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PROFESSOR: [UNINTELLIGIBLE]
and we will spend the next couple of weeks grading them.
But that was pretty fun on Friday so [UNINTELLIGIBLE].
We've been talking these past couple of weeks--
we've been talking the past couple of weeks about serious
games, games for education, games as an art form, as a
means of expression.
And we're going to be continuing some of those
discussions later on.
But the whole idea is to sort of give you, to sort of prep
you, for a situation where you're going to make a game
for a client.
And for this last assignment, you're actually going to be
making a game based on a problem that Lisa is going to
be talking about.
GUEST SPEAKER 1: My name is Jim [UNINTELLIGIBLE].
I'm a clinical psychologist.
I work at--
I was at Beth Israel, I'm just starting at Brigham and
Women's Hospital, one of the Harvard mafia hospitals.
And my area is using interactive media for clinical
training but especially for
treatment of clinical problems.
So we make computer programs to help treat clinical
disorders in psychology.
GUEST SPEAKER 2: It's my turn to stand up.
I'm [UNINTELLIGIBLE].
I'm a psychiatrist at UMass.
I trained in the same place like Jim used
to work, Beth Israel.
And my focus is primarily clinical.
I'm an attending psychiatrist in a variety of settings,
inpatient, outpatient.
And what I brought up to Jim and then Phillip was a
practical question that I will try to present, which is
helping psychiatry residents deal with angry, agitated, and
potentially [UNINTELLIGIBLE] patients.
Later this is a significant and largely unknown issue.
Certainly the research is picking up, and we don't quite
understand the extent of the problem.
And but I'll say more.
I'll save it for our presentation.
Thank you for coming here.
PROFESSOR: So when they contacted me, there was the
usual interest in trying to make some sort of digital
piece of software to help the training residents in learning
how to deal with violence in mental institutions.
And immediately the first thing that I thought, well
before we jump right into digital, let's try doing
something in analog first.
Let's try prototyping something first.
But it also occurred to me that, in the real world of
game design, there's actually a lot more jobs in game design
outside of the game industry than inside the game industry.
There are a lot of companies out there that are basically
looking for solutions.
Some of which may be games.
And you might end up working in some of those capacities.
A lot of folks in advertising for instance
are involved in games.
A lot of folks who are interested in improving
teaching methods, or improving simulations, working on--
trying to think of an example--
public awareness.
And people who are also now working in website design and
in various online services, who are trying to think about
how to make their experiences a little bit more game like.
There are really really good ways of doing that, and there
are really really bad ways of doing that.
And for the most part what we're hoping is that, if you
end up getting one of those jobs, you're going to be able
to bring some of your personal insight as having actually
done game design, as opposed to just copying what games
have done, and just assuming, well, it kind of looks like a
game, therefore it is a game.
You guys know that now.
So this is kind of get your feet wet, in terms of
designing something, designing for somebody else's needs.
The important thing to keep in mind is, who is going to be
playing your game, or who's this game intended for.
And in what context are they going to be playing your game.
One of the particular problems that you're trying to address,
what's the part of the system that
you're trying to simulate.
And what kinds of insights do you hope people are going to
get out of that.
The problem they're going to talk about it huge.
If you noticed I uploaded actually four readings to the
class website.
Only one of them is required, but all of them are useful.
I will be uploading more.
These are all reference material for the team to use
however you wish.
Because the problem is so huge and vast, you don't have to
solve the whole problem.
You pick one thing that you're excited about, that you're
interested about, and that you think that you might have a
good strategy.
Do the usual brainstorm.
We're going to be going through brainstorming and team
selection pretty much just this week.
And try to identify some small part that might be addressable
with a card game or a board game, or I'll talk a little
bit about role-playing games in a couple of weeks.
So with that being said I'm going to turn
it over to you guys.
GUEST SPEAKER 2: OK so we'll try to take turns to talk
about violence in psychiatry, in particular.
So as Jim has pointed out, violence is a large issue.
What I'm going to try to focus on, as I mentioned earlier,
rather than engaging with psychiatric patients,
especially psychiatric patients on an inpatient
program, which is where the question for me came from.
And obviously violence can be looked at in
a variety of ways.
And I think in one of the handouts that I sent to
Philip, Violence in Mental Illness, they talk about the
biological, psychological theories that the social
dimension of violence and how it can be understood.
If you look at the human development, and no matter
what theory you consider, either a traditional
drive-based theory like Freud or Erikson's stages, each
seems to define a certain developmental goal, and often,
achieving or achieving in a faulty way that goal can
create potential for aggression
and sometimes violence.
A little child or an adult who's dependent or needs are
frustrated may try to takeover and get those met, in one way
or another.
So what I use as a [UNINTELLIGIBLE] metaphor for
the origins of violence is a communication breakdown.
At some level, something doesn't happen right between
the person who gets angry and those around him or her.
So in a most generic way, basically communication is
less about who says what to whom, than in what channel,
and with what affect.
The breakdown can occur at many levels.
Again, this is the generic form.
I hope I'll [UNINTELLIGIBLE]
what I mean.
And especially what can be done at a practical level,
let's say when you are the resident on call at night.
And the staff calls you up and says so and so is getting out
of control.
She's raising her voice, threatening, pounding walls,
wanting to get out, refusing medications.
How do you approach such a person?
And again, the intervention can happen
at different levels.
And actually one goal of the training, or potentially the
game that you might consider, is what to do.
How do you establish when do you engage fully, by yourself,
with outside help, when intervention is minimal and
you just bring pens with you, restrain the patient, use
pharmacology.
So it's a continuum of interventions.
I'm going to just focus on what to do when you can
actually engage the patient.
Again, continuing the metaphor is what Walter Fisher has
described as this type of narrative, rationality, as
opposed to the traditional rational paradigm that defines
people as thinking beings that actually do make decisions and
base their actions on evidential reasoning.
Or rational people.
We analyze the situation.
We come up with the best possible outcome.
Walter Fisher talks about that fact that we are all
storytellers, that we try to interact and understand others
based on the narrative that we have about
ourselves and about others.
My assumption, and again, this is just the introductory
metaphor if you want, that at some point violence can be
caused by a disruption in this narrative.
Things don't make sense anymore.
We feel misunderstood.
We feel the victim of an injustice.
And that those principles apply to somebody who is
struggling with a mental illness.
Where things have a much narrower window of opportunity
than for people who are able to flexibly adapt to the
demands of reality.
So we all know who this is, and the reason I put it up--
and I have to admit I haven't looked into the copyright, I
know there are longer and longer copyright rules for
using cartoons, so you'll have to forgive me.
My point is that this is an angry person.
And as someone who is communicating.
I think we get quickly and clearly the fact that his
emotional range may be intense,
but it's fairly narrow.
It doesn't cover like a spectrum.
And the communication is fairly simple.
He's in distress.
He is imposing his point of view, his space.
He could become very aggressive and assaultive.
I think that the language is very simplistic.
How would we approach the Hulk in trying to calm him down and
change his color?
That's the end of my introductory metaphor.
And please, feel free to interrupt, jump in, and make
this presentation as long or as short as you want me to.
There are many slides, but I'm not going to go through every
single line.
I'm just using this as a stimulus for the conversation
especially from your perspective
and from your needs.
As I said, I'm a clinical provider, I'm a psychiatrist.
