WEBVTT 00:00:00.000 --> 00:00:00.040 align:middle line:90% 00:00:00.040 --> 00:00:02.470 align:middle line:84% The following content is provided under a Creative 00:00:02.470 --> 00:00:03.880 align:middle line:90% Commons license. 00:00:03.880 --> 00:00:06.920 align:middle line:84% Your support will help MIT OpenCourseWare continue to 00:00:06.920 --> 00:00:10.570 align:middle line:84% offer high quality educational resources for free. 00:00:10.570 --> 00:00:13.470 align:middle line:84% To make a donation or view additional materials from 00:00:13.470 --> 00:00:19.300 align:middle line:84% hundreds of MIT courses, visit MIT OpenCourseWare at 00:00:19.300 --> 00:00:20.790 align:middle line:90% ocw.mit.edu. 00:00:20.790 --> 00:00:24.290 align:middle line:84% Some content in this audio is not covered under a Creative 00:00:24.290 --> 00:00:25.780 align:middle line:90% Commons license. 00:00:25.780 --> 00:00:29.790 align:middle line:84% For more information, see the course materials on the MIT 00:00:29.790 --> 00:00:31.320 align:middle line:90% OpenCourseWare website. 00:00:31.320 --> 00:00:33.160 align:middle line:90% PROFESSOR: [UNINTELLIGIBLE] 00:00:33.160 --> 00:00:36.210 align:middle line:84% and we will spend the next couple of weeks grading them. 00:00:36.210 --> 00:00:39.440 align:middle line:84% But that was pretty fun on Friday so [UNINTELLIGIBLE]. 00:00:39.440 --> 00:00:43.370 align:middle line:90% 00:00:43.370 --> 00:00:45.560 align:middle line:84% We've been talking these past couple of weeks-- 00:00:45.560 --> 00:00:50.290 align:middle line:90% 00:00:50.290 --> 00:00:53.380 align:middle line:84% we've been talking the past couple of weeks about serious 00:00:53.380 --> 00:00:57.624 align:middle line:84% games, games for education, games as an art form, as a 00:00:57.624 --> 00:00:58.440 align:middle line:90% means of expression. 00:00:58.440 --> 00:01:00.280 align:middle line:84% And we're going to be continuing some of those 00:01:00.280 --> 00:01:03.220 align:middle line:90% discussions later on. 00:01:03.220 --> 00:01:06.660 align:middle line:84% But the whole idea is to sort of give you, to sort of prep 00:01:06.660 --> 00:01:09.620 align:middle line:84% you, for a situation where you're going to make a game 00:01:09.620 --> 00:01:10.360 align:middle line:90% for a client. 00:01:10.360 --> 00:01:12.400 align:middle line:84% And for this last assignment, you're actually going to be 00:01:12.400 --> 00:01:16.596 align:middle line:84% making a game based on a problem that Lisa is going to 00:01:16.596 --> 00:01:17.846 align:middle line:90% be talking about. 00:01:17.846 --> 00:01:21.090 align:middle line:90% 00:01:21.090 --> 00:01:22.490 align:middle line:84% GUEST SPEAKER 1: My name is Jim [UNINTELLIGIBLE]. 00:01:22.490 --> 00:01:24.240 align:middle line:90% I'm a clinical psychologist. 00:01:24.240 --> 00:01:24.720 align:middle line:90% I work at-- 00:01:24.720 --> 00:01:26.960 align:middle line:84% I was at Beth Israel, I'm just starting at Brigham and 00:01:26.960 --> 00:01:31.250 align:middle line:84% Women's Hospital, one of the Harvard mafia hospitals. 00:01:31.250 --> 00:01:39.240 align:middle line:84% And my area is using interactive media for clinical 00:01:39.240 --> 00:01:40.780 align:middle line:90% training but especially for 00:01:40.780 --> 00:01:42.196 align:middle line:90% treatment of clinical problems. 00:01:42.196 --> 00:01:45.300 align:middle line:84% So we make computer programs to help treat clinical 00:01:45.300 --> 00:01:47.392 align:middle line:90% disorders in psychology. 00:01:47.392 --> 00:01:50.368 align:middle line:84% GUEST SPEAKER 2: It's my turn to stand up. 00:01:50.368 --> 00:01:51.860 align:middle line:90% I'm [UNINTELLIGIBLE]. 00:01:51.860 --> 00:01:53.590 align:middle line:90% I'm a psychiatrist at UMass. 00:01:53.590 --> 00:01:56.529 align:middle line:84% I trained in the same place like Jim used 00:01:56.529 --> 00:01:58.994 align:middle line:90% to work, Beth Israel. 00:01:58.994 --> 00:02:01.952 align:middle line:84% And my focus is primarily clinical. 00:02:01.952 --> 00:02:06.389 align:middle line:84% I'm an attending psychiatrist in a variety of settings, 00:02:06.389 --> 00:02:07.375 align:middle line:90% inpatient, outpatient. 00:02:07.375 --> 00:02:11.430 align:middle line:84% And what I brought up to Jim and then Phillip was a 00:02:11.430 --> 00:02:17.540 align:middle line:84% practical question that I will try to present, which is 00:02:17.540 --> 00:02:21.374 align:middle line:84% helping psychiatry residents deal with angry, agitated, and 00:02:21.374 --> 00:02:24.350 align:middle line:84% potentially [UNINTELLIGIBLE] patients. 00:02:24.350 --> 00:02:30.804 align:middle line:84% Later this is a significant and largely unknown issue. 00:02:30.804 --> 00:02:35.784 align:middle line:84% Certainly the research is picking up, and we don't quite 00:02:35.784 --> 00:02:37.278 align:middle line:84% understand the extent of the problem. 00:02:37.278 --> 00:02:39.270 align:middle line:90% And but I'll say more. 00:02:39.270 --> 00:02:41.770 align:middle line:84% I'll save it for our presentation. 00:02:41.770 --> 00:02:44.060 align:middle line:90% Thank you for coming here. 00:02:44.060 --> 00:02:48.780 align:middle line:84% PROFESSOR: So when they contacted me, there was the 00:02:48.780 --> 00:02:51.565 align:middle line:84% usual interest in trying to make some sort of digital 00:02:51.565 --> 00:02:55.629 align:middle line:84% piece of software to help the training residents in learning 00:02:55.629 --> 00:03:02.260 align:middle line:84% how to deal with violence in mental institutions. 00:03:02.260 --> 00:03:06.120 align:middle line:84% And immediately the first thing that I thought, well 00:03:06.120 --> 00:03:07.940 align:middle line:84% before we jump right into digital, let's try doing 00:03:07.940 --> 00:03:09.900 align:middle line:90% something in analog first. 00:03:09.900 --> 00:03:12.740 align:middle line:84% Let's try prototyping something first. 00:03:12.740 --> 00:03:16.316 align:middle line:84% But it also occurred to me that, in the real world of 00:03:16.316 --> 00:03:20.950 align:middle line:84% game design, there's actually a lot more jobs in game design 00:03:20.950 --> 00:03:23.680 align:middle line:84% outside of the game industry than inside the game industry. 00:03:23.680 --> 00:03:26.100 align:middle line:84% There are a lot of companies out there that are basically 00:03:26.100 --> 00:03:27.800 align:middle line:90% looking for solutions. 00:03:27.800 --> 00:03:29.700 align:middle line:90% Some of which may be games. 00:03:29.700 --> 00:03:35.290 align:middle line:84% And you might end up working in some of those capacities. 00:03:35.290 --> 00:03:37.200 align:middle line:84% A lot of folks in advertising for instance 00:03:37.200 --> 00:03:38.715 align:middle line:90% are involved in games. 00:03:38.715 --> 00:03:41.880 align:middle line:84% A lot of folks who are interested in improving 00:03:41.880 --> 00:03:47.980 align:middle line:84% teaching methods, or improving simulations, working on-- 00:03:47.980 --> 00:03:51.860 align:middle line:84% trying to think of an example-- 00:03:51.860 --> 00:03:53.730 align:middle line:90% public awareness. 00:03:53.730 --> 00:04:00.910 align:middle line:84% And people who are also now working in website design and 00:04:00.910 --> 00:04:04.200 align:middle line:84% in various online services, who are trying to think about 00:04:04.200 --> 00:04:07.010 align:middle line:84% how to make their experiences a little bit more game like. 00:04:07.010 --> 00:04:09.580 align:middle line:84% There are really really good ways of doing that, and there 00:04:09.580 --> 00:04:11.460 align:middle line:84% are really really bad ways of doing that. 00:04:11.460 --> 00:04:14.780 align:middle line:84% And for the most part what we're hoping is that, if you 00:04:14.780 --> 00:04:16.538 align:middle line:84% end up getting one of those jobs, you're going to be able 00:04:16.538 --> 00:04:19.440 align:middle line:84% to bring some of your personal insight as having actually 00:04:19.440 --> 00:04:23.015 align:middle line:84% done game design, as opposed to just copying what games 00:04:23.015 --> 00:04:27.217 align:middle line:84% have done, and just assuming, well, it kind of looks like a 00:04:27.217 --> 00:04:28.250 align:middle line:90% game, therefore it is a game. 00:04:28.250 --> 00:04:32.460 align:middle line:90% You guys know that now. 00:04:32.460 --> 00:04:35.910 align:middle line:84% So this is kind of get your feet wet, in terms of 00:04:35.910 --> 00:04:41.170 align:middle line:84% designing something, designing for somebody else's needs. 00:04:41.170 --> 00:04:45.080 align:middle line:84% The important thing to keep in mind is, who is going to be 00:04:45.080 --> 00:04:48.740 align:middle line:84% playing your game, or who's this game intended for. 00:04:48.740 --> 00:04:51.640 align:middle line:84% And in what context are they going to be playing your game. 00:04:51.640 --> 00:04:54.710 align:middle line:84% One of the particular problems that you're trying to address, 00:04:54.710 --> 00:04:56.030 align:middle line:84% what's the part of the system that 00:04:56.030 --> 00:04:58.690 align:middle line:90% you're trying to simulate. 00:04:58.690 --> 00:05:05.040 align:middle line:84% And what kinds of insights do you hope people are going to 00:05:05.040 --> 00:05:06.010 align:middle line:90% get out of that. 00:05:06.010 --> 00:05:08.060 align:middle line:84% The problem they're going to talk about it huge. 00:05:08.060 --> 00:05:10.650 align:middle line:84% If you noticed I uploaded actually four readings to the 00:05:10.650 --> 00:05:12.630 align:middle line:90% class website. 00:05:12.630 --> 00:05:15.220 align:middle line:84% Only one of them is required, but all of them are useful. 00:05:15.220 --> 00:05:16.670 align:middle line:90% I will be uploading more. 00:05:16.670 --> 00:05:19.780 align:middle line:84% These are all reference material for the team to use 00:05:19.780 --> 00:05:21.370 align:middle line:90% however you wish. 00:05:21.370 --> 00:05:24.080 align:middle line:84% Because the problem is so huge and vast, you don't have to 00:05:24.080 --> 00:05:24.910 align:middle line:90% solve the whole problem. 00:05:24.910 --> 00:05:27.870 align:middle line:84% You pick one thing that you're excited about, that you're 00:05:27.870 --> 00:05:29.690 align:middle line:84% interested about, and that you think that you might have a 00:05:29.690 --> 00:05:31.950 align:middle line:90% good strategy. 00:05:31.950 --> 00:05:32.940 align:middle line:90% Do the usual brainstorm. 00:05:32.940 --> 00:05:35.277 align:middle line:84% We're going to be going through brainstorming and team 00:05:35.277 --> 00:05:37.980 align:middle line:84% selection pretty much just this week. 00:05:37.980 --> 00:05:40.540 align:middle line:90% 00:05:40.540 --> 00:05:44.445 align:middle line:84% And try to identify some small part that might be addressable 00:05:44.445 --> 00:05:48.205 align:middle line:84% with a card game or a board game, or I'll talk a little 00:05:48.205 --> 00:05:51.442 align:middle line:84% bit about role-playing games in a couple of weeks. 00:05:51.442 --> 00:05:54.680 align:middle line:84% So with that being said I'm going to turn 00:05:54.680 --> 00:05:59.000 align:middle line:90% it over to you guys. 00:05:59.000 --> 00:06:02.298 align:middle line:84% GUEST SPEAKER 2: OK so we'll try to take turns to talk 00:06:02.298 --> 00:06:08.250 align:middle line:84% about violence in psychiatry, in particular. 00:06:08.250 --> 00:06:12.370 align:middle line:84% So as Jim has pointed out, violence is a large issue. 00:06:12.370 --> 00:06:17.260 align:middle line:84% What I'm going to try to focus on, as I mentioned earlier, 00:06:17.260 --> 00:06:19.676 align:middle line:84% rather than engaging with psychiatric patients, 00:06:19.676 --> 00:06:22.634 align:middle line:84% especially psychiatric patients on an inpatient 00:06:22.634 --> 00:06:30.980 align:middle line:84% program, which is where the question for me came from. 00:06:30.980 --> 00:06:36.330 align:middle line:84% And obviously violence can be looked at in 00:06:36.330 --> 00:06:38.280 align:middle line:90% a variety of ways. 00:06:38.280 --> 00:06:43.596 align:middle line:84% And I think in one of the handouts that I sent to 00:06:43.596 --> 00:06:49.045 align:middle line:84% Philip, Violence in Mental Illness, they talk about the 00:06:49.045 --> 00:06:52.496 align:middle line:84% biological, psychological theories that the social 00:06:52.496 --> 00:06:57.919 align:middle line:84% dimension of violence and how it can be understood. 00:06:57.919 --> 00:07:02.370 align:middle line:84% If you look at the human development, and no matter 00:07:02.370 --> 00:07:04.934 align:middle line:84% what theory you consider, either a traditional 00:07:04.934 --> 00:07:10.000 align:middle line:84% drive-based theory like Freud or Erikson's stages, each 00:07:10.000 --> 00:07:16.370 align:middle line:84% seems to define a certain developmental goal, and often, 00:07:16.370 --> 00:07:20.330 align:middle line:84% achieving or achieving in a faulty way that goal can 00:07:20.330 --> 00:07:24.128 align:middle line:90% create potential for aggression 00:07:24.128 --> 00:07:26.900 align:middle line:90% and sometimes violence. 00:07:26.900 --> 00:07:32.340 align:middle line:84% A little child or an adult who's dependent or needs are 00:07:32.340 --> 00:07:39.312 align:middle line:84% frustrated may try to takeover and get those met, in one way 00:07:39.312 --> 00:07:40.980 align:middle line:90% or another. 00:07:40.980 --> 00:07:46.752 align:middle line:84% So what I use as a [UNINTELLIGIBLE] metaphor for 00:07:46.752 --> 00:07:51.750 align:middle line:84% the origins of violence is a communication breakdown. 00:07:51.750 --> 00:07:56.286 align:middle line:84% At some level, something doesn't happen right between 00:07:56.286 --> 00:08:02.130 align:middle line:84% the person who gets angry and those around him or her. 00:08:02.130 --> 00:08:06.080 align:middle line:84% So in a most generic way, basically communication is 00:08:06.080 --> 00:08:10.045 align:middle line:84% less about who says what to whom, than in what channel, 00:08:10.045 --> 00:08:12.440 align:middle line:90% and with what affect. 00:08:12.440 --> 00:08:14.606 align:middle line:84% The breakdown can occur at many levels. 00:08:14.606 --> 00:08:18.078 align:middle line:84% Again, this is the generic form. 00:08:18.078 --> 00:08:19.250 align:middle line:90% I hope I'll [UNINTELLIGIBLE] 00:08:19.250 --> 00:08:20.170 align:middle line:90% what I mean. 00:08:20.170 --> 00:08:25.320 align:middle line:84% And especially what can be done at a practical level, 00:08:25.320 --> 00:08:28.644 align:middle line:84% let's say when you are the resident on call at night. 00:08:28.644 --> 00:08:31.787 align:middle line:84% And the staff calls you up and says so and so is getting out 00:08:31.787 --> 00:08:32.549 align:middle line:90% of control. 00:08:32.549 --> 00:08:36.747 align:middle line:84% She's raising her voice, threatening, pounding walls, 00:08:36.747 --> 00:08:38.580 align:middle line:84% wanting to get out, refusing medications. 00:08:38.580 --> 00:08:40.860 align:middle line:84% How do you approach such a person? 00:08:40.860 --> 00:08:42.780 align:middle line:84% And again, the intervention can happen 00:08:42.780 --> 00:08:43.500 align:middle line:90% at different levels. 00:08:43.500 --> 00:08:50.190 align:middle line:84% And actually one goal of the training, or potentially the 00:08:50.190 --> 00:08:54.090 align:middle line:84% game that you might consider, is what to do. 00:08:54.090 --> 00:08:58.390 align:middle line:84% How do you establish when do you engage fully, by yourself, 00:08:58.390 --> 00:09:01.670 align:middle line:84% with outside help, when intervention is minimal and 00:09:01.670 --> 00:09:06.560 align:middle line:84% you just bring pens with you, restrain the patient, use 00:09:06.560 --> 00:09:07.350 align:middle line:90% pharmacology. 00:09:07.350 --> 00:09:08.640 align:middle line:84% So it's a continuum of interventions. 00:09:08.640 --> 00:09:12.038 align:middle line:84% I'm going to just focus on what to do when you can 00:09:12.038 --> 00:09:15.950 align:middle line:90% actually engage the patient. 