ON MSAI PRE-TREATMENT TESTING

I 2 3 4 5 6 7 T-group us. Volunteer controls

;P -0.294 -0.476 -0.764 $0.732 0.141 SX (NS) (NS) (NS) (NS) (NS)

'I-group us. Non-volunteer controls x 0.196 -0.168 -1.09 0.333 0.308 SX (NS) (NS) (NS) (NS) (NS)

Volunteer controls us. Non-volunteer controls x 0.527 0.643 0.231 -0.676 0.090 SX (NS) (NS) (NS) (NS) (NS)

Post-treatment testing

Scale 1 2 3 4 5 T-group us. Volunteer controls x 1 -44 1 a95 0-396 2.66 0.058 S X (NS) (NS) (NS) (NS) (NS)

2 X (NS) (NS) (NS) (NS) (NS)

J X (NS) (NS) (NS) (NS) (NS)

T-group us. Non-volunteer controls x 0.632 1-41 0.143 4.80 -0.234

Volunteer controls us. Non-volunteer controls ;P -0.632 -1.43 -0.360 -1.44 -0.323

* = significant beyond 5 per cent level. E'

68 THE ENCOUNTER-SENSITIVITY TRAINING GROUP

TABLE 7 RESULTS OF &TESTS ON THE DIFFERENCE BETWEEN DECEMBER 1968 AND MAY 1969 MEANS,

CORRELATED OBSERVATIONS, FOR THE SEVEN MSAI SCALES (TWO-TAILED TESTS)

T-group T-group Non-volunteers N = 9 controls N = 9 Jv = 93

Scale 1 2 3 4 5 6 7

t 1-18 2-34* 0.714 1-51

2 4 0 * - 1 -04

- 1 -68

t - 1 -07 - 1 -53 -0.582 -0.623 -0.926

0.150 -0.712

t -4.40t

2.06 -1.12

3.00t -6.36* 37-10?

-1.10 positive represents an increase in score from December 1968 to May 1969. Negative, a decrease.

* p < 0.05. t p < 0.01

Table 7 summarizes the results of the comparisons before and after on the Medical Students Attitude Inventory. As indicated in Table 6, the experimental T-group showed changes on two scales, 2 and 6, indicating some increase in com- passion and perceptiveness in the care of patients and their families, and increase in the willing acceptance of the responsibility for the initiation and continuing co-ordination of efforts directed toward the patient's problems as they relate to his health.

This is in comparison with the T-group control group who showed no significant differences in pre- and post-testing. In contrast the non volunteer controls showed a statistically significant decrease in scale scores measuring respect for the diginity of man (Scale no.1) and the score measuring respect for science and its value (Scale no. 5). For the non-volunteer controls there is also an increase in scores measuring intellectual honesty and capacity for self-evaluation (Scale no. 4) and a sense of responsibility for the care of patients (Scale no. 6). It is clear that the scores which show change, and particularly those which are different between the various groups seem most related to the interpersonal human dimensions. I t is surprising to note that the non-voluntary controls had some decrease in the appreciation of research, considering that the medical school in which they were studying places emphasis on research pursuits. The relative stability of the volun- tary controls suggests that in many respects the group had already examined their own motivations very clearly and did not change in their attitudes in the absence of a group facilitation. In terms of the original motivation for the programme, the fact that the experimental T-group did not change in the measures of respect for the dignity, self-esteem, and value of man, while the non-voluntary controls showed a significant decrease in such attitudes should be noted.

The findings as summarized would suggest that there were few significant differ- ences between the three groups at the initiation of the programme. They would also indicate that the most significant effect as measured by the MSAI was in the T-group controls maintaining their interest in man and the human elements in medical practice, while the non-voluntary controls seemed to lose to some greater extent some measure of the humanistic motives.

ALEXANDER C. ROSEN AND JOSHUA S. GOLDEN 69

Obviously, this represents but a small initiation of the relevant research which should be pursued. A more extensive and more elaborate training procedure is k ing pursued involving a larger number of freshman medical students in en- counter groups. This should serve to explore further the preliminary findings cited above.