I deal with patients all the time, many of whom are angry
or potentially angry or potentially assaultive.
And I may do things after so many years instinctively.
But sometimes I have to think through, OK, this is the
situation, how do I do to maximize the benefit for the
patient I'm treating and to keep myself safe.
I've been assaulted just once, in 15 years.
It was like in the movies.
A VA patient, former Green Beret, who got upset with the
system, and picked up a very heavy armchair and lifted it
above his head.
And we established eye contact then.
I think he wondered, what should I do with this puny
little doctor?
Should I squash him or not?
And at the end, I guess it was a last, you know, split second
moment, he decided to throw it to my side.
A large section of the wall came down, so I was looking at
it wondering, well I could have been
that wall coming down.
He ran out.
It took him a while--
for people to catch up with him.
And two cruisers full of police officers to subdue him.
So I guess, no communication there.
He was just subdued.
What's the magnitude of the problem?
I think it's substantial.
And actually more than 10 years ago, there were some
isolated reports of how significant the problem was in
terms of the trainees, and especially psychiatry
trainees, being the target of verbal and physical violence.
On this first page I talk about medical
students in one study.
Numbers are relatively small.
But again, the study is 14 years old.
A survey of psychiatry residents showed that assaults
or threats of violence are clearly one of the most
difficult events in their training.
And some were wondering introspectively if this is the
right field for them.
Actually some students may wonder reading this literature
whether psychiatry is the right field
for them to go into.
And as you see in the fourth article, almost two-thirds of
psychiatry residents were assaulted at least once during
their training.
And obviously like with any dangerous situation, the risk
of post-traumatic symptoms can be substantial.
Either acute stress response or longer lasting issues.
The idea of improving their training and their ability to
deal with the situation has multiple benefits.
Those who know what to do are never or
almost never assaulted.
Not only that, if they happened to be exposed, the
likelihood of developing post-traumatic goes down
significantly.
So I don't think I need to demonstrate
that point any further.
The assault rate in a more [UNINTELLIGIBLE] relatively
recent study, 10 years old, pretty old, you see that
overall the number of assault rate was 30% to 40%.
Men tended to be slightly more physically
assaulted than women.
AUDIENCE: Can you define what assault means, exactly?
What qualifies as assault?
GUEST SPEAKER 2: Assault basically means kind of laying
hands on the person.
And the assault resulting in an injury, of any kind.
Skin being kind of broken through or--
AUDIENCE: Just holding the clinician
wouldn't be an assault?
GUEST SPEAKER 2: Well it would be an assault because that
kind of grabbing action could actually result in injury.
And I think it would be probably very limiting to talk
only about physical injuries, especially since the
psychological consequences are often the longer lasting and
much more significant.
I think what the surveys have shown also is that how
unprepared trainees in the mental health and outside the
mental health field are actually.
Often this is reduced to a few lectures, especially during
orientation.
And then they are thrown into the lion cage and they learn
on the job.
And many of these findings are introspective.
Many trainees felt that well, I didn't say anything, because
I thought I was supposed to toughen up and bite the bullet
and move on.
Or this is part of the job, I chose this, it's my fault.
Or maybe I did something wrong.
Maybe I was the one who made it so the assault happened.
So a lot of reasons that were just, again, not looked into.
Fear of being scrutinized.
How come that I'm the one that was
assaulted, and not 10 trainees.
How I'm going to explain this.
I was so frightened that I cannot even remember clearly
what happened to me.
So there are a variety of reasons why
people who are in training--
and again, I'm focusing on a again a very small segment, a
specific group of trainees in medical
and psychiatric training.
But I could easily think of other situations of people who
are exposed to the potential for violence and where such
training would be helpful.
Up until now, and for the most part the data that I was able
to collect, and most people in looking at this have been able
to collect is fairly limited.
There are certain limited number of programs.
Methodologically the research is quite faulty.
You can just talk about how limited the generalizability
of the findings are.
And often people have talked about what
happened in the past.
So clearly the recall bias is a major limiting factor in
understanding what happened.
Also, as Jim asked me, so how do you define assault.
One of the biggest problems with most research in this
field is that defining assault, aggression, is done
in very idiosyncratic ways.
It's hard to compare different studies.
So this is a compilation of what people in different areas
have thought about in terms of improving
the psychiatric training.
And as you see most often, in the last few years, the idea
of using simulation to expose the trainees to a protected
environment that has clearly defined boundaries and
consequences, and basically that can be repeated almost in
identical fashion in order to gain proficiency, this coming
up more and more.
What many training programs are doing is to use
standardized patients that use actors.
And that of course would behave in
a programmed fashion.
They make get up to you and make fists, but hopefully
they'll not get so much into the role and then they're
punching you.
GUEST SPEAKER 1: I think this is the real challenge, is that
there's different levels of learning.
You can learn kind of a list of facts, things to do if your
patient starts to get agitated and threatening.
And you can learn how to take a test on it and forget it the
next day, especially if it doesn't come up
for you right away.
And then there's the question of internalizing it so you
actually have not just kind of a working knowledge but really
understand what you should do in different kinds of
circumstances.
And that's where the idea of role playing with live role
plays for the trainees--
it could be residents, and mental health providers--
can really be helpful so they have some sense, some
semblance of this kind of training.
But the tricky things with these role plays is it's not
easy to ensure that everybody receives high quality access
to well trained actors.
Here at Harvard Medical School, they probably do.
At UMass, they probably do.
But there's a lot of places.
And if you expand beyond psychiatry to every mental
health center in the country, every caseworker who is going
out to visit a patient at their home, or social worker,
they're definitely not getting this kind of training.
And so the ones who really I think you said before are
really well trained are the nurses, actually.
Because they get a different kind of training that's really
pretty effective, it sounds like.
But the mental health care providers
often have no training.
And then they're the ones who are kind of in a closed room
with the person who can become really violent.
Especially if it's at their home, or an inpatient unit.
GUEST SPEAKER 2: Jim was making reference to that
psychiatrist at MGH who last year was stabbed by a patient
in the outpatient clinic.
GUEST SPEAKER 1: You all hear about this last year?
Can you just describe the situation?
GUEST SPEAKER 2: Well, it was late in the evening, when most
things like this have the potential of happening.
This was a neuro evaluation or [UNINTELLIGIBLE]
in the Bipolar Clinic at MGH.
Basically he was angry from the beginning and was able to
stab repeatedly.
An off guard person who just happened to walk by.
GUEST SPEAKER 1: It was a police officer, right?
GUEST SPEAKER 2: Yeah.
He was one of the security people for
that particular clinic.
He came and he had a gun.
I don't know how often off-duty security people carry
their guns.
But he opened and killed the patient.
So he was charged.
Eventually was cleared.
For using excessive force.
GUEST SPEAKER 1: What happened to the psychiatrist?
GUEST SPEAKER 2: Well, the psychiatrist was admitted into
the hospital and required extensive surgeries.
She was stabbed in the chest and in the neck.
It was a fairly gruesome-- she survived and I think she's
back at work.
But this is an extreme case.
And I'm afraid that many of the things that we talk about,
the principles that we may come up with, may not
necessarily be so helpful, other than thinking back at a
level of intervention.
It is quite conceivable that for somebody who charges at
you, you won't be able to talk him down, you won't be able to
use any of the nice de-escalation principles that
I'm going to talk about in a few minutes.