00:09:15.950 --> 00:09:21.060 align:middle line:84% Again, continuing the metaphor is what Walter Fisher has 00:09:21.060 --> 00:09:26.970 align:middle line:84% described as this type of narrative, rationality, as 00:09:26.970 --> 00:09:32.930 align:middle line:84% opposed to the traditional rational paradigm that defines 00:09:32.930 --> 00:09:41.190 align:middle line:84% people as thinking beings that actually do make decisions and 00:09:41.190 --> 00:09:43.855 align:middle line:84% base their actions on evidential reasoning. 00:09:43.855 --> 00:09:45.810 align:middle line:90% Or rational people. 00:09:45.810 --> 00:09:47.016 align:middle line:90% We analyze the situation. 00:09:47.016 --> 00:09:50.130 align:middle line:84% We come up with the best possible outcome. 00:09:50.130 --> 00:09:54.170 align:middle line:84% Walter Fisher talks about that fact that we are all 00:09:54.170 --> 00:09:58.040 align:middle line:84% storytellers, that we try to interact and understand others 00:09:58.040 --> 00:10:00.990 align:middle line:84% based on the narrative that we have about 00:10:00.990 --> 00:10:02.445 align:middle line:90% ourselves and about others. 00:10:02.445 --> 00:10:04.870 align:middle line:84% My assumption, and again, this is just the introductory 00:10:04.870 --> 00:10:09.800 align:middle line:84% metaphor if you want, that at some point violence can be 00:10:09.800 --> 00:10:14.830 align:middle line:84% caused by a disruption in this narrative. 00:10:14.830 --> 00:10:16.330 align:middle line:84% Things don't make sense anymore. 00:10:16.330 --> 00:10:18.840 align:middle line:90% We feel misunderstood. 00:10:18.840 --> 00:10:21.650 align:middle line:84% We feel the victim of an injustice. 00:10:21.650 --> 00:10:25.488 align:middle line:84% And that those principles apply to somebody who is 00:10:25.488 --> 00:10:26.721 align:middle line:84% struggling with a mental illness. 00:10:26.721 --> 00:10:31.158 align:middle line:84% Where things have a much narrower window of opportunity 00:10:31.158 --> 00:10:34.273 align:middle line:84% than for people who are able to flexibly adapt to the 00:10:34.273 --> 00:10:35.523 align:middle line:90% demands of reality. 00:10:35.523 --> 00:10:37.590 align:middle line:90% 00:10:37.590 --> 00:10:44.250 align:middle line:84% So we all know who this is, and the reason I put it up-- 00:10:44.250 --> 00:10:48.606 align:middle line:84% and I have to admit I haven't looked into the copyright, I 00:10:48.606 --> 00:10:52.610 align:middle line:84% know there are longer and longer copyright rules for 00:10:52.610 --> 00:10:56.440 align:middle line:84% using cartoons, so you'll have to forgive me. 00:10:56.440 --> 00:10:59.820 align:middle line:84% My point is that this is an angry person. 00:10:59.820 --> 00:11:02.840 align:middle line:84% And as someone who is communicating. 00:11:02.840 --> 00:11:07.540 align:middle line:84% I think we get quickly and clearly the fact that his 00:11:07.540 --> 00:11:09.744 align:middle line:90% emotional range may be intense, 00:11:09.744 --> 00:11:10.648 align:middle line:90% but it's fairly narrow. 00:11:10.648 --> 00:11:15.200 align:middle line:84% It doesn't cover like a spectrum. 00:11:15.200 --> 00:11:17.560 align:middle line:84% And the communication is fairly simple. 00:11:17.560 --> 00:11:18.670 align:middle line:90% He's in distress. 00:11:18.670 --> 00:11:23.080 align:middle line:84% He is imposing his point of view, his space. 00:11:23.080 --> 00:11:28.843 align:middle line:84% He could become very aggressive and assaultive. 00:11:28.843 --> 00:11:31.880 align:middle line:84% I think that the language is very simplistic. 00:11:31.880 --> 00:11:35.010 align:middle line:84% How would we approach the Hulk in trying to calm him down and 00:11:35.010 --> 00:11:36.756 align:middle line:90% change his color? 00:11:36.756 --> 00:11:40.172 align:middle line:84% That's the end of my introductory metaphor. 00:11:40.172 --> 00:11:43.588 align:middle line:90% 00:11:43.588 --> 00:11:47.492 align:middle line:84% And please, feel free to interrupt, jump in, and make 00:11:47.492 --> 00:11:53.860 align:middle line:84% this presentation as long or as short as you want me to. 00:11:53.860 --> 00:11:57.430 align:middle line:84% There are many slides, but I'm not going to go through every 00:11:57.430 --> 00:11:58.259 align:middle line:90% single line. 00:11:58.259 --> 00:12:01.241 align:middle line:84% I'm just using this as a stimulus for the conversation 00:12:01.241 --> 00:12:03.229 align:middle line:84% especially from your perspective 00:12:03.229 --> 00:12:05.217 align:middle line:90% and from your needs. 00:12:05.217 --> 00:12:08.199 align:middle line:84% As I said, I'm a clinical provider, I'm a psychiatrist. 00:12:08.199 --> 00:12:12.843 align:middle line:84% I deal with patients all the time, many of whom are angry 00:12:12.843 --> 00:12:15.810 align:middle line:84% or potentially angry or potentially assaultive. 00:12:15.810 --> 00:12:19.715 align:middle line:84% And I may do things after so many years instinctively. 00:12:19.715 --> 00:12:23.042 align:middle line:84% But sometimes I have to think through, OK, this is the 00:12:23.042 --> 00:12:26.935 align:middle line:84% situation, how do I do to maximize the benefit for the 00:12:26.935 --> 00:12:29.273 align:middle line:84% patient I'm treating and to keep myself safe. 00:12:29.273 --> 00:12:32.908 align:middle line:84% I've been assaulted just once, in 15 years. 00:12:32.908 --> 00:12:36.150 align:middle line:90% It was like in the movies. 00:12:36.150 --> 00:12:41.021 align:middle line:84% A VA patient, former Green Beret, who got upset with the 00:12:41.021 --> 00:12:46.865 align:middle line:84% system, and picked up a very heavy armchair and lifted it 00:12:46.865 --> 00:12:48.813 align:middle line:90% above his head. 00:12:48.813 --> 00:12:52.130 align:middle line:84% And we established eye contact then. 00:12:52.130 --> 00:12:54.770 align:middle line:84% I think he wondered, what should I do with this puny 00:12:54.770 --> 00:12:55.422 align:middle line:90% little doctor? 00:12:55.422 --> 00:12:58.120 align:middle line:90% Should I squash him or not? 00:12:58.120 --> 00:13:02.530 align:middle line:84% And at the end, I guess it was a last, you know, split second 00:13:02.530 --> 00:13:05.298 align:middle line:84% moment, he decided to throw it to my side. 00:13:05.298 --> 00:13:09.561 align:middle line:84% A large section of the wall came down, so I was looking at 00:13:09.561 --> 00:13:11.780 align:middle line:84% it wondering, well I could have been 00:13:11.780 --> 00:13:12.766 align:middle line:90% that wall coming down. 00:13:12.766 --> 00:13:13.259 align:middle line:90% He ran out. 00:13:13.259 --> 00:13:15.724 align:middle line:90% It took him a while-- 00:13:15.724 --> 00:13:18.190 align:middle line:84% for people to catch up with him. 00:13:18.190 --> 00:13:21.910 align:middle line:84% And two cruisers full of police officers to subdue him. 00:13:21.910 --> 00:13:25.540 align:middle line:84% So I guess, no communication there. 00:13:25.540 --> 00:13:27.440 align:middle line:90% He was just subdued. 00:13:27.440 --> 00:13:29.720 align:middle line:84% What's the magnitude of the problem? 00:13:29.720 --> 00:13:31.160 align:middle line:90% I think it's substantial. 00:13:31.160 --> 00:13:34.435 align:middle line:84% And actually more than 10 years ago, there were some 00:13:34.435 --> 00:13:41.079 align:middle line:84% isolated reports of how significant the problem was in 00:13:41.079 --> 00:13:42.850 align:middle line:84% terms of the trainees, and especially psychiatry 00:13:42.850 --> 00:13:50.724 align:middle line:84% trainees, being the target of verbal and physical violence. 00:13:50.724 --> 00:13:54.265 align:middle line:84% On this first page I talk about medical 00:13:54.265 --> 00:13:56.680 align:middle line:90% students in one study. 00:13:56.680 --> 00:13:58.612 align:middle line:90% Numbers are relatively small. 00:13:58.612 --> 00:14:05.820 align:middle line:84% But again, the study is 14 years old. 00:14:05.820 --> 00:14:08.790 align:middle line:84% A survey of psychiatry residents showed that assaults 00:14:08.790 --> 00:14:13.550 align:middle line:84% or threats of violence are clearly one of the most 00:14:13.550 --> 00:14:15.010 align:middle line:84% difficult events in their training. 00:14:15.010 --> 00:14:18.226 align:middle line:84% And some were wondering introspectively if this is the 00:14:18.226 --> 00:14:19.680 align:middle line:90% right field for them. 00:14:19.680 --> 00:14:22.585 align:middle line:84% Actually some students may wonder reading this literature 00:14:22.585 --> 00:14:24.740 align:middle line:84% whether psychiatry is the right field 00:14:24.740 --> 00:14:27.620 align:middle line:90% for them to go into. 00:14:27.620 --> 00:14:35.456 align:middle line:84% And as you see in the fourth article, almost two-thirds of 00:14:35.456 --> 00:14:38.414 align:middle line:84% psychiatry residents were assaulted at least once during 00:14:38.414 --> 00:14:40.400 align:middle line:90% their training. 00:14:40.400 --> 00:14:44.520 align:middle line:84% And obviously like with any dangerous situation, the risk 00:14:44.520 --> 00:14:46.925 align:middle line:84% of post-traumatic symptoms can be substantial. 00:14:46.925 --> 00:14:52.660 align:middle line:84% Either acute stress response or longer lasting issues. 00:14:52.660 --> 00:14:57.804 align:middle line:84% The idea of improving their training and their ability to 00:14:57.804 --> 00:15:01.850 align:middle line:84% deal with the situation has multiple benefits. 00:15:01.850 --> 00:15:04.523 align:middle line:84% Those who know what to do are never or 00:15:04.523 --> 00:15:05.490 align:middle line:90% almost never assaulted. 00:15:05.490 --> 00:15:09.758 align:middle line:84% Not only that, if they happened to be exposed, the 00:15:09.758 --> 00:15:12.026 align:middle line:84% likelihood of developing post-traumatic goes down 00:15:12.026 --> 00:15:12.512 align:middle line:90% significantly. 00:15:12.512 --> 00:15:16.400 align:middle line:84% So I don't think I need to demonstrate 00:15:16.400 --> 00:15:17.858 align:middle line:90% that point any further. 00:15:17.858 --> 00:15:21.510 align:middle line:84% The assault rate in a more [UNINTELLIGIBLE] relatively 00:15:21.510 --> 00:15:26.846 align:middle line:84% recent study, 10 years old, pretty old, you see that 00:15:26.846 --> 00:15:31.520 align:middle line:84% overall the number of assault rate was 30% to 40%. 00:15:31.520 --> 00:15:34.256 align:middle line:84% Men tended to be slightly more physically 00:15:34.256 --> 00:15:35.714 align:middle line:90% assaulted than women. 00:15:35.714 --> 00:15:39.602 align:middle line:84% AUDIENCE: Can you define what assault means, exactly? 00:15:39.602 --> 00:15:41.060 align:middle line:90% What qualifies as assault? 00:15:41.060 --> 00:15:44.766 align:middle line:84% GUEST SPEAKER 2: Assault basically means kind of laying 00:15:44.766 --> 00:15:46.590 align:middle line:90% hands on the person. 00:15:46.590 --> 00:15:51.680 align:middle line:84% And the assault resulting in an injury, of any kind. 00:15:51.680 --> 00:15:56.890 align:middle line:84% Skin being kind of broken through or-- 00:15:56.890 --> 00:15:59.245 align:middle line:84% AUDIENCE: Just holding the clinician 00:15:59.245 --> 00:16:00.335 align:middle line:90% wouldn't be an assault? 00:16:00.335 --> 00:16:02.938 align:middle line:84% GUEST SPEAKER 2: Well it would be an assault because that 00:16:02.938 --> 00:16:08.090 align:middle line:84% kind of grabbing action could actually result in injury. 00:16:08.090 --> 00:16:13.614 align:middle line:84% And I think it would be probably very limiting to talk 00:16:13.614 --> 00:16:15.240 align:middle line:84% only about physical injuries, especially since the 00:16:15.240 --> 00:16:19.386 align:middle line:84% psychological consequences are often the longer lasting and 00:16:19.386 --> 00:16:22.230 align:middle line:90% much more significant. 00:16:22.230 --> 00:16:25.230 align:middle line:84% I think what the surveys have shown also is that how 00:16:25.230 --> 00:16:29.990 align:middle line:84% unprepared trainees in the mental health and outside the 00:16:29.990 --> 00:16:31.150 align:middle line:84% mental health field are actually. 00:16:31.150 --> 00:16:34.860 align:middle line:84% Often this is reduced to a few lectures, especially during 00:16:34.860 --> 00:16:36.150 align:middle line:90% orientation. 00:16:36.150 --> 00:16:40.970 align:middle line:84% And then they are thrown into the lion cage and they learn 00:16:40.970 --> 00:16:42.790 align:middle line:90% on the job. 00:16:42.790 --> 00:16:47.050 align:middle line:84% And many of these findings are introspective. 00:16:47.050 --> 00:16:51.220 align:middle line:84% Many trainees felt that well, I didn't say anything, because 00:16:51.220 --> 00:16:54.310 align:middle line:84% I thought I was supposed to toughen up and bite the bullet 00:16:54.310 --> 00:16:55.190 align:middle line:90% and move on. 00:16:55.190 --> 00:16:58.240 align:middle line:84% Or this is part of the job, I chose this, it's my fault. 00:16:58.240 --> 00:17:00.050 align:middle line:84% Or maybe I did something wrong. 00:17:00.050 --> 00:17:03.580 align:middle line:84% Maybe I was the one who made it so the assault happened. 00:17:03.580 --> 00:17:09.450 align:middle line:84% So a lot of reasons that were just, again, not looked into. 00:17:09.450 --> 00:17:10.314 align:middle line:90% Fear of being scrutinized. 00:17:10.314 --> 00:17:12.500 align:middle line:84% How come that I'm the one that was 00:17:12.500 --> 00:17:16.119 align:middle line:90% assaulted, and not 10 trainees. 00:17:16.119 --> 00:17:17.869 align:middle line:90% How I'm going to explain this. 00:17:17.869 --> 00:17:20.324 align:middle line:84% I was so frightened that I cannot even remember clearly 00:17:20.324 --> 00:17:20.730 align:middle line:90% what happened to me. 00:17:20.730 --> 00:17:22.670 align:middle line:84% So there are a variety of reasons why 00:17:22.670 --> 00:17:24.170 align:middle line:90% people who are in training-- 00:17:24.170 --> 00:17:28.310 align:middle line:84% and again, I'm focusing on a again a very small segment, a 00:17:28.310 --> 00:17:31.232 align:middle line:84% specific group of trainees in medical 00:17:31.232 --> 00:17:32.206 align:middle line:90% and psychiatric training. 00:17:32.206 --> 00:17:35.615 align:middle line:84% But I could easily think of other situations of people who 00:17:35.615 --> 00:17:38.605 align:middle line:84% are exposed to the potential for violence and where such 00:17:38.605 --> 00:17:40.880 align:middle line:90% training would be helpful. 00:17:40.880 --> 00:17:46.026 align:middle line:84% Up until now, and for the most part the data that I was able 00:17:46.026 --> 00:17:48.882 align:middle line:84% to collect, and most people in looking at this have been able 00:17:48.882 --> 00:17:51.270 align:middle line:90% to collect is fairly limited. 00:17:51.270 --> 00:17:53.890 align:middle line:84% There are certain limited number of programs. 00:17:53.890 --> 00:17:56.760 align:middle line:84% Methodologically the research is quite faulty. 00:17:56.760 --> 00:18:03.160 align:middle line:84% You can just talk about how limited the generalizability 00:18:03.160 --> 00:18:03.965 align:middle line:90% of the findings are. 00:18:03.965 --> 00:18:06.585 align:middle line:84% And often people have talked about what 00:18:06.585 --> 00:18:07.680 align:middle line:90% happened in the past. 00:18:07.680 --> 00:18:11.772 align:middle line:84% So clearly the recall bias is a major limiting factor in 00:18:11.772 --> 00:18:15.120 align:middle line:90% understanding what happened. 00:18:15.120 --> 00:18:18.980 align:middle line:84% Also, as Jim asked me, so how do you define assault. 00:18:18.980 --> 00:18:21.860 align:middle line:84% One of the biggest problems with most research in this 00:18:21.860 --> 00:18:26.774 align:middle line:84% field is that defining assault, aggression, is done 00:18:26.774 --> 00:18:29.330 align:middle line:90% in very idiosyncratic ways. 00:18:29.330 --> 00:18:31.955 align:middle line:84% It's hard to compare different studies. 