DISCUSSION

The suggested differences in a group following one academic year’s participation deserves examination. The students in experimental and control groups did not differ at the start, so the group process probably affected the results. Clearly the changes in the experimental group were in accord with the desired goals of the group leaders, suggesting at least that leaders of ‘encounter groups’ can and do influence the attitudes of group members. Whether this phenomenon is thought to be ethical or desirable in medical education is moot. That faculty inevitably influences student attitudes, in whatever direction, is not. The problem then be- comes one of deciding upon acceptable ‘faculty models’ and finding flesh-and- blood examples who can do the influencing. If a programme of ‘encountergroup’ experiences is offered more extensively, the task of hd ing and training suitable faculty ‘leaders’ grows very complex. Establishing some consensus and homo- geneity of goals among the leaders is a fascinating and awe-inspiring job, to be discussed in a subsequent publication.

The effects of the student group members upon one another is another com- plicated matter. One would expect, and find, that group members reward noble and humanistic sentiments, when voiced or demonstrated. However, with time there is greater acceptance of human frailties and a reaction against saying ‘the correct things’, which are labelled ‘phoney’. Thus, one would expect the expression of petty, selfish, or negative sentiments which abound in freshman medical stu- dents, especially under the constant pressure of academic stresses, social depriva- tion, and usually, financial need. In the experience of the group, negative feelings do get expressed. The value of their being aired in a group is that faculty leaders, with some perspective of time and distance from the stresses, can modify their effects, support the student members when they are criticized, and remind the students of what the effects of suffering and bad treatment are upon human beings. Thus the students’ own behaviour and current experience serves as the basis for learning about the future behaviour of sick people, under stress, whom they will treat.

The cost of ‘encounter groups’ as an educational effort is substantial. Our experimental group volunteered, and met with surprising consistency on their own time and, at their initiative, continued the process throughout the year. With the mounting pressures of an overcrowded curriculum and with a diminution in anxiety as students become adjusted to the new medical school environment, the need for the group drops. The ultimate judgement as to its value is not possible by measuring tangibles. How can one compare the value of about 100 hours of ‘encounter groups’ with equivalent amounts of biochemistry experiments or memorizing the names of nerves? The students, at least the volunteers, seem to want to spend the time in groups in addition to the other subjects. Whether their

70 THE ENCOUNTER-SENSITIVITY TRAINING GROUP

judgement is or is not sound, the results of their experience seem beneficial. The effects of similar group experiences on students who are disinterested or antagon- istic toward them deserves study, and it will be the topic of a future publication.

LA DYNAMIQUE DE G R O U P E C O M M E C O M P L E M E N T A LA F O R M A T I O N MEDICALE

ALEXANDER C. ROSEN et JOSHUA S. GOLDEN

On a tent6 d’tlaborer un programme pour aider les ttudiants entrant dans une Facult6 de Mtdecine B faire face aux exptnences de dtshumanisation gnible et amhe qui surviennent pendant les prerni2res semaines ou les premiers mok de leurs ttudes. Un groupe exptrimental d‘ttudiants volontaires a participt 2 une exptrience de groupe pour y discuter de ces tensions et chercher 2i tclairer, pour eux-m2mes, leurs objectifs et leurs buts professionnels. 11s ont ttt comparts avec la promotion dans son ensemble, et avec douze volontaires qui n’ont pas ttt invitts B se joindre au groupe exptrimental. La comparaison a portt sur des mesures des attitudes des ttudiants en mtdecine, des enquttes sur leurs tchelles de valeur personnelle et les rtsultats obtenus au Minnesota Multiphasic Personality Inventory et au Leary Interpersonal Check List.

Le groupe contrale non volontaire a montrt une diminution significative des attitudes mesurtes concernant la dignitt de l’individu pour l’estime de soi et la valeur de la science; le groupe exptrimental ne subit pas la m2me chute. Initiale- ment, il n’y avait pas de difftrence du point de vue personnalitt entre les deux groupes contrble et le groupe exptrimental. Des commentaires oraux et tcrits et les rhultats des tests indiquent combien l’exptrience de groupe peut aider les ttudiants B devenir des mtdecins plus efficaces.