But, figuring out what do, I think it means
[UNINTELLIGIBLE].
AUDIENCE: You mentioned that nurses have a different
training system for this, and it seems to be effective.
What is that training, like what is different about what
nurses get taught?
GUEST SPEAKER 2: Well, there are some, in most states,
there are some regulations that try to implement some
level of training or are designed specifically for
patients who get out of control.
And that's not only psychiatry.
Emergency room teams have probably the most highest rate
of assaultive patients, across diagnostic departments.
Often psychiatric patients, especially patients using
substance abuse, will get out of control.
So if you want to become an emergency physician, or if you
work in the field as an EMT or another capacity, you'll have
to deal with these situations.
What makes the nurses somewhat better trained is that they
often are the frontline staff dealing with
out of control patients.
And I think that's probably pretty sad, because physicians
should be equally, and trainees, physicians and
trainees should be equally well trained.
But on the nursing front, there has been some progress.
In Massachusetts, the Department of Mental Health
has some mandatory training.
But there's a lot of red tape there, but there a lot of
helpful aspects, including aspects
related to stop attacks.
And I wish I could have presented a recording of a
training session for staff.
When I went to it, I thought it would be something like a
very spectacular kind of kung-fu, how you do it.
When in fact, the emphasis is how to keep yourself safe, and
believe it or not how to keep the person safe, the person
that you're blocking the punches, the person that may
be trying to strangle you, or keep you in a stronghold, or
scratch you, or rip your hair.
Again, even when you're trying to be intervene or you're
trying to protect yourself, and keep the
other person safe.
No punching, kicking, no kind of spectacular steps.
But again, that's also I feel could be an interesting topic
for a simulation.
How do you interact with--
especially since again I'm a totally kind of
outsider in the field.
Having kids, they were asking me the other day about
Microsoft's Kinect.
And I thought that was really interesting because the level
of interaction with computer generated interfaces is very
interesting, and certainly would be a safe bet to be
attacked by somebody from the TV.
AUDIENCE: It sounds like the nurses get better training
because the states require them to have better training.
GUEST SPEAKER 2: That's correct.
That's a part of it.
I've been trying at UMass to suggest that not only the
staff physicians get exposed to the training but even the
psychiatry trainees and other trainees, especially in
emergency medicine.
They should all really know about it.
GUEST SPEAKER 1: I suspect some of this have to do with
the benefits of being in a union.
So a union can demand that nurses receive this better
training, where the physicians don't have a union.
GUEST SPEAKER 2: It's also about numbers.
On any unit, you have six, seven
nurses for one physician.
And the nurses are there in shifts around the clock.
So their likelihood of being exposed to an out-of-control
patient are much higher.
Usually on these units people intervene as a team.
And as a team leader that tries to apply so many of the
principles I'm going to talk about.
And then if there is need for seclusion or restraints, then
that has to be done in a coordinated fashion.
And things are much clearer, as I said,
on the nursing front.
Maybe because they are doing it all the time and because
there are some tight regulations,
because they're unionized.
And at least half of the literature really comes from
the nursing direction.
So that's a tangent.
PROFESSOR: Just want to ride off the Kinect comment that
you were making.
We will be talking about a little bit more about live
action games so that's kind of how you prototype something
that's going to be a motion gesture computer game.
You don't obfuscate.
Actually having to write code to do that, that sort of body
recognition, is kind of annoying and expensive.
But you can test off a lot of ideas just by having two
people play with coding.
Safety becomes the biggest concern for
the players as well.
It's kind of interesting in this particular case that you
are trying to teach someone how to prevent
damage to both parties.
That actually kind of helps you with the
design a lot actually.
That's only one problem.
You'll go into more details about the kinds of things to
prevent it escalating into actual conflict.
GUEST SPEAKER 2: And the idea is basically to do your best
to not end up at that particular extreme of direct
combat, which is not--
So ideally you don't have to go there.
And as I said in 15 years I've been assaulted once.
I'm sure I was lucky.
People think that my eyebrows are intimidating.
So don't tend to get very [UNINTELLIGIBLE].
Again I'm going to tell a few, you know, tell you about a few
pearls and a few tricks that I personally use.
It may not be helpful for everybody.
Over time, you develop you own style.
The idea is to be able to make an assessment and try to take
preventative steps.
And I think that's the secret.
And this is what I hope better training may be the user
simulation and gaming would be helpful.
Now I'm going to just, I'm going to jump into talking
about prevention and [UNINTELLIGIBLE]
but identifying how you assess and how you think about the
potential for violence.
And these are some known risk factors for aggression.
Obviously the history of violence is the top.
How recent, how frequently, those people become
assaultive.
What's the pattern of escalation.
What are the associated symptoms.
What happens before somebody becomes assaultive.
Why is this important?
Because you can do, and probably should do before, you
engage with the patient an assessment at that level.
And it will help you figure out how deep to get involved,
how likely you are to [UNINTELLIGIBLE] the patient.
Versus saying, oh, I don't need this, I need help, let's
go in as a team.
So that-- that makes it important.
People often talk about violence and a rise in
tendencies.
Young people tend to be more assaultive,
and there's no surprise.
Also older people who have dementia and get more
disinhibited and more likely to become reactive.
I always like to tell the story about a
patient with dementia.
I was moonlighting, and he swung at me as I was passing.
And then I went to talk to him.
Well, I don't know, you just passed by, and I was upset,
and you were the closest.
So I thought I would try to--
So there was no way for me to predict that.
It wasn't a serious thing, it wasn't a predatory type of
assaultiveness where somebody plans.
Doesn't like you, goes after you.
A colleague of mine was attacked by a patient.
The patient watched when people were not around, went
into the doctors room, locked the
door, and started punching.
So that's a totally different animal.
So the distinction between impulsive, affective if you
want or the type of aggression and the predatory is essential
to keep in mind.
In some subcultures, violence is not allowed certainly much
more frequent.
People of a lower socioeconomic status may be
more likely to become assaultive.
Patients of a limited cognitive ability, especially
when institutionalized, are way more likely to become
assaultive.
And then it's many, many diagnoses increase the
likelihood of assaultiveness.
The top are psychotic disorders, like schizophrenia.
Mood disorders like bipolar.
I told you about what we call cognitive disorders,
especially dementia and confusional states.
Patients that have had traumatic brain injuries or
that have had epilepsy.
GUEST SPEAKER 1: There's a real problem with Iraq or
Afghanistan veterans, when they have had an IE explode
under their vehicle.
And they had a brain injury.
Now they have a lot of disinhibition about violence.
And they can just go off sometimes very unexpectedly.
GUEST SPEAKER 2: The frontal lobe exerts a sort of
inhibitory influence on our ability to function.
And that allows us to plan, to think
ahead, to sequence events.
This is the executive function of our frontal lobe.
When it's impaired either in a trauma, or after surgery, or
being in an accident, or becoming demented, that
ability to operate in that fashion may be impaired.
Violence is a possible side effect.
Substance abuse are at the top of the list, because of the
disinhibition, both during the intoxication phase and during
the withdrawal people tend to become very agitated and
assaultive.
There are certain personality disorders.
So when we think about the percentage order, we have this
enduring maladaptive patterns of relating to you and to
others and to the world.