00:18:31.955 --> 00:18:34.902 align:middle line:90% 00:18:34.902 --> 00:18:39.790 align:middle line:84% So this is a compilation of what people in different areas 00:18:39.790 --> 00:18:42.460 align:middle line:84% have thought about in terms of improving 00:18:42.460 --> 00:18:43.860 align:middle line:90% the psychiatric training. 00:18:43.860 --> 00:18:49.886 align:middle line:84% And as you see most often, in the last few years, the idea 00:18:49.886 --> 00:18:56.590 align:middle line:84% of using simulation to expose the trainees to a protected 00:18:56.590 --> 00:19:00.320 align:middle line:84% environment that has clearly defined boundaries and 00:19:00.320 --> 00:19:05.297 align:middle line:84% consequences, and basically that can be repeated almost in 00:19:05.297 --> 00:19:09.225 align:middle line:84% identical fashion in order to gain proficiency, this coming 00:19:09.225 --> 00:19:12.171 align:middle line:90% up more and more. 00:19:12.171 --> 00:19:16.410 align:middle line:84% What many training programs are doing is to use 00:19:16.410 --> 00:19:20.076 align:middle line:84% standardized patients that use actors. 00:19:20.076 --> 00:19:23.338 align:middle line:84% And that of course would behave in 00:19:23.338 --> 00:19:26.720 align:middle line:90% a programmed fashion. 00:19:26.720 --> 00:19:29.810 align:middle line:84% They make get up to you and make fists, but hopefully 00:19:29.810 --> 00:19:32.980 align:middle line:84% they'll not get so much into the role and then they're 00:19:32.980 --> 00:19:33.755 align:middle line:90% punching you. 00:19:33.755 --> 00:19:37.420 align:middle line:84% GUEST SPEAKER 1: I think this is the real challenge, is that 00:19:37.420 --> 00:19:40.271 align:middle line:84% there's different levels of learning. 00:19:40.271 --> 00:19:42.320 align:middle line:84% You can learn kind of a list of facts, things to do if your 00:19:42.320 --> 00:19:44.270 align:middle line:84% patient starts to get agitated and threatening. 00:19:44.270 --> 00:19:46.970 align:middle line:84% And you can learn how to take a test on it and forget it the 00:19:46.970 --> 00:19:49.020 align:middle line:84% next day, especially if it doesn't come up 00:19:49.020 --> 00:19:51.110 align:middle line:90% for you right away. 00:19:51.110 --> 00:19:53.400 align:middle line:84% And then there's the question of internalizing it so you 00:19:53.400 --> 00:19:56.380 align:middle line:84% actually have not just kind of a working knowledge but really 00:19:56.380 --> 00:19:58.140 align:middle line:84% understand what you should do in different kinds of 00:19:58.140 --> 00:19:59.540 align:middle line:90% circumstances. 00:19:59.540 --> 00:20:03.270 align:middle line:84% And that's where the idea of role playing with live role 00:20:03.270 --> 00:20:04.440 align:middle line:90% plays for the trainees-- 00:20:04.440 --> 00:20:06.960 align:middle line:84% it could be residents, and mental health providers-- 00:20:06.960 --> 00:20:10.390 align:middle line:84% can really be helpful so they have some sense, some 00:20:10.390 --> 00:20:15.120 align:middle line:84% semblance of this kind of training. 00:20:15.120 --> 00:20:18.180 align:middle line:84% But the tricky things with these role plays is it's not 00:20:18.180 --> 00:20:23.490 align:middle line:84% easy to ensure that everybody receives high quality access 00:20:23.490 --> 00:20:25.270 align:middle line:90% to well trained actors. 00:20:25.270 --> 00:20:28.310 align:middle line:84% Here at Harvard Medical School, they probably do. 00:20:28.310 --> 00:20:29.610 align:middle line:90% At UMass, they probably do. 00:20:29.610 --> 00:20:30.850 align:middle line:90% But there's a lot of places. 00:20:30.850 --> 00:20:33.122 align:middle line:84% And if you expand beyond psychiatry to every mental 00:20:33.122 --> 00:20:35.560 align:middle line:84% health center in the country, every caseworker who is going 00:20:35.560 --> 00:20:38.720 align:middle line:84% out to visit a patient at their home, or social worker, 00:20:38.720 --> 00:20:41.310 align:middle line:84% they're definitely not getting this kind of training. 00:20:41.310 --> 00:20:45.510 align:middle line:84% And so the ones who really I think you said before are 00:20:45.510 --> 00:20:46.940 align:middle line:84% really well trained are the nurses, actually. 00:20:46.940 --> 00:20:49.090 align:middle line:84% Because they get a different kind of training that's really 00:20:49.090 --> 00:20:50.980 align:middle line:84% pretty effective, it sounds like. 00:20:50.980 --> 00:20:52.870 align:middle line:84% But the mental health care providers 00:20:52.870 --> 00:20:53.900 align:middle line:90% often have no training. 00:20:53.900 --> 00:20:55.980 align:middle line:84% And then they're the ones who are kind of in a closed room 00:20:55.980 --> 00:20:59.040 align:middle line:84% with the person who can become really violent. 00:20:59.040 --> 00:21:01.665 align:middle line:84% Especially if it's at their home, or an inpatient unit. 00:21:01.665 --> 00:21:03.750 align:middle line:84% GUEST SPEAKER 2: Jim was making reference to that 00:21:03.750 --> 00:21:07.000 align:middle line:84% psychiatrist at MGH who last year was stabbed by a patient 00:21:07.000 --> 00:21:08.650 align:middle line:90% in the outpatient clinic. 00:21:08.650 --> 00:21:10.475 align:middle line:84% GUEST SPEAKER 1: You all hear about this last year? 00:21:10.475 --> 00:21:12.295 align:middle line:84% Can you just describe the situation? 00:21:12.295 --> 00:21:14.826 align:middle line:84% GUEST SPEAKER 2: Well, it was late in the evening, when most 00:21:14.826 --> 00:21:17.230 align:middle line:84% things like this have the potential of happening. 00:21:17.230 --> 00:21:22.620 align:middle line:84% This was a neuro evaluation or [UNINTELLIGIBLE] 00:21:22.620 --> 00:21:25.490 align:middle line:90% in the Bipolar Clinic at MGH. 00:21:25.490 --> 00:21:31.333 align:middle line:84% Basically he was angry from the beginning and was able to 00:21:31.333 --> 00:21:32.800 align:middle line:90% stab repeatedly. 00:21:32.800 --> 00:21:36.280 align:middle line:84% An off guard person who just happened to walk by. 00:21:36.280 --> 00:21:37.720 align:middle line:84% GUEST SPEAKER 1: It was a police officer, right? 00:21:37.720 --> 00:21:38.290 align:middle line:90% GUEST SPEAKER 2: Yeah. 00:21:38.290 --> 00:21:41.360 align:middle line:84% He was one of the security people for 00:21:41.360 --> 00:21:42.360 align:middle line:90% that particular clinic. 00:21:42.360 --> 00:21:44.340 align:middle line:90% He came and he had a gun. 00:21:44.340 --> 00:21:47.830 align:middle line:84% I don't know how often off-duty security people carry 00:21:47.830 --> 00:21:49.240 align:middle line:90% their guns. 00:21:49.240 --> 00:21:52.130 align:middle line:84% But he opened and killed the patient. 00:21:52.130 --> 00:21:55.724 align:middle line:90% So he was charged. 00:21:55.724 --> 00:21:58.210 align:middle line:90% Eventually was cleared. 00:21:58.210 --> 00:21:59.690 align:middle line:90% For using excessive force. 00:21:59.690 --> 00:22:01.020 align:middle line:84% GUEST SPEAKER 1: What happened to the psychiatrist? 00:22:01.020 --> 00:22:03.686 align:middle line:84% GUEST SPEAKER 2: Well, the psychiatrist was admitted into 00:22:03.686 --> 00:22:07.074 align:middle line:84% the hospital and required extensive surgeries. 00:22:07.074 --> 00:22:10.946 align:middle line:84% She was stabbed in the chest and in the neck. 00:22:10.946 --> 00:22:14.095 align:middle line:84% It was a fairly gruesome-- she survived and I think she's 00:22:14.095 --> 00:22:14.940 align:middle line:90% back at work. 00:22:14.940 --> 00:22:16.980 align:middle line:90% But this is an extreme case. 00:22:16.980 --> 00:22:21.450 align:middle line:84% And I'm afraid that many of the things that we talk about, 00:22:21.450 --> 00:22:23.800 align:middle line:84% the principles that we may come up with, may not 00:22:23.800 --> 00:22:28.620 align:middle line:84% necessarily be so helpful, other than thinking back at a 00:22:28.620 --> 00:22:29.445 align:middle line:90% level of intervention. 00:22:29.445 --> 00:22:33.230 align:middle line:84% It is quite conceivable that for somebody who charges at 00:22:33.230 --> 00:22:36.066 align:middle line:84% you, you won't be able to talk him down, you won't be able to 00:22:36.066 --> 00:22:40.682 align:middle line:84% use any of the nice de-escalation principles that 00:22:40.682 --> 00:22:42.480 align:middle line:84% I'm going to talk about in a few minutes. 00:22:42.480 --> 00:22:45.290 align:middle line:84% But, figuring out what do, I think it means 00:22:45.290 --> 00:22:45.982 align:middle line:90% [UNINTELLIGIBLE]. 00:22:45.982 --> 00:22:50.690 align:middle line:84% AUDIENCE: You mentioned that nurses have a different 00:22:50.690 --> 00:22:53.720 align:middle line:84% training system for this, and it seems to be effective. 00:22:53.720 --> 00:22:56.630 align:middle line:90% 00:22:56.630 --> 00:22:59.150 align:middle line:84% What is that training, like what is different about what 00:22:59.150 --> 00:23:00.386 align:middle line:90% nurses get taught? 00:23:00.386 --> 00:23:05.420 align:middle line:84% GUEST SPEAKER 2: Well, there are some, in most states, 00:23:05.420 --> 00:23:11.484 align:middle line:84% there are some regulations that try to implement some 00:23:11.484 --> 00:23:14.412 align:middle line:84% level of training or are designed specifically for 00:23:14.412 --> 00:23:17.600 align:middle line:84% patients who get out of control. 00:23:17.600 --> 00:23:19.430 align:middle line:84% And that's not only psychiatry. 00:23:19.430 --> 00:23:25.595 align:middle line:84% Emergency room teams have probably the most highest rate 00:23:25.595 --> 00:23:29.640 align:middle line:84% of assaultive patients, across diagnostic departments. 00:23:29.640 --> 00:23:32.278 align:middle line:84% Often psychiatric patients, especially patients using 00:23:32.278 --> 00:23:35.530 align:middle line:84% substance abuse, will get out of control. 00:23:35.530 --> 00:23:39.690 align:middle line:84% So if you want to become an emergency physician, or if you 00:23:39.690 --> 00:23:42.649 align:middle line:84% work in the field as an EMT or another capacity, you'll have 00:23:42.649 --> 00:23:44.400 align:middle line:90% to deal with these situations. 00:23:44.400 --> 00:23:50.460 align:middle line:84% What makes the nurses somewhat better trained is that they 00:23:50.460 --> 00:23:54.032 align:middle line:84% often are the frontline staff dealing with 00:23:54.032 --> 00:23:55.180 align:middle line:90% out of control patients. 00:23:55.180 --> 00:23:57.478 align:middle line:84% And I think that's probably pretty sad, because physicians 00:23:57.478 --> 00:24:01.350 align:middle line:84% should be equally, and trainees, physicians and 00:24:01.350 --> 00:24:04.254 align:middle line:84% trainees should be equally well trained. 00:24:04.254 --> 00:24:08.580 align:middle line:84% But on the nursing front, there has been some progress. 00:24:08.580 --> 00:24:11.170 align:middle line:84% In Massachusetts, the Department of Mental Health 00:24:11.170 --> 00:24:13.250 align:middle line:90% has some mandatory training. 00:24:13.250 --> 00:24:17.590 align:middle line:84% But there's a lot of red tape there, but there a lot of 00:24:17.590 --> 00:24:20.455 align:middle line:84% helpful aspects, including aspects 00:24:20.455 --> 00:24:23.412 align:middle line:90% related to stop attacks. 00:24:23.412 --> 00:24:28.410 align:middle line:84% And I wish I could have presented a recording of a 00:24:28.410 --> 00:24:31.270 align:middle line:90% training session for staff. 00:24:31.270 --> 00:24:35.230 align:middle line:84% When I went to it, I thought it would be something like a 00:24:35.230 --> 00:24:37.593 align:middle line:84% very spectacular kind of kung-fu, how you do it. 00:24:37.593 --> 00:24:41.510 align:middle line:84% When in fact, the emphasis is how to keep yourself safe, and 00:24:41.510 --> 00:24:44.410 align:middle line:84% believe it or not how to keep the person safe, the person 00:24:44.410 --> 00:24:49.620 align:middle line:84% that you're blocking the punches, the person that may 00:24:49.620 --> 00:24:55.040 align:middle line:84% be trying to strangle you, or keep you in a stronghold, or 00:24:55.040 --> 00:24:57.750 align:middle line:90% scratch you, or rip your hair. 00:24:57.750 --> 00:25:00.170 align:middle line:84% Again, even when you're trying to be intervene or you're 00:25:00.170 --> 00:25:03.109 align:middle line:84% trying to protect yourself, and keep the 00:25:03.109 --> 00:25:04.558 align:middle line:90% other person safe. 00:25:04.558 --> 00:25:10.360 align:middle line:84% No punching, kicking, no kind of spectacular steps. 00:25:10.360 --> 00:25:15.816 align:middle line:84% But again, that's also I feel could be an interesting topic 00:25:15.816 --> 00:25:17.812 align:middle line:90% for a simulation. 00:25:17.812 --> 00:25:20.806 align:middle line:90% How do you interact with-- 00:25:20.806 --> 00:25:24.299 align:middle line:84% especially since again I'm a totally kind of 00:25:24.299 --> 00:25:26.810 align:middle line:90% outsider in the field. 00:25:26.810 --> 00:25:31.020 align:middle line:84% Having kids, they were asking me the other day about 00:25:31.020 --> 00:25:32.270 align:middle line:90% Microsoft's Kinect. 00:25:32.270 --> 00:25:34.190 align:middle line:90% 00:25:34.190 --> 00:25:37.985 align:middle line:84% And I thought that was really interesting because the level 00:25:37.985 --> 00:25:43.890 align:middle line:84% of interaction with computer generated interfaces is very 00:25:43.890 --> 00:25:47.335 align:middle line:84% interesting, and certainly would be a safe bet to be 00:25:47.335 --> 00:25:50.245 align:middle line:84% attacked by somebody from the TV. 00:25:50.245 --> 00:25:54.530 align:middle line:84% AUDIENCE: It sounds like the nurses get better training 00:25:54.530 --> 00:25:58.840 align:middle line:84% because the states require them to have better training. 00:25:58.840 --> 00:25:59.760 align:middle line:84% GUEST SPEAKER 2: That's correct. 00:25:59.760 --> 00:26:00.680 align:middle line:90% That's a part of it. 00:26:00.680 --> 00:26:04.950 align:middle line:84% I've been trying at UMass to suggest that not only the 00:26:04.950 --> 00:26:09.930 align:middle line:84% staff physicians get exposed to the training but even the 00:26:09.930 --> 00:26:12.110 align:middle line:84% psychiatry trainees and other trainees, especially in 00:26:12.110 --> 00:26:13.270 align:middle line:90% emergency medicine. 00:26:13.270 --> 00:26:16.204 align:middle line:84% They should all really know about it. 00:26:16.204 --> 00:26:18.921 align:middle line:84% GUEST SPEAKER 1: I suspect some of this have to do with 00:26:18.921 --> 00:26:20.156 align:middle line:84% the benefits of being in a union. 00:26:20.156 --> 00:26:23.614 align:middle line:84% So a union can demand that nurses receive this better 00:26:23.614 --> 00:26:26.084 align:middle line:84% training, where the physicians don't have a union. 00:26:26.084 --> 00:26:28.090 align:middle line:84% GUEST SPEAKER 2: It's also about numbers. 00:26:28.090 --> 00:26:31.720 align:middle line:84% On any unit, you have six, seven 00:26:31.720 --> 00:26:33.420 align:middle line:90% nurses for one physician. 00:26:33.420 --> 00:26:36.400 align:middle line:84% And the nurses are there in shifts around the clock. 00:26:36.400 --> 00:26:39.686 align:middle line:84% So their likelihood of being exposed to an out-of-control 00:26:39.686 --> 00:26:42.320 align:middle line:90% patient are much higher. 00:26:42.320 --> 00:26:46.380 align:middle line:84% Usually on these units people intervene as a team. 00:26:46.380 --> 00:26:51.796 align:middle line:84% And as a team leader that tries to apply so many of the 00:26:51.796 --> 00:26:52.800 align:middle line:84% principles I'm going to talk about. 00:26:52.800 --> 00:26:57.216 align:middle line:84% And then if there is need for seclusion or restraints, then 00:26:57.216 --> 00:27:00.330 align:middle line:84% that has to be done in a coordinated fashion. 00:27:00.330 --> 00:27:02.894 align:middle line:84% And things are much clearer, as I said, 00:27:02.894 --> 00:27:04.630 align:middle line:90% on the nursing front. 00:27:04.630 --> 00:27:06.340 align:middle line:84% Maybe because they are doing it all the time and because 00:27:06.340 --> 00:27:08.498 align:middle line:84% there are some tight regulations, 00:27:08.498 --> 00:27:11.942 align:middle line:90% because they're unionized. 00:27:11.942 --> 00:27:16.472 align:middle line:84% And at least half of the literature really comes from 00:27:16.472 --> 00:27:17.650 align:middle line:90% the nursing direction. 00:27:17.650 --> 00:27:23.050 align:middle line:90% So that's a tangent. 00:27:23.050 --> 00:27:27.215 align:middle line:84% PROFESSOR: Just want to ride off the Kinect comment that 00:27:27.215 --> 00:27:28.065 align:middle line:90% you were making. 00:27:28.065 --> 00:27:30.125 align:middle line:84% We will be talking about a little bit more about live 00:27:30.125 --> 00:27:33.790 align:middle line:84% action games so that's kind of how you prototype something 00:27:33.790 --> 00:27:37.156 align:middle line:84% that's going to be a motion gesture computer game. 00:27:37.156 --> 00:27:38.320 align:middle line:90% You don't obfuscate. 00:27:38.320 --> 00:27:42.434 align:middle line:84% Actually having to write code to do that, that sort of body 00:27:42.434 --> 00:27:45.843 align:middle line:84% recognition, is kind of annoying and expensive. 00:27:45.843 --> 00:27:50.226 align:middle line:84% But you can test off a lot of ideas just by having two 00:27:50.226 --> 00:27:51.690 align:middle line:90% people play with coding. 00:27:51.690 --> 00:27:54.500 align:middle line:84% Safety becomes the biggest concern for 00:27:54.500 --> 00:27:55.530 align:middle line:90% the players as well. 00:27:55.530 --> 00:27:58.659 align:middle line:84% It's kind of interesting in this particular case that you 00:27:58.659 --> 00:28:00.887 align:middle line:84% are trying to teach someone how to prevent 00:28:00.887 --> 00:28:04.440 align:middle line:90% damage to both parties. 00:28:04.440 --> 00:28:06.030 align:middle line:84% That actually kind of helps you with the 00:28:06.030 --> 00:28:09.050 align:middle line:90% design a lot actually. 00:28:09.050 --> 00:28:12.145 align:middle line:90% That's only one problem. 00:28:12.145 --> 00:28:16.065 align:middle line:84% You'll go into more details about the kinds of things to 00:28:16.065 --> 00:28:19.516 align:middle line:84% prevent it escalating into actual conflict. 00:28:19.516 --> 00:28:24.446 align:middle line:84% GUEST SPEAKER 2: And the idea is basically to do your best 00:28:24.446 --> 00:28:27.897 align:middle line:84% to not end up at that particular extreme of direct 00:28:27.897 --> 00:28:31.850 align:middle line:90% combat, which is not-- 00:28:31.850 --> 00:28:33.520 align:middle line:84% So ideally you don't have to go there. 00:28:33.520 --> 00:28:36.580 align:middle line:84% And as I said in 15 years I've been assaulted once. 00:28:36.580 --> 00:28:38.340 align:middle line:90% I'm sure I was lucky. 00:28:38.340 --> 00:28:43.750 align:middle line:84% People think that my eyebrows are intimidating. 00:28:43.750 --> 00:28:50.198 align:middle line:84% So don't tend to get very [UNINTELLIGIBLE]. 00:28:50.198 --> 00:28:53.500 align:middle line:84% Again I'm going to tell a few, you know, tell you about a few 00:28:53.500 --> 00:28:55.470 align:middle line:84% pearls and a few tricks that I personally use. 00:28:55.470 --> 00:29:00.010 align:middle line:84% It may not be helpful for everybody. 00:29:00.010 --> 00:29:02.070 align:middle line:84% Over time, you develop you own style. 00:29:02.070 --> 00:29:08.168 align:middle line:84% The idea is to be able to make an assessment and try to take 00:29:08.168 --> 00:29:09.136 align:middle line:90% preventative steps. 00:29:09.136 --> 00:29:10.588 align:middle line:90% And I think that's the secret. 00:29:10.588 --> 00:29:14.460 align:middle line:84% And this is what I hope better training may be the user 00:29:14.460 --> 00:29:16.396 align:middle line:84% simulation and gaming would be helpful. 00:29:16.396 --> 00:29:19.300 align:middle line:90% 00:29:19.300 --> 00:29:25.010 align:middle line:84% Now I'm going to just, I'm going to jump into talking 00:29:25.010 --> 00:29:29.195 align:middle line:84% about prevention and [UNINTELLIGIBLE] 00:29:29.195 --> 00:29:32.930 align:middle line:84% but identifying how you assess and how you think about the 00:29:32.930 --> 00:29:34.380 align:middle line:90% potential for violence. 00:29:34.380 --> 00:29:41.282 align:middle line:84% And these are some known risk factors for aggression. 00:29:41.282 --> 00:29:45.154 align:middle line:84% Obviously the history of violence is the top. 00:29:45.154 --> 00:29:51.132 align:middle line:84% How recent, how frequently, those people become 00:29:51.132 --> 00:29:52.750 align:middle line:90% assaultive. 00:29:52.750 --> 00:29:55.210 align:middle line:84% What's the pattern of escalation. 00:29:55.210 --> 00:29:56.260 align:middle line:84% What are the associated symptoms. 00:29:56.260 --> 00:30:00.480 align:middle line:84% What happens before somebody becomes assaultive. 00:30:00.480 --> 00:30:02.030 align:middle line:90% Why is this important? 00:30:02.030 --> 00:30:05.999 align:middle line:84% Because you can do, and probably should do before, you 00:30:05.999 --> 00:30:09.410 align:middle line:84% engage with the patient an assessment at that level. 00:30:09.410 --> 00:30:13.170 align:middle line:84% And it will help you figure out how deep to get involved, 00:30:13.170 --> 00:30:15.050 align:middle line:84% how likely you are to [UNINTELLIGIBLE] the patient. 00:30:15.050 --> 00:30:19.206 align:middle line:84% Versus saying, oh, I don't need this, I need help, let's 00:30:19.206 --> 00:30:20.454 align:middle line:90% go in as a team. 00:30:20.454 --> 00:30:23.850 align:middle line:84% So that-- that makes it important. 00:30:23.850 --> 00:30:25.830 align:middle line:84% People often talk about violence and a rise in 00:30:25.830 --> 00:30:26.630 align:middle line:90% tendencies. 00:30:26.630 --> 00:30:28.920 align:middle line:84% Young people tend to be more assaultive, 00:30:28.920 --> 00:30:30.710 align:middle line:90% and there's no surprise. 00:30:30.710 --> 00:30:36.590 align:middle line:84% Also older people who have dementia and get more 00:30:36.590 --> 00:30:40.991 align:middle line:84% disinhibited and more likely to become reactive. 00:30:40.991 --> 00:30:43.191 align:middle line:84% I always like to tell the story about a 00:30:43.191 --> 00:30:43.925 align:middle line:90% patient with dementia. 00:30:43.925 --> 00:30:47.125 align:middle line:84% I was moonlighting, and he swung at me as I was passing. 00:30:47.125 --> 00:30:49.065 align:middle line:84% And then I went to talk to him. 00:30:49.065 --> 00:30:52.680 align:middle line:84% Well, I don't know, you just passed by, and I was upset, 00:30:52.680 --> 00:30:53.800 align:middle line:90% and you were the closest. 00:30:53.800 --> 00:30:56.790 align:middle line:90% So I thought I would try to-- 00:30:56.790 --> 00:31:01.320 align:middle line:84% So there was no way for me to predict that. 00:31:01.320 --> 00:31:05.336 align:middle line:84% It wasn't a serious thing, it wasn't a predatory type of 00:31:05.336 --> 00:31:07.292 align:middle line:84% assaultiveness where somebody plans. 00:31:07.292 --> 00:31:10.715 align:middle line:84% Doesn't like you, goes after you. 00:31:10.715 --> 00:31:15.116 align:middle line:84% A colleague of mine was attacked by a patient. 00:31:15.116 --> 00:31:19.517 align:middle line:84% The patient watched when people were not around, went 00:31:19.517 --> 00:31:22.290 align:middle line:84% into the doctors room, locked the 00:31:22.290 --> 00:31:24.160 align:middle line:90% door, and started punching. 00:31:24.160 --> 00:31:26.684 align:middle line:84% So that's a totally different animal. 00:31:26.684 --> 00:31:29.521 align:middle line:84% So the distinction between impulsive, affective if you 00:31:29.521 --> 00:31:36.710 align:middle line:84% want or the type of aggression and the predatory is essential 00:31:36.710 --> 00:31:39.640 align:middle line:90% to keep in mind. 00:31:39.640 --> 00:31:48.080 align:middle line:84% In some subcultures, violence is not allowed certainly much 00:31:48.080 --> 00:31:49.020 align:middle line:90% more frequent. 00:31:49.020 --> 00:31:53.322 align:middle line:84% People of a lower socioeconomic status may be 00:31:53.322 --> 00:31:56.160 align:middle line:84% more likely to become assaultive. 00:31:56.160 --> 00:31:59.035 align:middle line:84% Patients of a limited cognitive ability, especially 00:31:59.035 --> 00:32:02.899 align:middle line:84% when institutionalized, are way more likely to become 00:32:02.899 --> 00:32:03.382 align:middle line:90% assaultive. 00:32:03.382 --> 00:32:07.725 align:middle line:84% And then it's many, many diagnoses increase the 00:32:07.725 --> 00:32:09.705 align:middle line:90% likelihood of assaultiveness. 00:32:09.705 --> 00:32:13.170 align:middle line:84% The top are psychotic disorders, like schizophrenia. 00:32:13.170 --> 00:32:18.120 align:middle line:90% Mood disorders like bipolar. 00:32:18.120 --> 00:32:22.390 align:middle line:84% I told you about what we call cognitive disorders, 00:32:22.390 --> 00:32:26.460 align:middle line:84% especially dementia and confusional states. 00:32:26.460 --> 00:32:30.080 align:middle line:84% Patients that have had traumatic brain injuries or 00:32:30.080 --> 00:32:32.966 align:middle line:90% that have had epilepsy. 00:32:32.966 --> 00:32:35.852 align:middle line:84% GUEST SPEAKER 1: There's a real problem with Iraq or 00:32:35.852 --> 00:32:39.410 align:middle line:84% Afghanistan veterans, when they have had an IE explode 00:32:39.410 --> 00:32:40.540 align:middle line:90% under their vehicle. 00:32:40.540 --> 00:32:42.660 align:middle line:90% And they had a brain injury. 00:32:42.660 --> 00:32:44.750 align:middle line:84% Now they have a lot of disinhibition about violence. 00:32:44.750 --> 00:32:48.745 align:middle line:84% And they can just go off sometimes very unexpectedly. 00:32:48.745 --> 00:32:51.730 align:middle line:84% GUEST SPEAKER 2: The frontal lobe exerts a sort of 00:32:51.730 --> 00:32:57.370 align:middle line:84% inhibitory influence on our ability to function. 00:32:57.370 --> 00:33:00.350 align:middle line:84% And that allows us to plan, to think 00:33:00.350 --> 00:33:03.200 align:middle line:90% ahead, to sequence events. 00:33:03.200 --> 00:33:07.000 align:middle line:84% This is the executive function of our frontal lobe. 00:33:07.000 --> 00:33:11.864 align:middle line:84% When it's impaired either in a trauma, or after surgery, or 00:33:11.864 --> 00:33:16.256 align:middle line:84% being in an accident, or becoming demented, that 00:33:16.256 --> 00:33:22.112 align:middle line:84% ability to operate in that fashion may be impaired. 00:33:22.112 --> 00:33:25.040 align:middle line:84% Violence is a possible side effect. 00:33:25.040 --> 00:33:28.330 align:middle line:84% Substance abuse are at the top of the list, because of the 00:33:28.330 --> 00:33:33.412 align:middle line:84% disinhibition, both during the intoxication phase and during 00:33:33.412 --> 00:33:36.085 align:middle line:84% the withdrawal people tend to become very agitated and 00:33:36.085 --> 00:33:37.800 align:middle line:90% assaultive. 00:33:37.800 --> 00:33:41.668 align:middle line:84% There are certain personality disorders. 00:33:41.668 --> 00:33:46.840 align:middle line:84% So when we think about the percentage order, we have this 00:33:46.840 --> 00:33:51.315 align:middle line:84% enduring maladaptive patterns of relating to you and to 00:33:51.315 --> 00:33:53.428 align:middle line:90% others and to the world. 00:33:53.428 --> 00:33:56.886 align:middle line:84% The obsessive compulsive personality disorder likes to 00:33:56.886 --> 00:33:58.862 align:middle line:84% have things organized, planned. 00:33:58.862 --> 00:34:01.002 align:middle line:84% Nothing-- even going on vacation is 00:34:01.002 --> 00:34:01.826 align:middle line:90% an exhausting task. 00:34:01.826 --> 00:34:05.165 align:middle line:84% Nothing has to happen randomly. 00:34:05.165 --> 00:34:09.690 align:middle line:84% The grandiose personalities really need this kind of 00:34:09.690 --> 00:34:12.550 align:middle line:84% feeling coming from all directions. 00:34:12.550 --> 00:34:15.210 align:middle line:84% They need to be in the limelight. 00:34:15.210 --> 00:34:19.370 align:middle line:84% They use people, not as real people but as people that 00:34:19.370 --> 00:34:23.320 align:middle line:84% provide sustenance to their own self esteem. 00:34:23.320 --> 00:34:27.844 align:middle line:84% Two type of personality disorders are particularly 00:34:27.844 --> 00:34:31.630 align:middle line:90% likely to promote violence. 00:34:31.630 --> 00:34:37.340 align:middle line:84% The antisocial and you may have heard the term borderline 00:34:37.340 --> 00:34:40.723 align:middle line:84% personality disorder, which is basically at core has 00:34:40.723 --> 00:34:43.675 align:middle line:84% significant instability and emotions and interpersonal 00:34:43.675 --> 00:34:49.579 align:middle line:84% relationships and identity and basically 00:34:49.579 --> 00:34:51.750 align:middle line:90% their lives are a mess. 00:34:51.750 --> 00:34:55.260 align:middle line:84% Often they feel abandoned, they feel put down. 00:34:55.260 --> 00:34:59.504 align:middle line:84% They may get briefly paranoid and often they become 00:34:59.504 --> 00:35:00.390 align:middle line:90% assaultive. 00:35:00.390 --> 00:35:04.360 align:middle line:84% So again, I'm throwing a lot of terms and 00:35:04.360 --> 00:35:05.320 align:middle line:90% definitions at you. 00:35:05.320 --> 00:35:10.803 align:middle line:84% I don't want to make this a lecture about psychiatry. 00:35:10.803 --> 00:35:14.033 align:middle line:84% But these are conditions that I think are 00:35:14.033 --> 00:35:15.276 align:middle line:90% helpful to think about. 00:35:15.276 --> 00:35:19.252 align:middle line:84% AUDIENCE: When people with delusional disorders like 00:35:19.252 --> 00:35:22.731 align:middle line:84% schizophrenia get violent, is it usually because they are 00:35:22.731 --> 00:35:24.719 align:middle line:84% frustrated about something or is it because they suddenly 00:35:24.719 --> 00:35:27.701 align:middle line:84% have some sort of delusion about their clinician that 00:35:27.701 --> 00:35:30.925 align:middle line:84% involves requiring them to take some sort of action that 00:35:30.925 --> 00:35:31.875 align:middle line:90% is violent? 00:35:31.875 --> 00:35:33.150 align:middle line:90% GUEST SPEAKER 2: I think both. 00:35:33.150 --> 00:35:37.086 align:middle line:84% I think even people that have a psychotic disorder have the 00:35:37.086 --> 00:35:40.040 align:middle line:84% right to feel the victim of an injustice or 00:35:40.040 --> 00:35:41.650 align:middle line:90% feel frustrated or-- 00:35:41.650 --> 00:35:44.437 align:middle line:84% many of the reasons that I talked about could happen. 00:35:44.437 --> 00:35:49.427 align:middle line:84% But in particular, I think the other 00:35:49.427 --> 00:35:50.425 align:middle line:90% point is equally important. 00:35:50.425 --> 00:35:52.920 align:middle line:84% That they may act on a delusional conviction. 00:35:52.920 --> 00:35:59.820 align:middle line:84% Or their psychosis may also have hallucinations. 00:35:59.820 --> 00:36:04.733 align:middle line:84% And command auditory hallucinations are known to 00:36:04.733 --> 00:36:07.840 align:middle line:84% often be the forerunners of a violent attack. 00:36:07.840 --> 00:36:10.720 align:middle line:84% You talk about me and say things. 00:36:10.720 --> 00:36:14.810 align:middle line:84% Or the voice tells me, I'm going to go after you. 00:36:14.810 --> 00:36:21.310 align:middle line:84% And the person feels hopeless to resist that. 00:36:21.310 --> 00:36:24.210 align:middle line:84% I discharged a patient, was doing great. 00:36:24.210 --> 00:36:25.870 align:middle line:90% Next day he comes back. 00:36:25.870 --> 00:36:30.060 align:middle line:84% Went home, the voice told him that he needs to hurt his 00:36:30.060 --> 00:36:33.490 align:middle line:84% mother, otherwise he'll get disemboweled. 00:36:33.490 --> 00:36:37.360 align:middle line:84% So he started punching her and then chased her with a knife. 00:36:37.360 --> 00:36:42.137 align:middle line:84% She had to hide in a neighbor's house until the 00:36:42.137 --> 00:36:43.530 align:middle line:90% police arrived. 