The obsessive compulsive personality disorder likes to
have things organized, planned.
Nothing-- even going on vacation is
an exhausting task.
Nothing has to happen randomly.
The grandiose personalities really need this kind of
feeling coming from all directions.
They need to be in the limelight.
They use people, not as real people but as people that
provide sustenance to their own self esteem.
Two type of personality disorders are particularly
likely to promote violence.
The antisocial and you may have heard the term borderline
personality disorder, which is basically at core has
significant instability and emotions and interpersonal
relationships and identity and basically
their lives are a mess.
Often they feel abandoned, they feel put down.
They may get briefly paranoid and often they become
assaultive.
So again, I'm throwing a lot of terms and
definitions at you.
I don't want to make this a lecture about psychiatry.
But these are conditions that I think are
helpful to think about.
AUDIENCE: When people with delusional disorders like
schizophrenia get violent, is it usually because they are
frustrated about something or is it because they suddenly
have some sort of delusion about their clinician that
involves requiring them to take some sort of action that
is violent?
GUEST SPEAKER 2: I think both.
I think even people that have a psychotic disorder have the
right to feel the victim of an injustice or
feel frustrated or--
many of the reasons that I talked about could happen.
But in particular, I think the other
point is equally important.
That they may act on a delusional conviction.
Or their psychosis may also have hallucinations.
And command auditory hallucinations are known to
often be the forerunners of a violent attack.
You talk about me and say things.
Or the voice tells me, I'm going to go after you.
And the person feels hopeless to resist that.
I discharged a patient, was doing great.
Next day he comes back.
Went home, the voice told him that he needs to hurt his
mother, otherwise he'll get disemboweled.
So he started punching her and then chased her with a knife.
She had to hide in a neighbor's house until the
police arrived.
There is an interesting threat control override here that
people who have looked at violence have prescribed as
being sometimes the proximal cause for violence.
People feel directly threatened.
And they also have this overpowering urge that they
need to act on that they cannot resist.
It's a controversial concept.
I'm not so sure why we should give this particular
association a higher status than other delusional
convictions about the neighbors watching me or
planning to kill me, or putting together a variety of
clues that my friends are really trying to get rid of me
and then I need to protect myself.
But you are absolutely right.
What's interesting even though patients with 20 psychiatric
disorders may have their reasons to become assaultive,
in the overall bigger scheme of things, when you look at
actual violent assaults committed in society, they're
responsible for a tiny one.
So it's an interesting way of looking at numbers.
Yes they could become violent, but the reality is that their
numbers, the actual violent acts, are very small.
But anyway this may just be a kind of statistical trick.
AUDIENCE: You're talking about the number of cases of violent
episodes compared to the general population.
GUEST SPEAKER 2: Exactly.
That's exactly the problem right there.
And then there are various acute findings when you
examine the patient.
On what we call the mental status examination.
Obviously, hostilities, suspiciousness, agitation are
all associated with violence.
I want us to focus one minute on the so-called aggressive
attributional style, how do we respond to stress when we have
a perception of threat.
This is the threat override delusion that I mentioned.
I think that's quite relevant.
What happens in conditions of uncertainty, and many of these
patients may have to think in a distorted fashion.
I was talking at the beginning about the
communication breakdown.
You have the layer of the mental illness that shrinks
your options.
You have a particular situation to deal with that
makes you even more likely to become assaulted.
And this constellation of cognitive distortions may make
it more likely for you to become assaulted.
Neglecting the base information, which assigns a
high weight to certain events that otherwise are low
frequency, attending only to facts that would confirm your
assumptions, I think--
AUDIENCE: So if the psychiatrist's office calls to
reschedule an appointment, the person assumes that this is
because the psychiatrist doesn't like him.
This person doesn't want to treat me, they don't like me,
they don't want me to be their patient because they
rescheduled me.
GUEST SPEAKER 2: Ignoring facts that could disconfirm
your hypothesis.
I just talked to the psychiatrist who was nice to
me, but still the fact that he called and canceled is the
overriding explanation that he doesn't like me.
Or focusing on common events just because you remember
them, which is an interesting way of explaining.
The fact that you remember them and it brings
them up in the rack.
And other disconfirming evidence is
totally kind of ignored.
AUDIENCE: In spite the assumption that the train on
the other platform always seems to arrive first.
Because those are the ones you remember.
GUEST SPEAKER 2: Or the garden variety, the
grass is always greener.
And I talked about medications and street drugs.
Some are more likely to be associated.
Alcohol just by the sheer volume.
And especially because withdrawal is so violent.
It's a significant issue.
The intoxication phase, your level of coordination, your
perception of facts, it's just they're so off that you are
more likely to lose control.
Antidepressants have an interesting impact, because in
people that have an underlying tendency to swing in their
moods may actually all [? blend those ?] things.
You may have heard of the news of antidepressants promoting
violence and suicide in adolescents.
And while statisticians are still scratching their heads
to figure out the exact numbers, the truth is that
mood is very unstable in adolescents.
And often initial depression may turn out to
be something else.
You give somebody an antidepressant, call him or
her for followup in six or eight months.
In the meanwhile, lots of things could happen.
And I think in those cases, when actually those young
adolescents committed suicide, it was not so much about
antidepressants causing it.
Probably the antidepressants made the symptoms worse.
It was very poor followup and poor diagnostic.
But anyway, this is getting too technical.
I included this last minute.
This is an interesting summary of a nationwide study focusing
on violence risk assessment.
Let me just take two minutes about useful measures in
assessing dynamic to the violence.
People have looked at violence in two ways.
They have put together all those factors
that I presented initially.
And they have looked at the perspective of those who have
become violent.
And they compiled the history, clinical
risk assessment scale.
The problem is that when you're dealing with somebody,
those scales, even though they may give you a good image of
what happens in the long run, they may not help you deal
with the immediate situation.
So clinical scales have been used in [UNINTELLIGIBLE].
One developed in Norway, the other one, the dynamic
appraisal, developed in Australia.
These are the items for the HCR-20.
And it's almost like a repetition of what I said
earlier in terms of risk factors.
This is the historical risk factors.
And these are validated, because they have been used
for more than 15 years.
The clinical scale is the dynamic part of the HCR.
And then the risk management scale is trying to project in
the future what you have to do in order to ensure safety,
what could go wrong.
GUEST SPEAKER 1: So the value of these scales is kind of
sizing up the likelihood of this person coming violent, in
the absence of other information.
The best predictor is probably what they're actually doing
behaviorally in front of you.
They're reaching for something heavy, I take that in and
weigh that heavily.
But in the absence of anything else, you know that the people
who meet a certain profile are more likely to be violent as a
psychiatric patient than others.
GUEST SPEAKER 2: This is a dynamic scale that looks at
what happens in front of you, as you pointed out.
You're considering confusion or debility, how boisterous
and how verbally threatening the person is.
The most recent one is the dynamic appraisal of the
situation aggression that has seven factors that seems to be
the best one [UNINTELLIGIBLE]
assessment or prediction of violence
over the next 24 hours.
And this is an interesting psychopathy and an index.
Psychopathy has an interesting history.
I think the current version that we all talk about is
antisocial personality.
But basically refers to people with minimal capacity for
empathy, whose moral dimensions is fairly
primitive, who engage in stealing, cheating, violence,
and don't have a lot of moral drawbacks to do it.