00:36:43.530 --> 00:36:47.836 align:middle line:84% There is an interesting threat control override here that 00:36:47.836 --> 00:36:52.130 align:middle line:84% people who have looked at violence have prescribed as 00:36:52.130 --> 00:36:56.340 align:middle line:84% being sometimes the proximal cause for violence. 00:36:56.340 --> 00:36:59.423 align:middle line:84% People feel directly threatened. 00:36:59.423 --> 00:37:05.345 align:middle line:84% And they also have this overpowering urge that they 00:37:05.345 --> 00:37:08.110 align:middle line:84% need to act on that they cannot resist. 00:37:08.110 --> 00:37:09.450 align:middle line:90% It's a controversial concept. 00:37:09.450 --> 00:37:12.190 align:middle line:84% I'm not so sure why we should give this particular 00:37:12.190 --> 00:37:16.492 align:middle line:84% association a higher status than other delusional 00:37:16.492 --> 00:37:20.420 align:middle line:84% convictions about the neighbors watching me or 00:37:20.420 --> 00:37:23.240 align:middle line:84% planning to kill me, or putting together a variety of 00:37:23.240 --> 00:37:28.330 align:middle line:84% clues that my friends are really trying to get rid of me 00:37:28.330 --> 00:37:29.530 align:middle line:84% and then I need to protect myself. 00:37:29.530 --> 00:37:31.230 align:middle line:90% But you are absolutely right. 00:37:31.230 --> 00:37:34.890 align:middle line:84% What's interesting even though patients with 20 psychiatric 00:37:34.890 --> 00:37:38.680 align:middle line:84% disorders may have their reasons to become assaultive, 00:37:38.680 --> 00:37:41.780 align:middle line:84% in the overall bigger scheme of things, when you look at 00:37:41.780 --> 00:37:46.240 align:middle line:84% actual violent assaults committed in society, they're 00:37:46.240 --> 00:37:48.270 align:middle line:90% responsible for a tiny one. 00:37:48.270 --> 00:37:52.343 align:middle line:84% So it's an interesting way of looking at numbers. 00:37:52.343 --> 00:37:57.170 align:middle line:84% Yes they could become violent, but the reality is that their 00:37:57.170 --> 00:38:00.130 align:middle line:84% numbers, the actual violent acts, are very small. 00:38:00.130 --> 00:38:04.906 align:middle line:84% But anyway this may just be a kind of statistical trick. 00:38:04.906 --> 00:38:07.997 align:middle line:84% AUDIENCE: You're talking about the number of cases of violent 00:38:07.997 --> 00:38:11.495 align:middle line:84% episodes compared to the general population. 00:38:11.495 --> 00:38:12.120 align:middle line:90% GUEST SPEAKER 2: Exactly. 00:38:12.120 --> 00:38:15.600 align:middle line:84% That's exactly the problem right there. 00:38:15.600 --> 00:38:19.505 align:middle line:84% And then there are various acute findings when you 00:38:19.505 --> 00:38:20.960 align:middle line:90% examine the patient. 00:38:20.960 --> 00:38:23.870 align:middle line:84% On what we call the mental status examination. 00:38:23.870 --> 00:38:26.295 align:middle line:84% Obviously, hostilities, suspiciousness, agitation are 00:38:26.295 --> 00:38:28.235 align:middle line:90% all associated with violence. 00:38:28.235 --> 00:38:35.220 align:middle line:90% 00:38:35.220 --> 00:38:38.630 align:middle line:84% I want us to focus one minute on the so-called aggressive 00:38:38.630 --> 00:38:48.527 align:middle line:84% attributional style, how do we respond to stress when we have 00:38:48.527 --> 00:38:51.960 align:middle line:90% a perception of threat. 00:38:51.960 --> 00:38:57.927 align:middle line:84% This is the threat override delusion that I mentioned. 00:38:57.927 --> 00:38:59.899 align:middle line:90% I think that's quite relevant. 00:38:59.899 --> 00:39:02.860 align:middle line:90% 00:39:02.860 --> 00:39:06.690 align:middle line:84% What happens in conditions of uncertainty, and many of these 00:39:06.690 --> 00:39:10.930 align:middle line:84% patients may have to think in a distorted fashion. 00:39:10.930 --> 00:39:16.690 align:middle line:84% I was talking at the beginning about the 00:39:16.690 --> 00:39:19.380 align:middle line:90% communication breakdown. 00:39:19.380 --> 00:39:22.132 align:middle line:84% You have the layer of the mental illness that shrinks 00:39:22.132 --> 00:39:22.910 align:middle line:90% your options. 00:39:22.910 --> 00:39:25.640 align:middle line:84% You have a particular situation to deal with that 00:39:25.640 --> 00:39:30.850 align:middle line:84% makes you even more likely to become assaulted. 00:39:30.850 --> 00:39:34.215 align:middle line:84% And this constellation of cognitive distortions may make 00:39:34.215 --> 00:39:37.400 align:middle line:84% it more likely for you to become assaulted. 00:39:37.400 --> 00:39:40.400 align:middle line:84% Neglecting the base information, which assigns a 00:39:40.400 --> 00:39:45.960 align:middle line:84% high weight to certain events that otherwise are low 00:39:45.960 --> 00:39:52.360 align:middle line:84% frequency, attending only to facts that would confirm your 00:39:52.360 --> 00:39:55.510 align:middle line:90% assumptions, I think-- 00:39:55.510 --> 00:39:59.040 align:middle line:84% AUDIENCE: So if the psychiatrist's office calls to 00:39:59.040 --> 00:40:02.350 align:middle line:84% reschedule an appointment, the person assumes that this is 00:40:02.350 --> 00:40:04.820 align:middle line:84% because the psychiatrist doesn't like him. 00:40:04.820 --> 00:40:07.850 align:middle line:84% This person doesn't want to treat me, they don't like me, 00:40:07.850 --> 00:40:09.350 align:middle line:84% they don't want me to be their patient because they 00:40:09.350 --> 00:40:10.785 align:middle line:90% rescheduled me. 00:40:10.785 --> 00:40:13.720 align:middle line:84% GUEST SPEAKER 2: Ignoring facts that could disconfirm 00:40:13.720 --> 00:40:16.440 align:middle line:90% your hypothesis. 00:40:16.440 --> 00:40:19.649 align:middle line:84% I just talked to the psychiatrist who was nice to 00:40:19.649 --> 00:40:23.450 align:middle line:84% me, but still the fact that he called and canceled is the 00:40:23.450 --> 00:40:26.530 align:middle line:84% overriding explanation that he doesn't like me. 00:40:26.530 --> 00:40:30.875 align:middle line:84% Or focusing on common events just because you remember 00:40:30.875 --> 00:40:33.920 align:middle line:84% them, which is an interesting way of explaining. 00:40:33.920 --> 00:40:36.050 align:middle line:84% The fact that you remember them and it brings 00:40:36.050 --> 00:40:38.135 align:middle line:90% them up in the rack. 00:40:38.135 --> 00:40:40.510 align:middle line:84% And other disconfirming evidence is 00:40:40.510 --> 00:40:42.885 align:middle line:90% totally kind of ignored. 00:40:42.885 --> 00:40:45.270 align:middle line:84% AUDIENCE: In spite the assumption that the train on 00:40:45.270 --> 00:40:47.420 align:middle line:84% the other platform always seems to arrive first. 00:40:47.420 --> 00:40:50.354 align:middle line:84% Because those are the ones you remember. 00:40:50.354 --> 00:40:52.310 align:middle line:84% GUEST SPEAKER 2: Or the garden variety, the 00:40:52.310 --> 00:40:55.740 align:middle line:90% grass is always greener. 00:40:55.740 --> 00:40:59.450 align:middle line:84% And I talked about medications and street drugs. 00:40:59.450 --> 00:41:01.220 align:middle line:84% Some are more likely to be associated. 00:41:01.220 --> 00:41:03.300 align:middle line:84% Alcohol just by the sheer volume. 00:41:03.300 --> 00:41:06.800 align:middle line:84% And especially because withdrawal is so violent. 00:41:06.800 --> 00:41:08.335 align:middle line:90% It's a significant issue. 00:41:08.335 --> 00:41:12.530 align:middle line:84% The intoxication phase, your level of coordination, your 00:41:12.530 --> 00:41:17.110 align:middle line:84% perception of facts, it's just they're so off that you are 00:41:17.110 --> 00:41:19.156 align:middle line:90% more likely to lose control. 00:41:19.156 --> 00:41:24.336 align:middle line:84% Antidepressants have an interesting impact, because in 00:41:24.336 --> 00:41:27.136 align:middle line:84% people that have an underlying tendency to swing in their 00:41:27.136 --> 00:41:29.100 align:middle line:84% moods may actually all [? blend those ?] things. 00:41:29.100 --> 00:41:34.460 align:middle line:84% You may have heard of the news of antidepressants promoting 00:41:34.460 --> 00:41:37.700 align:middle line:84% violence and suicide in adolescents. 00:41:37.700 --> 00:41:40.320 align:middle line:84% And while statisticians are still scratching their heads 00:41:40.320 --> 00:41:44.260 align:middle line:84% to figure out the exact numbers, the truth is that 00:41:44.260 --> 00:41:48.183 align:middle line:84% mood is very unstable in adolescents. 00:41:48.183 --> 00:41:51.350 align:middle line:84% And often initial depression may turn out to 00:41:51.350 --> 00:41:52.670 align:middle line:90% be something else. 00:41:52.670 --> 00:41:55.310 align:middle line:84% You give somebody an antidepressant, call him or 00:41:55.310 --> 00:41:57.240 align:middle line:84% her for followup in six or eight months. 00:41:57.240 --> 00:41:59.480 align:middle line:84% In the meanwhile, lots of things could happen. 00:41:59.480 --> 00:42:02.484 align:middle line:84% And I think in those cases, when actually those young 00:42:02.484 --> 00:42:07.600 align:middle line:84% adolescents committed suicide, it was not so much about 00:42:07.600 --> 00:42:09.010 align:middle line:90% antidepressants causing it. 00:42:09.010 --> 00:42:11.595 align:middle line:84% Probably the antidepressants made the symptoms worse. 00:42:11.595 --> 00:42:14.270 align:middle line:84% It was very poor followup and poor diagnostic. 00:42:14.270 --> 00:42:18.950 align:middle line:84% But anyway, this is getting too technical. 00:42:18.950 --> 00:42:20.400 align:middle line:90% I included this last minute. 00:42:20.400 --> 00:42:26.530 align:middle line:84% This is an interesting summary of a nationwide study focusing 00:42:26.530 --> 00:42:30.900 align:middle line:90% on violence risk assessment. 00:42:30.900 --> 00:42:37.454 align:middle line:84% Let me just take two minutes about useful measures in 00:42:37.454 --> 00:42:39.440 align:middle line:84% assessing dynamic to the violence. 00:42:39.440 --> 00:42:43.130 align:middle line:84% People have looked at violence in two ways. 00:42:43.130 --> 00:42:45.990 align:middle line:84% They have put together all those factors 00:42:45.990 --> 00:42:47.530 align:middle line:90% that I presented initially. 00:42:47.530 --> 00:42:53.053 align:middle line:84% And they have looked at the perspective of those who have 00:42:53.053 --> 00:42:53.210 align:middle line:90% become violent. 00:42:53.210 --> 00:42:56.040 align:middle line:84% And they compiled the history, clinical 00:42:56.040 --> 00:42:58.130 align:middle line:90% risk assessment scale. 00:42:58.130 --> 00:43:00.430 align:middle line:84% The problem is that when you're dealing with somebody, 00:43:00.430 --> 00:43:03.530 align:middle line:84% those scales, even though they may give you a good image of 00:43:03.530 --> 00:43:06.950 align:middle line:84% what happens in the long run, they may not help you deal 00:43:06.950 --> 00:43:08.490 align:middle line:90% with the immediate situation. 00:43:08.490 --> 00:43:12.910 align:middle line:84% So clinical scales have been used in [UNINTELLIGIBLE]. 00:43:12.910 --> 00:43:16.210 align:middle line:84% One developed in Norway, the other one, the dynamic 00:43:16.210 --> 00:43:17.860 align:middle line:84% appraisal, developed in Australia. 00:43:17.860 --> 00:43:21.325 align:middle line:84% These are the items for the HCR-20. 00:43:21.325 --> 00:43:25.550 align:middle line:84% And it's almost like a repetition of what I said 00:43:25.550 --> 00:43:26.570 align:middle line:84% earlier in terms of risk factors. 00:43:26.570 --> 00:43:28.750 align:middle line:84% This is the historical risk factors. 00:43:28.750 --> 00:43:30.780 align:middle line:84% And these are validated, because they have been used 00:43:30.780 --> 00:43:33.410 align:middle line:90% for more than 15 years. 00:43:33.410 --> 00:43:38.540 align:middle line:84% The clinical scale is the dynamic part of the HCR. 00:43:38.540 --> 00:43:41.480 align:middle line:84% And then the risk management scale is trying to project in 00:43:41.480 --> 00:43:45.710 align:middle line:84% the future what you have to do in order to ensure safety, 00:43:45.710 --> 00:43:47.400 align:middle line:90% what could go wrong. 00:43:47.400 --> 00:43:49.850 align:middle line:84% GUEST SPEAKER 1: So the value of these scales is kind of 00:43:49.850 --> 00:43:54.490 align:middle line:84% sizing up the likelihood of this person coming violent, in 00:43:54.490 --> 00:43:55.790 align:middle line:84% the absence of other information. 00:43:55.790 --> 00:43:58.280 align:middle line:84% The best predictor is probably what they're actually doing 00:43:58.280 --> 00:44:00.200 align:middle line:90% behaviorally in front of you. 00:44:00.200 --> 00:44:05.220 align:middle line:84% They're reaching for something heavy, I take that in and 00:44:05.220 --> 00:44:07.510 align:middle line:90% weigh that heavily. 00:44:07.510 --> 00:44:09.580 align:middle line:84% But in the absence of anything else, you know that the people 00:44:09.580 --> 00:44:15.365 align:middle line:84% who meet a certain profile are more likely to be violent as a 00:44:15.365 --> 00:44:16.960 align:middle line:84% psychiatric patient than others. 00:44:16.960 --> 00:44:19.477 align:middle line:84% GUEST SPEAKER 2: This is a dynamic scale that looks at 00:44:19.477 --> 00:44:22.960 align:middle line:84% what happens in front of you, as you pointed out. 00:44:22.960 --> 00:44:25.950 align:middle line:84% You're considering confusion or debility, how boisterous 00:44:25.950 --> 00:44:28.960 align:middle line:84% and how verbally threatening the person is. 00:44:28.960 --> 00:44:32.360 align:middle line:84% The most recent one is the dynamic appraisal of the 00:44:32.360 --> 00:44:36.030 align:middle line:84% situation aggression that has seven factors that seems to be 00:44:36.030 --> 00:44:38.330 align:middle line:90% the best one [UNINTELLIGIBLE] 00:44:38.330 --> 00:44:40.120 align:middle line:84% assessment or prediction of violence 00:44:40.120 --> 00:44:43.950 align:middle line:90% over the next 24 hours. 00:44:43.950 --> 00:44:50.028 align:middle line:84% And this is an interesting psychopathy and an index. 00:44:50.028 --> 00:44:53.300 align:middle line:84% Psychopathy has an interesting history. 00:44:53.300 --> 00:44:58.700 align:middle line:84% I think the current version that we all talk about is 00:44:58.700 --> 00:45:00.090 align:middle line:90% antisocial personality. 00:45:00.090 --> 00:45:04.860 align:middle line:84% But basically refers to people with minimal capacity for 00:45:04.860 --> 00:45:08.840 align:middle line:84% empathy, whose moral dimensions is fairly 00:45:08.840 --> 00:45:13.985 align:middle line:84% primitive, who engage in stealing, cheating, violence, 00:45:13.985 --> 00:45:19.320 align:middle line:84% and don't have a lot of moral drawbacks to do it. 00:45:19.320 --> 00:45:22.686 align:middle line:84% It seems to be associated with violence, not surprisingly. 00:45:22.686 --> 00:45:27.700 align:middle line:84% And this is actually a factor analysis that identifies those 00:45:27.700 --> 00:45:30.860 align:middle line:90% two dimensions. 00:45:30.860 --> 00:45:36.560 align:middle line:84% Now just at the end I want to talk about the de-escalation 00:45:36.560 --> 00:45:42.370 align:middle line:84% principles that I am actually now trying to incorporate in 00:45:42.370 --> 00:45:48.500 align:middle line:84% the standardized patients, because these should be fairly 00:45:48.500 --> 00:45:54.060 align:middle line:84% easy to at least present, and then maybe hopefully to teach 00:45:54.060 --> 00:45:56.892 align:middle line:84% the residents how to use in terms of dealing 00:45:56.892 --> 00:45:57.850 align:middle line:90% with agitated patients. 00:45:57.850 --> 00:46:04.654 align:middle line:84% So actually many of them are used by staff. 00:46:04.654 --> 00:46:09.630 align:middle line:84% How to start interaction with a violent patient. 00:46:09.630 --> 00:46:11.690 align:middle line:90% How to position yourself. 00:46:11.690 --> 00:46:14.560 align:middle line:90% Within arm's length. 00:46:14.560 --> 00:46:17.930 align:middle line:90% Probably at 45 degrees. 00:46:17.930 --> 00:46:20.170 align:middle line:90% For two reasons. 00:46:20.170 --> 00:46:25.250 align:middle line:84% One, in case you're attacked, to offer a much smaller 00:46:25.250 --> 00:46:28.990 align:middle line:84% surface of the impact and also to allow you a way to escape, 00:46:28.990 --> 00:46:31.910 align:middle line:90% you have to. 00:46:31.910 --> 00:46:34.170 align:middle line:84% Not obviously to block the exit door. 00:46:34.170 --> 00:46:37.490 align:middle line:84% Stand over if the person is leaning down or in the bed. 00:46:37.490 --> 00:46:39.870 align:middle line:90% Never turn your back. 00:46:39.870 --> 00:46:41.750 align:middle line:84% What to do with you your hands. 00:46:41.750 --> 00:46:44.840 align:middle line:84% Never make fists, or kind of keep your arms crossed, or 00:46:44.840 --> 00:46:50.840 align:middle line:84% behind you, or in your pockets, to kind of appear as 00:46:50.840 --> 00:46:52.770 align:middle line:90% nonthreatening as possible. 00:46:52.770 --> 00:46:55.535 align:middle line:84% How to regulate the eye contact. 00:46:55.535 --> 00:46:58.325 align:middle line:84% If it's too intense, it can become bothersome. 00:46:58.325 --> 00:47:02.915 align:middle line:84% If it lacks completely, then people could conclude that you 00:47:02.915 --> 00:47:05.682 align:middle line:84% are not really interested or involved. 00:47:05.682 --> 00:47:08.490 align:middle line:84% GUEST SPEAKER 1: The thing that's important to keep in 00:47:08.490 --> 00:47:11.910 align:middle line:84% mind with a psychiatric patient is, 00:47:11.910 --> 00:47:12.670 align:middle line:90% well, a couple things. 00:47:12.670 --> 00:47:16.930 align:middle line:84% One is that mental health patients are much more likely 00:47:16.930 --> 00:47:18.670 align:middle line:84% to be the victims of violence than 00:47:18.670 --> 00:47:19.370 align:middle line:90% actually to commit violence. 00:47:19.370 --> 00:47:22.490 align:middle line:84% And this is really the outlier, the unusual case 00:47:22.490 --> 00:47:25.340 align:middle line:84% where the psychiatric patient becomes violent. 00:47:25.340 --> 00:47:27.240 align:middle line:84% But obviously it's an important situation. 00:47:27.240 --> 00:47:30.090 align:middle line:84% It does happen frequently enough to be a real concern 00:47:30.090 --> 00:47:32.364 align:middle line:84% for the providers, for their well being. 00:47:32.364 --> 00:47:39.810 align:middle line:90% 00:47:39.810 --> 00:47:41.980 align:middle line:84% Basically there's different levels of what you have to 00:47:41.980 --> 00:47:43.150 align:middle line:90% understand how to do. 00:47:43.150 --> 00:47:46.135 align:middle line:84% One, how to protect yourself, and then two, how to protect 00:47:46.135 --> 00:47:46.410 align:middle line:90% the patient. 00:47:46.410 --> 00:47:50.752 align:middle line:84% It's almost like if your child who's 11 years old comes at 00:47:50.752 --> 00:47:53.440 align:middle line:84% you swinging, it's really different than if you're 00:47:53.440 --> 00:47:54.710 align:middle line:84% getting bumped on the subway in terms of what 00:47:54.710 --> 00:47:56.060 align:middle line:90% you're going to do. 00:47:56.060 --> 00:47:58.370 align:middle line:84% Now the person who's sitting in your office might be a lot 00:47:58.370 --> 00:47:59.160 align:middle line:90% bigger than your 11 year old. 00:47:59.160 --> 00:48:00.240 align:middle line:90% But you kind of get the idea. 00:48:00.240 --> 00:48:04.982 align:middle line:84% You're not trying to punish them, you're not trying to 00:48:04.982 --> 00:48:08.790 align:middle line:84% inflict any more harm on them than is absolutely needed in 00:48:08.790 --> 00:48:11.306 align:middle line:84% order to stop the situation and for you to get 00:48:11.306 --> 00:48:13.176 align:middle line:90% out, or let them out. 00:48:13.176 --> 00:48:13.940 align:middle line:90% GUEST SPEAKER 2: Yes. 00:48:13.940 --> 00:48:15.480 align:middle line:84% And that's important, and that's somewhat 00:48:15.480 --> 00:48:16.730 align:middle line:90% counter-intuitive. 00:48:16.730 --> 00:48:20.450 align:middle line:90% 00:48:20.450 --> 00:48:22.906 align:middle line:84% I'm just thinking, I'm trying to think in terms of potential 00:48:22.906 --> 00:48:28.870 align:middle line:84% simulation, and targets for our training paradigm. 00:48:28.870 --> 00:48:33.874 align:middle line:84% I think an important aspect is for the person who is going to 00:48:33.874 --> 00:48:36.075 align:middle line:84% the training to understand himself or herself. 00:48:36.075 --> 00:48:38.779 align:middle line:84% How what's the reaction when you are threatened. 00:48:38.779 --> 00:48:41.500 align:middle line:84% And how to continue to think on your feet. 00:48:41.500 --> 00:48:44.920 align:middle line:84% And take decisions that are not based on a flight or fight 00:48:44.920 --> 00:48:48.880 align:middle line:90% or tend and befriend attitude. 00:48:48.880 --> 00:48:52.840 align:middle line:84% This is not about dealing with a common situation. 00:48:52.840 --> 00:48:55.810 align:middle line:84% This is when you have to maintain your ability to 00:48:55.810 --> 00:48:58.955 align:middle line:84% remain therapeutic and helpful and to minimize harm to 00:48:58.955 --> 00:49:02.470 align:middle line:84% yourself and certainly harm to the other person. 00:49:02.470 --> 00:49:04.900 align:middle line:84% And the truth of the matter is that many people in these 00:49:04.900 --> 00:49:11.340 align:middle line:84% situations react the way that they've always done. 00:49:11.340 --> 00:49:15.540 align:middle line:84% I gave Jim the example of a social worker I work with, who 00:49:15.540 --> 00:49:19.660 align:middle line:84% every time when she is confronted by a patient, she 00:49:19.660 --> 00:49:24.633 align:middle line:84% gets angry and she gets defensive and tells things to 00:49:24.633 --> 00:49:26.820 align:middle line:90% her that I find are hurtful. 00:49:26.820 --> 00:49:29.710 align:middle line:84% And they are just adding gas to the fire. 00:49:29.710 --> 00:49:31.640 align:middle line:84% I need to intervene because you feel that it's almost 00:49:31.640 --> 00:49:33.850 align:middle line:84% like, you know, I'm there to umpire. 00:49:33.850 --> 00:49:35.010 align:middle line:90% OK, time out. 00:49:35.010 --> 00:49:35.440 align:middle line:90% Stop. 00:49:35.440 --> 00:49:38.296 align:middle line:90% We need to do something else. 00:49:38.296 --> 00:49:40.686 align:middle line:90% And I try to explain to her. 00:49:40.686 --> 00:49:42.450 align:middle line:90% She just doesn't get it. 00:49:42.450 --> 00:49:47.968 align:middle line:84% Or can theoretically figure it out but doesn't do a 00:49:47.968 --> 00:49:49.270 align:middle line:90% very good job at it. 00:49:49.270 --> 00:49:53.515 align:middle line:84% When we are angry or frightened, our behavior, the 00:49:53.515 --> 00:49:57.100 align:middle line:84% way we talk, the way we track, changes. 00:49:57.100 --> 00:50:00.544 align:middle line:84% And those things can be major triggers for the other person. 00:50:00.544 --> 00:50:03.780 align:middle line:84% GUEST SPEAKER 1: If you're staying really calm, and the 00:50:03.780 --> 00:50:06.975 align:middle line:84% other person's escalating, that's a real dampening force 00:50:06.975 --> 00:50:09.780 align:middle line:84% on that other person from escalating even more. 00:50:09.780 --> 00:50:13.396 align:middle line:84% And it's really, really hard to do, to stay professional. 00:50:13.396 --> 00:50:16.475 align:middle line:84% And recognizing that this aggression is 00:50:16.475 --> 00:50:17.910 align:middle line:90% really a medical symptom. 00:50:17.910 --> 00:50:20.986 align:middle line:84% It's like if they are bleeding on the floor. 00:50:20.986 --> 00:50:23.070 align:middle line:84% The difference obviously is that it could actually hurt 00:50:23.070 --> 00:50:24.220 align:middle line:90% you, the provider. 00:50:24.220 --> 00:50:26.435 align:middle line:84% But you need to recognize it as a medical symptom that 00:50:26.435 --> 00:50:28.820 align:middle line:84% needs to be dealt with as opposed to taking it really 00:50:28.820 --> 00:50:34.287 align:middle line:84% personally, or you being violent back. 00:50:34.287 --> 00:50:35.810 align:middle line:84% GUEST SPEAKER 2: How do you appear. 00:50:35.810 --> 00:50:38.210 align:middle line:90% How do you-- 00:50:38.210 --> 00:50:41.038 align:middle line:84% obviously, being calm, centered, self assured is 00:50:41.038 --> 00:50:41.986 align:middle line:90% always helpful. 00:50:41.986 --> 00:50:45.320 align:middle line:84% It's the message that you're conveying. 00:50:45.320 --> 00:50:50.460 align:middle line:84% Often if you respond to anger by being fearful or angry 00:50:50.460 --> 00:50:55.505 align:middle line:84% yourself, obviously these will just escalate. 00:50:55.505 --> 00:50:58.970 align:middle line:84% Or if you're fidgety and pacing, and gesturing 00:50:58.970 --> 00:51:03.302 align:middle line:84% yourself, and wondering, so what do I do now, I think the 00:51:03.302 --> 00:51:07.510 align:middle line:84% other person would clearly pick up that feeling. 00:51:07.510 --> 00:51:12.924 align:middle line:84% Touching most often than not is not a good idea. 00:51:12.924 --> 00:51:15.369 align:middle line:84% Even though instinctively we would like to calm the other 00:51:15.369 --> 00:51:17.325 align:middle line:84% person down or wonder what it is. 00:51:17.325 --> 00:51:21.230 align:middle line:84% This is how we learn to show empathy and that we care, we 00:51:21.230 --> 00:51:21.730 align:middle line:90% want to help. 00:51:21.730 --> 00:51:27.510 align:middle line:84% Well, it may not be a good idea. 00:51:27.510 --> 00:51:33.273 align:middle line:84% And then this could be a topic in itself. 00:51:33.273 --> 00:51:36.710 align:middle line:84% Active listening would be the most-- 00:51:36.710 --> 00:51:40.147 align:middle line:84% if you want the buzzword, in terms of the verbal 00:51:40.147 --> 00:51:42.130 align:middle line:90% de-escalation principle. 00:51:42.130 --> 00:51:46.650 align:middle line:84% Often when I'm called, and many of my colleagues are 00:51:46.650 --> 00:51:48.210 align:middle line:90% called in such situations. 00:51:48.210 --> 00:51:49.670 align:middle line:90% I introduce myself. 00:51:49.670 --> 00:51:53.246 align:middle line:84% I'm telling the person no matter how agitated 00:51:53.246 --> 00:51:55.745 align:middle line:90% he is why I'm here. 00:51:55.745 --> 00:51:58.400 align:middle line:90% And I'm trying to understand. 00:51:58.400 --> 00:52:02.260 align:middle line:84% I may not respond or react to the person's curses or 00:52:02.260 --> 00:52:03.200 align:middle line:90% threatening behavior. 00:52:03.200 --> 00:52:05.490 align:middle line:84% Of course I try to maintain a safe distance. 00:52:05.490 --> 00:52:07.815 align:middle line:90% And I continue my assessment. 00:52:07.815 --> 00:52:11.305 align:middle line:84% Can I deal with this, or I need help, or I need to stop 00:52:11.305 --> 00:52:13.916 align:middle line:90% and find another way. 00:52:13.916 --> 00:52:19.800 align:middle line:84% And I give that person feedback about what I see, how 00:52:19.800 --> 00:52:21.628 align:middle line:90% he or she makes me feel. 00:52:21.628 --> 00:52:24.400 align:middle line:84% I feel you are threatening, I feel uncomfortable, I think we 00:52:24.400 --> 00:52:24.910 align:middle line:90% need to stop. 00:52:24.910 --> 00:52:26.400 align:middle line:90% Do you want to talk? 00:52:26.400 --> 00:52:30.580 align:middle line:84% What are the issues that you're dealing with? 00:52:30.580 --> 00:52:37.214 align:middle line:84% And I also explain and set limits on what is acceptable 00:52:37.214 --> 00:52:39.120 align:middle line:90% and what is not acceptable. 00:52:39.120 --> 00:52:41.706 align:middle line:90% Often, that combination works. 00:52:41.706 --> 00:52:44.910 align:middle line:90% 00:52:44.910 --> 00:52:48.340 align:middle line:84% I listed pharmacotherapy and seclusion restraint because 00:52:48.340 --> 00:52:51.280 align:middle line:84% they are part of the process, and I think I would like 00:52:51.280 --> 00:52:56.670 align:middle line:84% people who are trained for this to understand that those 00:52:56.670 --> 00:52:57.920 align:middle line:90% things are available. 00:52:57.920 --> 00:53:04.290 align:middle line:90% 00:53:04.290 --> 00:53:05.757 align:middle line:90% Any questions so far? 00:53:05.757 --> 00:53:11.625 align:middle line:90% 00:53:11.625 --> 00:53:15.048 align:middle line:84% AUDIENCE: I've just got a couple of comments on 00:53:15.048 --> 00:53:16.026 align:middle line:90% [UNINTELLIGIBLE]. 00:53:16.026 --> 00:53:16.612 align:middle line:90% GUEST SPEAKER 1: Yeah. 00:53:16.612 --> 00:53:17.004 align:middle line:90% We can do that. 00:53:17.004 --> 00:53:18.960 align:middle line:84% And also I wanted to suggest and see what you think about 00:53:18.960 --> 00:53:22.924 align:middle line:84% this, if someone would like to play the role of a patient, I 00:53:22.924 --> 00:53:25.575 align:middle line:84% can meet with you briefly and just kind of prepare you to do 00:53:25.575 --> 00:53:28.170 align:middle line:84% that if anybody is interested in taking the role of the 00:53:28.170 --> 00:53:28.685 align:middle line:90% aggressive patient. 00:53:28.685 --> 00:53:30.445 align:middle line:90% You'd like to do that? 00:53:30.445 --> 00:53:33.910 align:middle line:84% Why don't you and I step out for just a couple of minutes. 00:53:33.910 --> 00:53:36.385 align:middle line:90% And then [UNINTELLIGIBLE]? 00:53:36.385 --> 00:53:37.635 align:middle line:90% [INTERPOSING VOICES] 00:53:37.635 --> 00:53:42.820 align:middle line:90% 00:53:42.820 --> 00:53:47.710 align:middle line:84% PROFESSOR: So there's a couple of things that have been 00:53:47.710 --> 00:53:50.780 align:middle line:84% brought up already, immediately seem to be 00:53:50.780 --> 00:53:54.830 align:middle line:84% possible places where you guys can think of what you're doing 00:53:54.830 --> 00:53:57.070 align:middle line:90% to do your project on. 00:53:57.070 --> 00:54:00.690 align:middle line:90% There's identifying factors. 00:54:00.690 --> 00:54:04.850 align:middle line:84% There's a whole bunch of different schemes and 00:54:04.850 --> 00:54:08.700 align:middle line:84% different metrics that people have been using. 00:54:08.700 --> 00:54:13.410 align:middle line:84% All the way from known personality types to 00:54:13.410 --> 00:54:16.790 align:middle line:84% socioeconomic factors and personal history. 00:54:16.790 --> 00:54:20.400 align:middle line:84% You could make some kind of [UNINTELLIGIBLE]. 00:54:20.400 --> 00:54:23.500 align:middle line:84% I can imagine, some sort of like can you figure out enough 00:54:23.500 --> 00:54:27.290 align:middle line:84% information before it's too late. 00:54:27.290 --> 00:54:30.266 align:middle line:84% The dynamic assessment of violence seems to be more of a 00:54:30.266 --> 00:54:32.050 align:middle line:90% time pressure kind of thing. 00:54:32.050 --> 00:54:34.870 align:middle line:84% Because you almost have to figure out on the spot. 00:54:34.870 --> 00:54:37.690 align:middle line:84% But factors are very different. 00:54:37.690 --> 00:54:41.730 align:middle line:84% But similarly I can find de-escalation. 00:54:41.730 --> 00:54:44.750 align:middle line:90% 00:54:44.750 --> 00:54:47.270 align:middle line:84% It seems kind of interesting, because it almost seems like 00:54:47.270 --> 00:54:48.840 align:middle line:90% you could make a word game. 00:54:48.840 --> 00:54:54.052 align:middle line:84% Or a face to face kind of thing out of that. 00:54:54.052 --> 00:54:59.645 align:middle line:84% Can you remember what you're supposed to do in conversation 00:54:59.645 --> 00:55:03.110 align:middle line:84% with each other without missing any of the 00:55:03.110 --> 00:55:04.100 align:middle line:90% [UNINTELLIGIBLE]. 00:55:04.100 --> 00:55:06.080 align:middle line:90% And that might be something. 