It seems to be associated with violence, not surprisingly.
And this is actually a factor analysis that identifies those
two dimensions.
Now just at the end I want to talk about the de-escalation
principles that I am actually now trying to incorporate in
the standardized patients, because these should be fairly
easy to at least present, and then maybe hopefully to teach
the residents how to use in terms of dealing
with agitated patients.
So actually many of them are used by staff.
How to start interaction with a violent patient.
How to position yourself.
Within arm's length.
Probably at 45 degrees.
For two reasons.
One, in case you're attacked, to offer a much smaller
surface of the impact and also to allow you a way to escape,
you have to.
Not obviously to block the exit door.
Stand over if the person is leaning down or in the bed.
Never turn your back.
What to do with you your hands.
Never make fists, or kind of keep your arms crossed, or
behind you, or in your pockets, to kind of appear as
nonthreatening as possible.
How to regulate the eye contact.
If it's too intense, it can become bothersome.
If it lacks completely, then people could conclude that you
are not really interested or involved.
GUEST SPEAKER 1: The thing that's important to keep in
mind with a psychiatric patient is,
well, a couple things.
One is that mental health patients are much more likely
to be the victims of violence than
actually to commit violence.
And this is really the outlier, the unusual case
where the psychiatric patient becomes violent.
But obviously it's an important situation.
It does happen frequently enough to be a real concern
for the providers, for their well being.
Basically there's different levels of what you have to
understand how to do.
One, how to protect yourself, and then two, how to protect
the patient.
It's almost like if your child who's 11 years old comes at
you swinging, it's really different than if you're
getting bumped on the subway in terms of what
you're going to do.
Now the person who's sitting in your office might be a lot
bigger than your 11 year old.
But you kind of get the idea.
You're not trying to punish them, you're not trying to
inflict any more harm on them than is absolutely needed in
order to stop the situation and for you to get
out, or let them out.
GUEST SPEAKER 2: Yes.
And that's important, and that's somewhat
counter-intuitive.
I'm just thinking, I'm trying to think in terms of potential
simulation, and targets for our training paradigm.
I think an important aspect is for the person who is going to
the training to understand himself or herself.
How what's the reaction when you are threatened.
And how to continue to think on your feet.
And take decisions that are not based on a flight or fight
or tend and befriend attitude.
This is not about dealing with a common situation.
This is when you have to maintain your ability to
remain therapeutic and helpful and to minimize harm to
yourself and certainly harm to the other person.
And the truth of the matter is that many people in these
situations react the way that they've always done.
I gave Jim the example of a social worker I work with, who
every time when she is confronted by a patient, she
gets angry and she gets defensive and tells things to
her that I find are hurtful.
And they are just adding gas to the fire.
I need to intervene because you feel that it's almost
like, you know, I'm there to umpire.
OK, time out.
Stop.
We need to do something else.
And I try to explain to her.
She just doesn't get it.
Or can theoretically figure it out but doesn't do a
very good job at it.
When we are angry or frightened, our behavior, the
way we talk, the way we track, changes.
And those things can be major triggers for the other person.
GUEST SPEAKER 1: If you're staying really calm, and the
other person's escalating, that's a real dampening force
on that other person from escalating even more.
And it's really, really hard to do, to stay professional.
And recognizing that this aggression is
really a medical symptom.
It's like if they are bleeding on the floor.
The difference obviously is that it could actually hurt
you, the provider.
But you need to recognize it as a medical symptom that
needs to be dealt with as opposed to taking it really
personally, or you being violent back.
GUEST SPEAKER 2: How do you appear.
How do you--
obviously, being calm, centered, self assured is
always helpful.
It's the message that you're conveying.
Often if you respond to anger by being fearful or angry
yourself, obviously these will just escalate.
Or if you're fidgety and pacing, and gesturing
yourself, and wondering, so what do I do now, I think the
other person would clearly pick up that feeling.
Touching most often than not is not a good idea.
Even though instinctively we would like to calm the other
person down or wonder what it is.
This is how we learn to show empathy and that we care, we
want to help.
Well, it may not be a good idea.
And then this could be a topic in itself.
Active listening would be the most--
if you want the buzzword, in terms of the verbal
de-escalation principle.
Often when I'm called, and many of my colleagues are
called in such situations.
I introduce myself.
I'm telling the person no matter how agitated
he is why I'm here.
And I'm trying to understand.
I may not respond or react to the person's curses or
threatening behavior.
Of course I try to maintain a safe distance.
And I continue my assessment.
Can I deal with this, or I need help, or I need to stop
and find another way.
And I give that person feedback about what I see, how
he or she makes me feel.
I feel you are threatening, I feel uncomfortable, I think we
need to stop.
Do you want to talk?
What are the issues that you're dealing with?
And I also explain and set limits on what is acceptable
and what is not acceptable.
Often, that combination works.
I listed pharmacotherapy and seclusion restraint because
they are part of the process, and I think I would like
people who are trained for this to understand that those
things are available.
Any questions so far?
AUDIENCE: I've just got a couple of comments on
[UNINTELLIGIBLE].
GUEST SPEAKER 1: Yeah.
We can do that.
And also I wanted to suggest and see what you think about
this, if someone would like to play the role of a patient, I
can meet with you briefly and just kind of prepare you to do
that if anybody is interested in taking the role of the
aggressive patient.
You'd like to do that?
Why don't you and I step out for just a couple of minutes.
And then [UNINTELLIGIBLE]?
[INTERPOSING VOICES]
PROFESSOR: So there's a couple of things that have been
brought up already, immediately seem to be
possible places where you guys can think of what you're doing
to do your project on.
There's identifying factors.
There's a whole bunch of different schemes and
different metrics that people have been using.
All the way from known personality types to
socioeconomic factors and personal history.
You could make some kind of [UNINTELLIGIBLE].
I can imagine, some sort of like can you figure out enough
information before it's too late.
The dynamic assessment of violence seems to be more of a
time pressure kind of thing.
Because you almost have to figure out on the spot.
But factors are very different.
But similarly I can find de-escalation.
It seems kind of interesting, because it almost seems like
you could make a word game.
Or a face to face kind of thing out of that.
Can you remember what you're supposed to do in conversation
with each other without missing any of the
[UNINTELLIGIBLE].
And that might be something.
That would be like a live action game but not
necessarily a physical game.
It would be more like a party game.
GUEST SPEAKER 2: One way--
this is, by the way, I didn't want to go there to
make this too long.
But these are some parts of a standardized patient that I'm
putting together, then I'm going to try actually to talk
to the simulation department at UMass, to be
played by an actor.
And this would be the training goals.
And I'm really particularly interested in how people
respond when they are exposed to an angry situation or even
to an angry face.
What do you have to do in order to
de-escalate the patient.
And what I think I'm going to suggest to the actor is that,
you are in the room and you're pacing up and down.
And appearing angry.
And you're allowed to use some generic swear words.
And to have a number of complaints.
Could be a number of them.
Nurse was too late to give me the medications.
The girlfriend didn't come in time.
You owe money.
You just had a job interview today and you missed it
because you're in the hospital.
Could be a number of things.
And then the person approaches you.
The trainee should follow some rules in terms of the verbal
and nonverbal de-escalation.
If that person is able to engage you, you can become
less angry, less agitated, more interested.
Pacing less, lower your voice.
If the trainee is just doing the right or wrong things, you
either stay at the same level or get more and more angry.
Of course, it's fairly demanding for a standardized
for an actor, because the nonverbal elements are easy.
How you regulate the distance.
How you look, how you approach.
You inhibit your natural tendencies to pat the person
on the shoulder, whatever.
But the verbal aspects are more difficult.
AUDIENCE: Improvising dialog on the spot is hard.
GUEST SPEAKER 2: Exactly.
But at the same time, the goals of the dialog are not.
Because you should probably find out what's going on, even
though, let's say, the actor will try to tell you about his
life, and how miserable things are.
You know, I lost my job, and I was kicked out.
But you need to try to bring the person
to what really happened.
I think that's very, very helpful because you're pinning
down a particular conflict that triggered it.
And if you are able to do that, then you
can take some steps.
OK.
I have a patient right now who has
difficulty expressing herself.
And systematically there's one particular shift where the
staff is not patient, doesn't wait for her.
You just need to give her a little bit more time.
And she gets upset and angry and starts pacing.
And I have to every time say, please, listen to her.
Or she comes up to me, she tells me the story and then I
have to go back to the staff.
People just don't have the patience or don't care.
So that's just a simple intervention.
This is why you need to find out what's going on.
And then, if you can get more information about what brought
the person to this place.
GUEST SPEAKER 1: OK.
I think we're prepared.
She did role play before I showed this, because
[UNINTELLIGIBLE].
GUEST SPEAKER 2: Do you want to do it?
You've been trained.
GUEST SPEAKER 1: No.
You're the expert actually.
GUEST SPEAKER 2: OK.
Alright.
Let's see what happens to me.
[AUDIENCE LAUGHTER]
So, I'm Dr. [? See. ?]
ROLE PLAYING PATIENT: Where's John?
I want to speak to John.
I respond to him and I want him.
Why isn't he here?
Why?
GUEST SPEAKER 2: Who's this person?
I don't know.
ROLE PLAYING PATIENT: Where's John?
I only want to speak to him.
GUEST SPEAKER 2: Well, Nurse John is not available.
ROLE PLAYING PATIENT: [BANGING NOISE]
Why isn't he available?
Why?
Only [UNINTELLIGIBLE].
I don't want to talk to you right now.
GUEST SPEAKER 2: How can I help you?
ROLE PLAYING PATIENT: Get Johnny.
GUEST SPEAKER 2: OK.
I can try to see if he's around.
ROLE PLAYING PATIENT: [BANGING NOISE]
You could [UNINTELLIGIBLE] now.
GUEST SPEAKER 2: OK.
But what else can I do?
ROLE PLAYING PATIENT: Um.
An education.
Stop it.
Not good.
Try to poison me.
You all want me dead.
GUEST SPEAKER 2: What am I trying to do to you?
ROLE PLAYING PATIENT: Doesn't [UNINTELLIGIBLE].
GUEST SPEAKER 2: OK.
I can talk about that.
So tell me what kind of problems do you have with the
medication?
ROLE PLAYING PATIENT: Trying to poison.
You all want me dead.
GUEST SPEAKER 2: So you don't think the
medication is helpful?
ROLE PLAYING PATIENT: Course not.
Trying to kill me.
[TEARING NOISE]
[LAUGHTER]
ROLE PLAYING PATIENT: They're watching me.
GUEST SPEAKER 2: What else can I do to help?
ROLE PLAYING PATIENT: [INAUDIBLE]
family.
GUEST SPEAKER 2: You want me to contact your family?
ROLE PLAYING PATIENT: No.
I hate them all.
They're all against me.
GUEST SPEAKER 2: It must be very hard, to not have anyone
to talk to or feel comfortable with.
ROLE PLAYING PATIENT: That's why I want to talk
[UNINTELLIGIBLE] with John.
GUEST SPEAKER 2: Well, I'm sorry you're
struggling so much.
And I know we haven't met before.
But I'm here and trying to be helpful to you.
ROLE PLAYING PATIENT: You want to kill me, don't you?
GUEST SPEAKER 2: No, I don't think I want to.
ROLE PLAYING PATIENT: [GRUNTING]
GUEST SPEAKER 2: So we have a number of options.
And I think you look angry.
And you're scaring people and you're scaring me.
ROLE PLAYING PATIENT: Fine.
GUEST SPEAKER 2: You're scaring me.
ROLE PLAYING PATIENT: [UNINTELLIGIBLE]
You're just laughing behind me.
You're not scared.
You're just laughing.
GUEST SPEAKER 2: No, I think you're a big, strong guy.
And when you get angry and upset, you get to be
intimidating.
And there are other--
ROLE PLAYING PATIENT: Is that why you're going to poison me?
Scared of me?
GUEST SPEAKER 2: No.
Well, I'm not trying to hurt you.
But we need to come up with a solution.
Because you could get hurt and other people could get hurt.
So we need to do something about that.
ROLE PLAYING PATIENT: I would be better off dead.
Everyone wants me dead.
GUEST SPEAKER 2: Well.
I understand you're quite distraught today.
And I want to help you.
I may not be able to, right away.
I'm going to try to get the nurse that you want.
But what if I do not get him?
What's the next best thing?
ROLE PLAYING PATIENT: [INAUDIBLE]
I don't know.
GUEST SPEAKER 2: Would it help to contact your family?
ROLE PLAYING PATIENT: Maybe mom.
I want my mom.
GUEST SPEAKER 2: OK.
I can try to reach out to her.
And do you think that if you change the medications maybe
you can try a combination that could help?
ROLE PLAYING PATIENT: As long as it's not poison.
GUEST SPEAKER 2: OK.
I hear you.
You don't like the medication.
You think that it's hurting you.
But it's helped in the past.
And maybe a different combination would be better.
Hmm?
ROLE PLAYING PATIENT: Maybe.
GUEST SPEAKER 2: Maybe?
Well, thank you.
We can go on like this.
[LAUGHTER, APPLAUSE]
[INTERPOSING VOICES]
AUDIENCE: I have a question concerning about the
disruption of narrative model of why violence occurs.
Is that pretty much accepted as the way--
GUEST SPEAKER 2: I just made it up for this.
[LAUGHTER]
AUDIENCE: I was just wondering if there were competing,
different theories, it might be useful for people to
understand more than one model, or is that [INAUDIBLE].
GUEST SPEAKER 2: The narrative perspective is, if you want, a
cry from the past.
I think the last 20 years, in science and certainly
medicine, have been dominated by hard evidence.
Actually, the evidence-based medicine has been taking over
the entire world, as the ultimate standard.
So there are lists of the strength of the evidence, and
randomized controlled designs are the best, and clinical
impression anecdotes are the worst.
So on this map, the narrative or a person-like story about
the patient may not be if you want the accepted model today.
But I think in dealing with individual cases, I feel that
makes a lot of sense.
When you have to deal with somebody who is very
distraught, if I tell him that the best available evidence
was published two years ago and showed that, you know, 20
milligrams of Abilify would work best for psychosis, I'm
not so sure that you would fuel the
warmth and the empathy.
But the reality, it could be that that
evidence is is right.
He's psychotic.
And he tried to a variety of medications.