00:55:06.080 --> 00:55:07.980 align:middle line:84% That would be like a live action game but not 00:55:07.980 --> 00:55:09.808 align:middle line:90% necessarily a physical game. 00:55:09.808 --> 00:55:12.550 align:middle line:84% It would be more like a party game. 00:55:12.550 --> 00:55:16.160 align:middle line:90% GUEST SPEAKER 2: One way-- 00:55:16.160 --> 00:55:18.295 align:middle line:84% this is, by the way, I didn't want to go there to 00:55:18.295 --> 00:55:19.080 align:middle line:90% make this too long. 00:55:19.080 --> 00:55:23.650 align:middle line:84% But these are some parts of a standardized patient that I'm 00:55:23.650 --> 00:55:27.340 align:middle line:84% putting together, then I'm going to try actually to talk 00:55:27.340 --> 00:55:30.538 align:middle line:84% to the simulation department at UMass, to be 00:55:30.538 --> 00:55:32.014 align:middle line:90% played by an actor. 00:55:32.014 --> 00:55:37.060 align:middle line:84% And this would be the training goals. 00:55:37.060 --> 00:55:40.465 align:middle line:84% And I'm really particularly interested in how people 00:55:40.465 --> 00:55:43.316 align:middle line:84% respond when they are exposed to an angry situation or even 00:55:43.316 --> 00:55:44.910 align:middle line:90% to an angry face. 00:55:44.910 --> 00:55:46.442 align:middle line:84% What do you have to do in order to 00:55:46.442 --> 00:55:47.750 align:middle line:90% de-escalate the patient. 00:55:47.750 --> 00:55:55.620 align:middle line:84% And what I think I'm going to suggest to the actor is that, 00:55:55.620 --> 00:55:58.130 align:middle line:84% you are in the room and you're pacing up and down. 00:55:58.130 --> 00:55:59.100 align:middle line:90% And appearing angry. 00:55:59.100 --> 00:56:03.170 align:middle line:84% And you're allowed to use some generic swear words. 00:56:03.170 --> 00:56:06.170 align:middle line:84% And to have a number of complaints. 00:56:06.170 --> 00:56:07.936 align:middle line:90% Could be a number of them. 00:56:07.936 --> 00:56:10.150 align:middle line:84% Nurse was too late to give me the medications. 00:56:10.150 --> 00:56:13.140 align:middle line:84% The girlfriend didn't come in time. 00:56:13.140 --> 00:56:14.530 align:middle line:90% You owe money. 00:56:14.530 --> 00:56:17.509 align:middle line:84% You just had a job interview today and you missed it 00:56:17.509 --> 00:56:18.540 align:middle line:84% because you're in the hospital. 00:56:18.540 --> 00:56:19.930 align:middle line:90% Could be a number of things. 00:56:19.930 --> 00:56:22.050 align:middle line:84% And then the person approaches you. 00:56:22.050 --> 00:56:24.660 align:middle line:90% 00:56:24.660 --> 00:56:30.400 align:middle line:84% The trainee should follow some rules in terms of the verbal 00:56:30.400 --> 00:56:32.040 align:middle line:90% and nonverbal de-escalation. 00:56:32.040 --> 00:56:37.270 align:middle line:84% If that person is able to engage you, you can become 00:56:37.270 --> 00:56:41.890 align:middle line:84% less angry, less agitated, more interested. 00:56:41.890 --> 00:56:45.910 align:middle line:90% Pacing less, lower your voice. 00:56:45.910 --> 00:56:49.970 align:middle line:84% If the trainee is just doing the right or wrong things, you 00:56:49.970 --> 00:56:53.460 align:middle line:84% either stay at the same level or get more and more angry. 00:56:53.460 --> 00:56:57.440 align:middle line:84% Of course, it's fairly demanding for a standardized 00:56:57.440 --> 00:57:01.990 align:middle line:84% for an actor, because the nonverbal elements are easy. 00:57:01.990 --> 00:57:03.250 align:middle line:90% How you regulate the distance. 00:57:03.250 --> 00:57:05.595 align:middle line:84% How you look, how you approach. 00:57:05.595 --> 00:57:10.055 align:middle line:84% You inhibit your natural tendencies to pat the person 00:57:10.055 --> 00:57:11.370 align:middle line:90% on the shoulder, whatever. 00:57:11.370 --> 00:57:14.180 align:middle line:84% But the verbal aspects are more difficult. 00:57:14.180 --> 00:57:15.410 align:middle line:84% AUDIENCE: Improvising dialog on the spot is hard. 00:57:15.410 --> 00:57:16.615 align:middle line:90% GUEST SPEAKER 2: Exactly. 00:57:16.615 --> 00:57:21.290 align:middle line:84% But at the same time, the goals of the dialog are not. 00:57:21.290 --> 00:57:25.410 align:middle line:84% Because you should probably find out what's going on, even 00:57:25.410 --> 00:57:28.820 align:middle line:84% though, let's say, the actor will try to tell you about his 00:57:28.820 --> 00:57:30.550 align:middle line:84% life, and how miserable things are. 00:57:30.550 --> 00:57:34.200 align:middle line:84% You know, I lost my job, and I was kicked out. 00:57:34.200 --> 00:57:36.850 align:middle line:84% But you need to try to bring the person 00:57:36.850 --> 00:57:37.400 align:middle line:90% to what really happened. 00:57:37.400 --> 00:57:41.820 align:middle line:84% I think that's very, very helpful because you're pinning 00:57:41.820 --> 00:57:46.630 align:middle line:84% down a particular conflict that triggered it. 00:57:46.630 --> 00:57:48.680 align:middle line:84% And if you are able to do that, then you 00:57:48.680 --> 00:57:50.340 align:middle line:90% can take some steps. 00:57:50.340 --> 00:57:50.980 align:middle line:90% OK. 00:57:50.980 --> 00:57:53.980 align:middle line:84% I have a patient right now who has 00:57:53.980 --> 00:57:55.970 align:middle line:90% difficulty expressing herself. 00:57:55.970 --> 00:58:01.045 align:middle line:84% And systematically there's one particular shift where the 00:58:01.045 --> 00:58:04.010 align:middle line:84% staff is not patient, doesn't wait for her. 00:58:04.010 --> 00:58:06.670 align:middle line:84% You just need to give her a little bit more time. 00:58:06.670 --> 00:58:09.300 align:middle line:84% And she gets upset and angry and starts pacing. 00:58:09.300 --> 00:58:12.105 align:middle line:84% And I have to every time say, please, listen to her. 00:58:12.105 --> 00:58:15.225 align:middle line:84% Or she comes up to me, she tells me the story and then I 00:58:15.225 --> 00:58:17.070 align:middle line:90% have to go back to the staff. 00:58:17.070 --> 00:58:20.900 align:middle line:84% People just don't have the patience or don't care. 00:58:20.900 --> 00:58:22.600 align:middle line:84% So that's just a simple intervention. 00:58:22.600 --> 00:58:25.660 align:middle line:84% This is why you need to find out what's going on. 00:58:25.660 --> 00:58:28.480 align:middle line:84% And then, if you can get more information about what brought 00:58:28.480 --> 00:58:32.724 align:middle line:90% the person to this place. 00:58:32.724 --> 00:58:33.690 align:middle line:90% GUEST SPEAKER 1: OK. 00:58:33.690 --> 00:58:36.600 align:middle line:90% I think we're prepared. 00:58:36.600 --> 00:58:39.790 align:middle line:84% She did role play before I showed this, because 00:58:39.790 --> 00:58:41.350 align:middle line:90% [UNINTELLIGIBLE]. 00:58:41.350 --> 00:58:42.530 align:middle line:84% GUEST SPEAKER 2: Do you want to do it? 00:58:42.530 --> 00:58:43.060 align:middle line:90% You've been trained. 00:58:43.060 --> 00:58:43.850 align:middle line:90% GUEST SPEAKER 1: No. 00:58:43.850 --> 00:58:45.940 align:middle line:90% You're the expert actually. 00:58:45.940 --> 00:58:47.937 align:middle line:90% GUEST SPEAKER 2: OK. 00:58:47.937 --> 00:58:48.931 align:middle line:90% Alright. 00:58:48.931 --> 00:58:51.416 align:middle line:90% Let's see what happens to me. 00:58:51.416 --> 00:58:56.890 align:middle line:90% [AUDIENCE LAUGHTER] 00:58:56.890 --> 00:59:00.765 align:middle line:90% So, I'm Dr. [? See. ?] 00:59:00.765 --> 00:59:01.980 align:middle line:84% ROLE PLAYING PATIENT: Where's John? 00:59:01.980 --> 00:59:03.772 align:middle line:90% I want to speak to John. 00:59:03.772 --> 00:59:07.070 align:middle line:84% I respond to him and I want him. 00:59:07.070 --> 00:59:08.610 align:middle line:90% Why isn't he here? 00:59:08.610 --> 00:59:09.200 align:middle line:90% Why? 00:59:09.200 --> 00:59:11.140 align:middle line:84% GUEST SPEAKER 2: Who's this person? 00:59:11.140 --> 00:59:12.110 align:middle line:90% I don't know. 00:59:12.110 --> 00:59:13.565 align:middle line:84% ROLE PLAYING PATIENT: Where's John? 00:59:13.565 --> 00:59:15.020 align:middle line:90% I only want to speak to him. 00:59:15.020 --> 00:59:17.384 align:middle line:84% GUEST SPEAKER 2: Well, Nurse John is not available. 00:59:17.384 --> 00:59:18.328 align:middle line:84% ROLE PLAYING PATIENT: [BANGING NOISE] 00:59:18.328 --> 00:59:19.744 align:middle line:90% Why isn't he available? 00:59:19.744 --> 00:59:21.640 align:middle line:90% Why? 00:59:21.640 --> 00:59:23.212 align:middle line:90% Only [UNINTELLIGIBLE]. 00:59:23.212 --> 00:59:25.642 align:middle line:84% I don't want to talk to you right now. 00:59:25.642 --> 00:59:27.586 align:middle line:84% GUEST SPEAKER 2: How can I help you? 00:59:27.586 --> 00:59:28.558 align:middle line:84% ROLE PLAYING PATIENT: Get Johnny. 00:59:28.558 --> 00:59:29.530 align:middle line:90% GUEST SPEAKER 2: OK. 00:59:29.530 --> 00:59:31.474 align:middle line:84% I can try to see if he's around. 00:59:31.474 --> 00:59:32.446 align:middle line:84% ROLE PLAYING PATIENT: [BANGING NOISE] 00:59:32.446 --> 00:59:34.390 align:middle line:84% You could [UNINTELLIGIBLE] now. 00:59:34.390 --> 00:59:35.860 align:middle line:90% GUEST SPEAKER 2: OK. 00:59:35.860 --> 00:59:37.822 align:middle line:90% But what else can I do? 00:59:37.822 --> 00:59:38.786 align:middle line:90% ROLE PLAYING PATIENT: Um. 00:59:38.786 --> 00:59:41.678 align:middle line:90% An education. 00:59:41.678 --> 00:59:42.642 align:middle line:90% Stop it. 00:59:42.642 --> 00:59:43.606 align:middle line:90% Not good. 00:59:43.606 --> 00:59:45.550 align:middle line:90% Try to poison me. 00:59:45.550 --> 00:59:46.460 align:middle line:90% You all want me dead. 00:59:46.460 --> 00:59:48.742 align:middle line:84% GUEST SPEAKER 2: What am I trying to do to you? 00:59:48.742 --> 00:59:51.097 align:middle line:84% ROLE PLAYING PATIENT: Doesn't [UNINTELLIGIBLE]. 00:59:51.097 --> 00:59:52.039 align:middle line:90% GUEST SPEAKER 2: OK. 00:59:52.039 --> 00:59:54.865 align:middle line:90% I can talk about that. 00:59:54.865 --> 00:59:57.526 align:middle line:84% So tell me what kind of problems do you have with the 00:59:57.526 --> 00:59:58.004 align:middle line:90% medication? 00:59:58.004 --> 00:59:59.450 align:middle line:84% ROLE PLAYING PATIENT: Trying to poison. 00:59:59.450 --> 01:00:01.822 align:middle line:90% You all want me dead. 01:00:01.822 --> 01:00:03.206 align:middle line:84% GUEST SPEAKER 2: So you don't think the 01:00:03.206 --> 01:00:05.070 align:middle line:90% medication is helpful? 01:00:05.070 --> 01:00:06.555 align:middle line:84% ROLE PLAYING PATIENT: Course not. 01:00:06.555 --> 01:00:09.030 align:middle line:90% Trying to kill me. 01:00:09.030 --> 01:00:10.020 align:middle line:90% [TEARING NOISE] 01:00:10.020 --> 01:00:11.505 align:middle line:90% [LAUGHTER] 01:00:11.505 --> 01:00:13.485 align:middle line:84% ROLE PLAYING PATIENT: They're watching me. 01:00:13.485 --> 01:00:17.940 align:middle line:90% 01:00:17.940 --> 01:00:22.395 align:middle line:84% GUEST SPEAKER 2: What else can I do to help? 01:00:22.395 --> 01:00:23.880 align:middle line:84% ROLE PLAYING PATIENT: [INAUDIBLE] 01:00:23.880 --> 01:00:24.970 align:middle line:90% family. 01:00:24.970 --> 01:00:27.195 align:middle line:84% GUEST SPEAKER 2: You want me to contact your family? 01:00:27.195 --> 01:00:27.940 align:middle line:90% ROLE PLAYING PATIENT: No. 01:00:27.940 --> 01:00:28.890 align:middle line:90% I hate them all. 01:00:28.890 --> 01:00:31.340 align:middle line:90% They're all against me. 01:00:31.340 --> 01:00:34.892 align:middle line:84% GUEST SPEAKER 2: It must be very hard, to not have anyone 01:00:34.892 --> 01:00:35.750 align:middle line:84% to talk to or feel comfortable with. 01:00:35.750 --> 01:00:37.160 align:middle line:84% ROLE PLAYING PATIENT: That's why I want to talk 01:00:37.160 --> 01:00:38.790 align:middle line:90% [UNINTELLIGIBLE] with John. 01:00:38.790 --> 01:00:40.500 align:middle line:84% GUEST SPEAKER 2: Well, I'm sorry you're 01:00:40.500 --> 01:00:43.104 align:middle line:90% struggling so much. 01:00:43.104 --> 01:00:45.990 align:middle line:84% And I know we haven't met before. 01:00:45.990 --> 01:00:48.395 align:middle line:84% But I'm here and trying to be helpful to you. 01:00:48.395 --> 01:00:50.836 align:middle line:84% ROLE PLAYING PATIENT: You want to kill me, don't you? 01:00:50.836 --> 01:00:53.476 align:middle line:84% GUEST SPEAKER 2: No, I don't think I want to. 01:00:53.476 --> 01:00:56.392 align:middle line:90% 01:00:56.392 --> 01:01:03.682 align:middle line:84% ROLE PLAYING PATIENT: [GRUNTING] 01:01:03.682 --> 01:01:06.438 align:middle line:84% GUEST SPEAKER 2: So we have a number of options. 01:01:06.438 --> 01:01:09.784 align:middle line:90% And I think you look angry. 01:01:09.784 --> 01:01:11.218 align:middle line:84% And you're scaring people and you're scaring me. 01:01:11.218 --> 01:01:12.005 align:middle line:90% ROLE PLAYING PATIENT: Fine. 01:01:12.005 --> 01:01:15.066 align:middle line:84% GUEST SPEAKER 2: You're scaring me. 01:01:15.066 --> 01:01:16.050 align:middle line:84% ROLE PLAYING PATIENT: [UNINTELLIGIBLE] 01:01:16.050 --> 01:01:18.018 align:middle line:84% You're just laughing behind me. 01:01:18.018 --> 01:01:19.002 align:middle line:90% You're not scared. 01:01:19.002 --> 01:01:19.494 align:middle line:90% You're just laughing. 01:01:19.494 --> 01:01:21.860 align:middle line:84% GUEST SPEAKER 2: No, I think you're a big, strong guy. 01:01:21.860 --> 01:01:25.325 align:middle line:84% And when you get angry and upset, you get to be 01:01:25.325 --> 01:01:25.820 align:middle line:90% intimidating. 01:01:25.820 --> 01:01:26.810 align:middle line:90% And there are other-- 01:01:26.810 --> 01:01:29.285 align:middle line:84% ROLE PLAYING PATIENT: Is that why you're going to poison me? 01:01:29.285 --> 01:01:29.780 align:middle line:90% Scared of me? 01:01:29.780 --> 01:01:30.770 align:middle line:90% GUEST SPEAKER 2: No. 01:01:30.770 --> 01:01:33.159 align:middle line:84% Well, I'm not trying to hurt you. 01:01:33.159 --> 01:01:36.652 align:middle line:84% But we need to come up with a solution. 01:01:36.652 --> 01:01:38.648 align:middle line:84% Because you could get hurt and other people could get hurt. 01:01:38.648 --> 01:01:41.642 align:middle line:84% So we need to do something about that. 01:01:41.642 --> 01:01:43.638 align:middle line:84% ROLE PLAYING PATIENT: I would be better off dead. 01:01:43.638 --> 01:01:45.135 align:middle line:90% Everyone wants me dead. 01:01:45.135 --> 01:01:46.133 align:middle line:90% GUEST SPEAKER 2: Well. 01:01:46.133 --> 01:01:50.624 align:middle line:84% I understand you're quite distraught today. 01:01:50.624 --> 01:01:53.119 align:middle line:90% And I want to help you. 01:01:53.119 --> 01:01:55.614 align:middle line:84% I may not be able to, right away. 01:01:55.614 --> 01:02:03.099 align:middle line:90% 01:02:03.099 --> 01:02:09.586 align:middle line:84% I'm going to try to get the nurse that you want. 01:02:09.586 --> 01:02:12.580 align:middle line:90% But what if I do not get him? 01:02:12.580 --> 01:02:16.073 align:middle line:90% What's the next best thing? 01:02:16.073 --> 01:02:17.323 align:middle line:84% ROLE PLAYING PATIENT: [INAUDIBLE] 01:02:17.323 --> 01:02:20.065 align:middle line:90% 01:02:20.065 --> 01:02:21.562 align:middle line:90% I don't know. 01:02:21.562 --> 01:02:26.053 align:middle line:84% GUEST SPEAKER 2: Would it help to contact your family? 01:02:26.053 --> 01:02:27.550 align:middle line:84% ROLE PLAYING PATIENT: Maybe mom. 01:02:27.550 --> 01:02:28.049 align:middle line:90% I want my mom. 01:02:28.049 --> 01:02:29.047 align:middle line:90% GUEST SPEAKER 2: OK. 01:02:29.047 --> 01:02:32.041 align:middle line:90% I can try to reach out to her. 01:02:32.041 --> 01:02:35.855 align:middle line:84% And do you think that if you change the medications maybe 01:02:35.855 --> 01:02:39.110 align:middle line:84% you can try a combination that could help? 01:02:39.110 --> 01:02:41.013 align:middle line:84% ROLE PLAYING PATIENT: As long as it's not poison. 01:02:41.013 --> 01:02:41.780 align:middle line:90% GUEST SPEAKER 2: OK. 01:02:41.780 --> 01:02:43.466 align:middle line:90% I hear you. 01:02:43.466 --> 01:02:46.424 align:middle line:90% You don't like the medication. 