Some of them made him fat and pushed his triglycerides up
and raised his blood pressure.
If I switch him to Abilify in two months, he'll get better.
But dealing with the immediate issue, I think it's just, it's
something else.
And that knowledge about medication, while helpful in
the long run, will not make it very good.
So this is why I came up with if you want, for the purpose
of this meeting, with a way of creating a metaphor that could
sustain my verbal and nonverbal de-escalation.
I'm trying to create some sense, some coherence, some
meaning, some meaning to that interaction.
And in doing that, I'm empathic and I'm trying to
channel the energies in a way that it's
almost like a beginning.
He's distraught.
He's ready to give up.
He's ready to shut himself away from the world.
I'm trying to reach out to him, without becoming his
friend, without becoming his brother or father.
And I think in a sense I'm restoring the
meaning of his narrative.
Somebody cares, somebody reaches out.
PROFESSOR: Because it seems like a very interesting system
for people, for designers to play with.
The idea of trying, even though there is this historic
narrative, and you may not know enough about the
narrative to be able to act on it.
But you'd find out things about it by
talking to the patient.
And what you're really trying to do is make things fit
within that person's narrative.
GUEST SPEAKER 2: You're filling the blanks that were
kind of somewhat destroyed by events.
And it could be a variety of events.
And at times you have to use your imagination.
It's almost like intuition.
I mean, I know the principles from every case, but how I'm
going to do it, it's not pre-programmed.
PROFESSOR: Seems like that's also something that you could
then play with from a design point of view.
This idea of disruptive narrative, and then how do you
put it back.
Just like putting the pieces back together [INAUDIBLE].
GUEST SPEAKER 2: That may be the reason-- and that's
another speculation, I'm just making this up--
why adventure games are so powerful.
Because, in a sense, you're finding a substitute narrative
that is much more controllable than your own.
And for the time of the game you're there.
It's almost like you're buying a few minutes, 10 minutes, 20
minutes of a different story line.
PROFESSOR: Actually, one of our researchers here looks
specifically at adventure games.
And her point of view is that playing adventure games is
like being a performer who hasn't been given the script.
You're still an actor in the story, and you have to figure
out what that story is in order to move it along.
There's one other thing that I do want to bring up.
Obviously, I don't want any of these games that you guys are
working on to be quizzes, to be really fun quizzes, even.
[INAUDIBLE]
all this stuff is about.
I do want you guys to be learning games.
And not just Trivial Pursuit, Psychiatric Version.
That's kind of pointless.
We have had games in the past in this class where people
basically pulled questions out of a hat and had to answer
them, with various penalties.
Kind of fun, but that's not what I've been
teaching you guys.
So try to think about systems.
Try to think about all these things that they want their
trainees to learn.
Think about how they can engage with the system, in
some small way, for your project.
AUDIENCE: Can I ask a question?
What are your thoughts, or what are the field's thoughts
on lying to people, so mitigate a situation.
GUEST SPEAKER 2: Well, I would call lying a distortion, in a
very general way.
And when people lie, they have to make a decision.
Often, people lie for a variety of reasons.
What I always am surprised by is the reason to make friends,
to get friendly, to resolve a situation.
And I don't believe in lying as a communication tool.
Given, it may make things easier in the short run.
Certainly clinically it's not helpful.
I was telling you about patients with borderline
pathology that has this affective and relational
instability that is basically taking over their lives.
They are some of the most accurate lie detectors that
you can imagine.
You cannot design something more perfect than that.
Especially having been in the system for a long time.
They can feel the lie even before it comes up.
And if you're going that path with them.
AUDIENCE: So this role play, for example, if you told
Bobby, well, let me go get John.
You wait here for a minute.
And then you know that John is not working right now.
He's nowhere in the hospital.
But you just told him that to safely get out, then you get
security to come back in with you, and you can
subdue him or something.
GUEST SPEAKER 2: That's a great example.
And that happens all the time.
Because often when you're in this place, many of your
requests are unreasonable.
So you need to set some limits.
And eventually you'll end up setting some limits.
He could have continued to escalate until attacking me,
breaking everything in the room.
I usually tell them about how they make others feel.
How unacceptable some of their behaviors are, and what are
the consequences.
So I'm going to probably tell you if this continues, I don't
have any other choice but to call security and you may end
up in restraints.
And with a chemical medication, it could be
injectable, you can take it by mouth.
So I'm coming up front with how the next few minutes, the
proximal future, looks like.
As opposed to kind of fudge it and get on his friendly side,
and, oh I don't mean anything, but the security will put you
in restraints.
So I don't want to buy him out by just becoming his friend.
If that involves lying--
that's-- some people do it.
When you're in the corner, you're--
OK, so what do I do now.
A little lie won't hurt.
And you do it.
Maybe it's just my--
GUEST SPEAKER 1: What you just mentioned too, that sort of
like good cop, bad cop.
Well, I wish we could have more of a conversation here,
but security needs to put you in restraints.
Security's the bad guy.
When that's exactly where you want the
patient to be anyways.
GUEST SPEAKER 2: I'm OK, but you know Jim.
He doesn't tolerate it.
He's the director and he's going to--
[LAUGHTER]
GUEST SPEAKER 2: Does that answer your question?
AUDIENCE: Yeah.
Would you--
[INTERPOSING VOICES]
AUDIENCE: I guess my followup is would you ever sneakily put
medicine in someone's food or do something [UNINTELLIGIBLE].
GUEST SPEAKER 2: It's not only a lawsuit waiting to happen,
of a major magnitude, but I don't think it's right.
Even though probably reality is that family members and
sometimes even providers in nursing homes may do that.
But I think it's--
GUEST SPEAKER 1: You may need to treat the person against
their will, which is often meaning putting them into
physical restraints, which is usually like leather kind of
things, kind of a straitjacket thing, or maybe to a bed.
And maybe physically inject them with something to really
sedate them.
But you should always be telling them what you're going
to do, right.
And the reason why you're doing it.
Even if they don't have any choice in the matter.
GUEST SPEAKER 2: And if you feel that the person is unable
to comprehend, then you may need to work towards
appointing a guardian who will take
decisions for that person.
And it's not necessarily that the legal field has pushed
itself very hard in field.
But I think it's fair.
You meet the person where that person is at,
and try to be helpful.
And I think, in my view, there is no substitute for being
upfront and saying this is what's going to happen.
He may not be my best friend, but he knows exactly.
I'm telling the patients often ahead what's going to happen.
In that sense, I'm giving them choices.
So if I end up taking them to court for
commitment, they know that.
And you would be surprised how angry they are at the
beginning and how OK they are later.
And how often they come up to me and say, thank you, I was
in a very bad space and I didn't want to, and I fought
you all the way but I think that was the best solution.
I don't necessarily do that to get that thanks.
I just do it as a principle.
Often it doesn't come.
It's not like people are grateful.
Often they leave the hospital.
GUEST SPEAKER 1: Let me show a little of this training, just
a few minutes.
This is a project I've been working on a lot for NASA,
which is basically to develop a mental health support system
for the long duration space cruise.
And this is kind of a whole other topic.
But just one piece of this was teaching the astronauts how to
manage conflict, interpersonal conflict more
effectively or safely.
Astronauts being a very different population from what
we were talking about.
[VIDEO PLAYBACK]
--Welcome to the virtual space station, where you can access
training and resources to help deal with the stresses of long
duration space flights.
In the training simulator, you'll interact with virtual
crew members to learn and practice managing some of the
problems that might come up on long duration missions.
The resources modules has more advanced training that you can
do to learn about adapting to the stresses of living in
isolation, plus interviews with long duration flyers.
It also has a number of ebooks and audio books on dealing
with stress.
Plus survival stories about polar missions and other
adventures.
In the self-assessment module, you'll find questionnaires--
[END VIDEO PLAYBACK]
GUEST SPEAKER 1: This is basically the whole interface.
What I'll show you here is our simulator.
[VIDEO PLAYBACK]
--This is the training simulator.
Click on the topic you would like to learn about.
Then the coach or mentor for that topic will takeover and
guide you through.
--
This is the conflict
management part of the simulator.
We recommend that you do the 10 minute briefing first.
After you complete each simulation--
[INTERPOSING VOICES]
Here's how these simulations work.
You're flight engineer one, or FE1.
Your crew mate, Chuck, is flight engineer two.
We'll be giving you three choices of what to say or do.
You can roll your mouse over them to hear how they're said.
Even though some options are more likely than others to
reduce the conflict, I recommend that you try out
options you might not choose in real life.
That's because all paths in these simulations lead to
teaching points.
You can click the backup button anytime if you want to
change your choice and go down another pathway.
You can click on the fair fighting manual at any time to
read some tips.
You'll also find this manual in the
resource module's library.
Now as you go through the simulation, I'll be right here
coaching you along the way.
OK.
Back to the simulation.
It's four months into your mission, with five and a half
left to go.
So far, the mission's been going pretty well.
But you're both tired, having had to sleep shift last night.
--
Is your display getting squirrelly?
Shoot, mine too.
Damn, I think the whole system's down.
It was the wrong cable.
When I was installing the recorder I
disconnected the A10 cable.
I fixed it right away but I think it screwed
up the whole system.
Look, if ground calls, don't tell them about the cable.
--
Ah, this is a tricky situation.
You believe it's important to tell the ground what happened.
At the same time, you don't want Chuck to get in trouble.
What's your response?
--
They'll spend hours trying to figure this out.
We got to tell them.
What's wrong with telling the ground.
--
You're saying make a choice.
--
OK, but you're putting me in a bad position.
--
I know.
But thanks you're a real friend.
I owe you big time.
--
Houston, this is FE2.
Go ahead.
No.
Negative.
I have no idea.
Yeah I know.
I already got the reboot started.
No, I guess it's too early to say what the impact is.
Roger that.
I'll let you know if it happens again.
FE2 out.
--
You're feeling very anxious having just heard Chuck lie to
the ground.
You're worried that this might backfire on you, if the ground
finds out that you knew what happened.
This makes you very angry at Chuck.
How would you like to respond?
[END VIDEO PLAYBACK]
GUEST SPEAKER 1: The reason I'm showing you this is that
this is one approach that I've taken to teaching how to
handle an interaction with somebody through sort of a
simulation.
Now this is obviously not a game.
There's no score.
There's no time limit.
It's more of an interactive movie.
But with the teaching points here, just like what Cesar's
given you is, we can give this to an astronaut and they'll
read it in 5-10 minutes and say, yup, got it, what's the
next thing.
That doesn't mean they actually can use it, remember
it, absorbed it.
and I'm not saying that this is the way they
should do your games.
But that this is one approach that we've taken to try to get
them more involved with the material in more of a
simulated way.
We can just do maybe one or two more of this.
What would you like to do here?
[VIDEO PLAYBACK]
--
Chuck, we need to talk about this.
--
What is there to talk about?
Ground doesn't need to know every single
little detail, alright?
Plus if we do tell them, next thing you know we're going to
be all over the news.
--
This was a good choice.
Even though Chuck seems exasperated, you know what's
going on in his mind.
Understanding what each other is thinking goes a long way to
solving conflict.
Chuck is concerned about the ruckus this might cause about
negative media attention.
But now you have something to work with.
What's your next move?
--
I know you--
you've been doing excellent work so far.
I can see you're really scared of them.
I know you don't want to draw a lot of attention.
What'll you think will happen if they figure it out?
--
OK.
You got a point.
I'll get fried.
Especially if it looked like I was trying to cover it up.
You know, this really is a team issue.
--
On one hand, you seemed to get Chuck to come around to your
perspective.
But the ground really needs to know what happened.
On the other hand, he's asking you to share the
responsibility, even though it really wasn't your fault.
You have mixed feelings.
You don't want to be blamed for a mistake you didn't make.
But you're concerned about keeping a good relationship
with Chuck.
How are you going to respond?
--
I'm sorry, Chuck.
But this was your mistake.
[INTERPOSING VOICES]
[LAUGHTER]
--
Houston, this is FE2.
--
Go ahead, FE2.
--
Houston, I think we found the problem.
The instructions you sent up for the recorder had some
serious problems.
When you follow the recorder connect procedure, you can end
up disconnecting A10.
It may need to be validated.
--
Copy that, FE2.
The procedures team ran through this in the mock-up,
but they can give it another look.
--
In any organization [LAUGHTER]
Sometimes this can help to create a bond within the
workgroup, because everybody has a common enemy.
But, even though scapegoating the ground may keep the crew
unified for a while,
[END VIDEO PLAYBACK]
GUEST SPEAKER 1: OK.
You kind of get the idea.
We'd like to be available by email, in case you guys have
any questions.
PROFESSOR: I'll sent out some tech information to the class
list and we're probably going to spend the rest of this week
being around all of you so we're not quite sure yet
exactly what we're going to do yet.
Hopefully [UNINTELLIGIBLE PHRASE].
I just have a couple more [UNINTELLIGIBLE] things to do.
I wanted to thank you guys first of all.
[APPLAUSE]
So let's see.
On next Wednesday, which is the Wednesday right before
Thanksgiving, I think a couple of folks are probably going to
be getting out--
because I've been hearing some daffy stuff about what the TSA
might be doing, and what people have been doing in
response to TSA [LAUGHTER].
Getting to the airport early, if you are flying out, might
be a good idea.
Because if everybody decides to refuse the bag scanner
scans and the body searches, then we're talking about some
real delays.
Anyway.
So I think what I'm going to do is [UNINTELLIGIBLE]
this class.
If there are teams who are really wanting to do a live
action game, and they want to get a head start on that, talk
to me directly.
And maybe what we can do is, meet up with you as a team.
And try to get some of ideas across.
Do a brainstorming with me.
I will also get into talking about live action games the
following week.
I'll schedule one of the classes for that.
So we're not going to miss that topic.
I just worried that if we get to it too late, and you are
making live action games, then you don't have enough material
to work with.
Finally, about this assignment, if the subject
matter is at all uncomfortable for you to work with, and you
can't really find something in this fairly large topic that
you will be comfortable working with and you can't
find a team, talk to me directly.
And we can work out some other assignment.
I can't say that I have an assignment in my back pocket
all ready to go, and more likely than not, I'm
half-assing it too.
I would much prefer folks to work on this problem that I
think is fascinating.
And a pretty big problem that you can find some small
project that you're comfortable with.
But if you are, I don't want to make anyone uncomfortable
due to [INAUDIBLE].
So just talk to me.