01:02:46.424 --> 01:02:48.396 align:middle line:84% You think that it's hurting you. 01:02:48.396 --> 01:02:50.368 align:middle line:90% But it's helped in the past. 01:02:50.368 --> 01:02:54.805 align:middle line:84% And maybe a different combination would be better. 01:02:54.805 --> 01:02:55.298 align:middle line:90% Hmm? 01:02:55.298 --> 01:02:56.284 align:middle line:90% ROLE PLAYING PATIENT: Maybe. 01:02:56.284 --> 01:02:57.534 align:middle line:90% GUEST SPEAKER 2: Maybe? 01:02:57.534 --> 01:03:02.228 align:middle line:90% 01:03:02.228 --> 01:03:03.674 align:middle line:90% Well, thank you. 01:03:03.674 --> 01:03:05.210 align:middle line:90% We can go on like this. 01:03:05.210 --> 01:03:13.130 align:middle line:90% [LAUGHTER, APPLAUSE] 01:03:13.130 --> 01:03:14.380 align:middle line:90% [INTERPOSING VOICES] 01:03:14.380 --> 01:03:27.968 align:middle line:90% 01:03:27.968 --> 01:03:32.570 align:middle line:84% AUDIENCE: I have a question concerning about the 01:03:32.570 --> 01:03:37.288 align:middle line:84% disruption of narrative model of why violence occurs. 01:03:37.288 --> 01:03:41.320 align:middle line:84% Is that pretty much accepted as the way-- 01:03:41.320 --> 01:03:44.320 align:middle line:84% GUEST SPEAKER 2: I just made it up for this. 01:03:44.320 --> 01:03:44.820 align:middle line:90% [LAUGHTER] 01:03:44.820 --> 01:03:47.300 align:middle line:84% AUDIENCE: I was just wondering if there were competing, 01:03:47.300 --> 01:03:50.811 align:middle line:84% different theories, it might be useful for people to 01:03:50.811 --> 01:03:52.759 align:middle line:84% understand more than one model, or is that [INAUDIBLE]. 01:03:52.759 --> 01:03:58.190 align:middle line:84% GUEST SPEAKER 2: The narrative perspective is, if you want, a 01:03:58.190 --> 01:04:00.000 align:middle line:90% cry from the past. 01:04:00.000 --> 01:04:03.731 align:middle line:84% I think the last 20 years, in science and certainly 01:04:03.731 --> 01:04:07.550 align:middle line:84% medicine, have been dominated by hard evidence. 01:04:07.550 --> 01:04:12.316 align:middle line:84% Actually, the evidence-based medicine has been taking over 01:04:12.316 --> 01:04:16.060 align:middle line:84% the entire world, as the ultimate standard. 01:04:16.060 --> 01:04:22.430 align:middle line:84% So there are lists of the strength of the evidence, and 01:04:22.430 --> 01:04:28.286 align:middle line:84% randomized controlled designs are the best, and clinical 01:04:28.286 --> 01:04:31.060 align:middle line:84% impression anecdotes are the worst. 01:04:31.060 --> 01:04:38.090 align:middle line:84% So on this map, the narrative or a person-like story about 01:04:38.090 --> 01:04:44.780 align:middle line:84% the patient may not be if you want the accepted model today. 01:04:44.780 --> 01:04:49.538 align:middle line:84% But I think in dealing with individual cases, I feel that 01:04:49.538 --> 01:04:51.017 align:middle line:90% makes a lot of sense. 01:04:51.017 --> 01:04:52.870 align:middle line:84% When you have to deal with somebody who is very 01:04:52.870 --> 01:04:57.560 align:middle line:84% distraught, if I tell him that the best available evidence 01:04:57.560 --> 01:05:01.954 align:middle line:84% was published two years ago and showed that, you know, 20 01:05:01.954 --> 01:05:05.930 align:middle line:84% milligrams of Abilify would work best for psychosis, I'm 01:05:05.930 --> 01:05:08.663 align:middle line:84% not so sure that you would fuel the 01:05:08.663 --> 01:05:10.403 align:middle line:90% warmth and the empathy. 01:05:10.403 --> 01:05:12.910 align:middle line:90% 01:05:12.910 --> 01:05:15.180 align:middle line:84% But the reality, it could be that that 01:05:15.180 --> 01:05:17.040 align:middle line:90% evidence is is right. 01:05:17.040 --> 01:05:18.260 align:middle line:90% He's psychotic. 01:05:18.260 --> 01:05:20.130 align:middle line:84% And he tried to a variety of medications. 01:05:20.130 --> 01:05:23.080 align:middle line:84% Some of them made him fat and pushed his triglycerides up 01:05:23.080 --> 01:05:25.365 align:middle line:90% and raised his blood pressure. 01:05:25.365 --> 01:05:30.310 align:middle line:84% If I switch him to Abilify in two months, he'll get better. 01:05:30.310 --> 01:05:37.600 align:middle line:84% But dealing with the immediate issue, I think it's just, it's 01:05:37.600 --> 01:05:38.572 align:middle line:90% something else. 01:05:38.572 --> 01:05:41.609 align:middle line:84% And that knowledge about medication, while helpful in 01:05:41.609 --> 01:05:42.470 align:middle line:84% the long run, will not make it very good. 01:05:42.470 --> 01:05:46.500 align:middle line:84% So this is why I came up with if you want, for the purpose 01:05:46.500 --> 01:05:53.210 align:middle line:84% of this meeting, with a way of creating a metaphor that could 01:05:53.210 --> 01:05:58.130 align:middle line:84% sustain my verbal and nonverbal de-escalation. 01:05:58.130 --> 01:06:03.720 align:middle line:84% I'm trying to create some sense, some coherence, some 01:06:03.720 --> 01:06:07.046 align:middle line:84% meaning, some meaning to that interaction. 01:06:07.046 --> 01:06:10.822 align:middle line:84% And in doing that, I'm empathic and I'm trying to 01:06:10.822 --> 01:06:14.430 align:middle line:84% channel the energies in a way that it's 01:06:14.430 --> 01:06:15.860 align:middle line:90% almost like a beginning. 01:06:15.860 --> 01:06:16.370 align:middle line:90% He's distraught. 01:06:16.370 --> 01:06:17.450 align:middle line:90% He's ready to give up. 01:06:17.450 --> 01:06:20.715 align:middle line:84% He's ready to shut himself away from the world. 01:06:20.715 --> 01:06:23.800 align:middle line:84% I'm trying to reach out to him, without becoming his 01:06:23.800 --> 01:06:27.300 align:middle line:84% friend, without becoming his brother or father. 01:06:27.300 --> 01:06:30.556 align:middle line:84% And I think in a sense I'm restoring the 01:06:30.556 --> 01:06:32.230 align:middle line:90% meaning of his narrative. 01:06:32.230 --> 01:06:35.462 align:middle line:84% Somebody cares, somebody reaches out. 01:06:35.462 --> 01:06:38.060 align:middle line:84% PROFESSOR: Because it seems like a very interesting system 01:06:38.060 --> 01:06:42.490 align:middle line:84% for people, for designers to play with. 01:06:42.490 --> 01:06:45.100 align:middle line:84% The idea of trying, even though there is this historic 01:06:45.100 --> 01:06:49.470 align:middle line:84% narrative, and you may not know enough about the 01:06:49.470 --> 01:06:51.596 align:middle line:84% narrative to be able to act on it. 01:06:51.596 --> 01:06:53.303 align:middle line:84% But you'd find out things about it by 01:06:53.303 --> 01:06:54.920 align:middle line:90% talking to the patient. 01:06:54.920 --> 01:06:59.015 align:middle line:84% And what you're really trying to do is make things fit 01:06:59.015 --> 01:07:00.955 align:middle line:84% within that person's narrative. 01:07:00.955 --> 01:07:03.290 align:middle line:84% GUEST SPEAKER 2: You're filling the blanks that were 01:07:03.290 --> 01:07:05.450 align:middle line:84% kind of somewhat destroyed by events. 01:07:05.450 --> 01:07:09.300 align:middle line:84% And it could be a variety of events. 01:07:09.300 --> 01:07:11.190 align:middle line:84% And at times you have to use your imagination. 01:07:11.190 --> 01:07:12.410 align:middle line:90% It's almost like intuition. 01:07:12.410 --> 01:07:15.450 align:middle line:84% I mean, I know the principles from every case, but how I'm 01:07:15.450 --> 01:07:20.414 align:middle line:84% going to do it, it's not pre-programmed. 01:07:20.414 --> 01:07:24.150 align:middle line:84% PROFESSOR: Seems like that's also something that you could 01:07:24.150 --> 01:07:26.700 align:middle line:84% then play with from a design point of view. 01:07:26.700 --> 01:07:30.550 align:middle line:84% This idea of disruptive narrative, and then how do you 01:07:30.550 --> 01:07:31.570 align:middle line:90% put it back. 01:07:31.570 --> 01:07:36.210 align:middle line:84% Just like putting the pieces back together [INAUDIBLE]. 01:07:36.210 --> 01:07:38.352 align:middle line:84% GUEST SPEAKER 2: That may be the reason-- and that's 01:07:38.352 --> 01:07:40.320 align:middle line:84% another speculation, I'm just making this up-- 01:07:40.320 --> 01:07:44.200 align:middle line:84% why adventure games are so powerful. 01:07:44.200 --> 01:07:46.100 align:middle line:84% Because, in a sense, you're finding a substitute narrative 01:07:46.100 --> 01:07:50.622 align:middle line:84% that is much more controllable than your own. 01:07:50.622 --> 01:07:55.230 align:middle line:84% And for the time of the game you're there. 01:07:55.230 --> 01:07:59.500 align:middle line:84% It's almost like you're buying a few minutes, 10 minutes, 20 01:07:59.500 --> 01:08:01.500 align:middle line:84% minutes of a different story line. 01:08:01.500 --> 01:08:03.690 align:middle line:84% PROFESSOR: Actually, one of our researchers here looks 01:08:03.690 --> 01:08:05.212 align:middle line:84% specifically at adventure games. 01:08:05.212 --> 01:08:07.570 align:middle line:84% And her point of view is that playing adventure games is 01:08:07.570 --> 01:08:12.440 align:middle line:84% like being a performer who hasn't been given the script. 01:08:12.440 --> 01:08:15.080 align:middle line:84% You're still an actor in the story, and you have to figure 01:08:15.080 --> 01:08:17.454 align:middle line:84% out what that story is in order to move it along. 01:08:17.454 --> 01:08:23.190 align:middle line:90% 01:08:23.190 --> 01:08:25.819 align:middle line:84% There's one other thing that I do want to bring up. 01:08:25.819 --> 01:08:28.550 align:middle line:84% Obviously, I don't want any of these games that you guys are 01:08:28.550 --> 01:08:33.819 align:middle line:84% working on to be quizzes, to be really fun quizzes, even. 01:08:33.819 --> 01:08:36.219 align:middle line:90% [INAUDIBLE] 01:08:36.219 --> 01:08:37.819 align:middle line:90% all this stuff is about. 01:08:37.819 --> 01:08:40.097 align:middle line:84% I do want you guys to be learning games. 01:08:40.097 --> 01:08:43.061 align:middle line:84% And not just Trivial Pursuit, Psychiatric Version. 01:08:43.061 --> 01:08:47.020 align:middle line:90% 01:08:47.020 --> 01:08:48.809 align:middle line:90% That's kind of pointless. 01:08:48.809 --> 01:08:51.600 align:middle line:84% We have had games in the past in this class where people 01:08:51.600 --> 01:08:55.526 align:middle line:84% basically pulled questions out of a hat and had to answer 01:08:55.526 --> 01:08:57.490 align:middle line:90% them, with various penalties. 01:08:57.490 --> 01:08:59.904 align:middle line:84% Kind of fun, but that's not what I've been 01:08:59.904 --> 01:09:01.729 align:middle line:90% teaching you guys. 01:09:01.729 --> 01:09:03.550 align:middle line:90% So try to think about systems. 01:09:03.550 --> 01:09:07.532 align:middle line:84% Try to think about all these things that they want their 01:09:07.532 --> 01:09:09.390 align:middle line:90% trainees to learn. 01:09:09.390 --> 01:09:12.892 align:middle line:84% Think about how they can engage with the system, in 01:09:12.892 --> 01:09:14.868 align:middle line:84% some small way, for your project. 01:09:14.868 --> 01:09:19.314 align:middle line:90% 01:09:19.314 --> 01:09:20.796 align:middle line:84% AUDIENCE: Can I ask a question? 01:09:20.796 --> 01:09:23.760 align:middle line:84% What are your thoughts, or what are the field's thoughts 01:09:23.760 --> 01:09:25.670 align:middle line:84% on lying to people, so mitigate a situation. 01:09:25.670 --> 01:09:28.485 align:middle line:90% 01:09:28.485 --> 01:09:36.120 align:middle line:84% GUEST SPEAKER 2: Well, I would call lying a distortion, in a 01:09:36.120 --> 01:09:39.745 align:middle line:90% very general way. 01:09:39.745 --> 01:09:45.222 align:middle line:84% And when people lie, they have to make a decision. 01:09:45.222 --> 01:09:49.614 align:middle line:84% Often, people lie for a variety of reasons. 01:09:49.614 --> 01:09:54.006 align:middle line:84% What I always am surprised by is the reason to make friends, 01:09:54.006 --> 01:09:57.422 align:middle line:84% to get friendly, to resolve a situation. 01:09:57.422 --> 01:10:05.175 align:middle line:84% And I don't believe in lying as a communication tool. 01:10:05.175 --> 01:10:09.925 align:middle line:84% Given, it may make things easier in the short run. 01:10:09.925 --> 01:10:13.818 align:middle line:84% Certainly clinically it's not helpful. 01:10:13.818 --> 01:10:17.269 align:middle line:84% I was telling you about patients with borderline 01:10:17.269 --> 01:10:20.720 align:middle line:84% pathology that has this affective and relational 01:10:20.720 --> 01:10:24.690 align:middle line:84% instability that is basically taking over their lives. 01:10:24.690 --> 01:10:28.427 align:middle line:84% They are some of the most accurate lie detectors that 01:10:28.427 --> 01:10:29.160 align:middle line:90% you can imagine. 01:10:29.160 --> 01:10:32.320 align:middle line:84% You cannot design something more perfect than that. 01:10:32.320 --> 01:10:34.750 align:middle line:84% Especially having been in the system for a long time. 01:10:34.750 --> 01:10:38.152 align:middle line:84% They can feel the lie even before it comes up. 01:10:38.152 --> 01:10:40.582 align:middle line:84% And if you're going that path with them. 01:10:40.582 --> 01:10:44.230 align:middle line:84% AUDIENCE: So this role play, for example, if you told 01:10:44.230 --> 01:10:46.070 align:middle line:84% Bobby, well, let me go get John. 01:10:46.070 --> 01:10:47.420 align:middle line:90% You wait here for a minute. 01:10:47.420 --> 01:10:50.210 align:middle line:84% And then you know that John is not working right now. 01:10:50.210 --> 01:10:51.550 align:middle line:90% He's nowhere in the hospital. 01:10:51.550 --> 01:10:54.430 align:middle line:84% But you just told him that to safely get out, then you get 01:10:54.430 --> 01:10:56.890 align:middle line:84% security to come back in with you, and you can 01:10:56.890 --> 01:10:57.445 align:middle line:90% subdue him or something. 01:10:57.445 --> 01:10:59.666 align:middle line:84% GUEST SPEAKER 2: That's a great example. 01:10:59.666 --> 01:11:01.986 align:middle line:90% And that happens all the time. 01:11:01.986 --> 01:11:05.420 align:middle line:84% Because often when you're in this place, many of your 01:11:05.420 --> 01:11:07.920 align:middle line:90% requests are unreasonable. 01:11:07.920 --> 01:11:11.150 align:middle line:84% So you need to set some limits. 01:11:11.150 --> 01:11:13.752 align:middle line:84% And eventually you'll end up setting some limits. 01:11:13.752 --> 01:11:15.730 align:middle line:84% He could have continued to escalate until attacking me, 01:11:15.730 --> 01:11:18.352 align:middle line:84% breaking everything in the room. 01:11:18.352 --> 01:11:22.708 align:middle line:84% I usually tell them about how they make others feel. 01:11:22.708 --> 01:11:27.548 align:middle line:84% How unacceptable some of their behaviors are, and what are 01:11:27.548 --> 01:11:28.516 align:middle line:90% the consequences. 01:11:28.516 --> 01:11:33.074 align:middle line:84% So I'm going to probably tell you if this continues, I don't 01:11:33.074 --> 01:11:36.278 align:middle line:84% have any other choice but to call security and you may end 01:11:36.278 --> 01:11:36.490 align:middle line:90% up in restraints. 01:11:36.490 --> 01:11:38.442 align:middle line:84% And with a chemical medication, it could be 01:11:38.442 --> 01:11:40.900 align:middle line:84% injectable, you can take it by mouth. 01:11:40.900 --> 01:11:45.168 align:middle line:84% So I'm coming up front with how the next few minutes, the 01:11:45.168 --> 01:11:47.144 align:middle line:90% proximal future, looks like. 01:11:47.144 --> 01:11:50.780 align:middle line:84% As opposed to kind of fudge it and get on his friendly side, 01:11:50.780 --> 01:11:54.918 align:middle line:84% and, oh I don't mean anything, but the security will put you 01:11:54.918 --> 01:11:56.072 align:middle line:90% in restraints. 01:11:56.072 --> 01:12:01.050 align:middle line:84% So I don't want to buy him out by just becoming his friend. 01:12:01.050 --> 01:12:03.050 align:middle line:90% If that involves lying-- 01:12:03.050 --> 01:12:05.190 align:middle line:90% that's-- some people do it. 01:12:05.190 --> 01:12:06.130 align:middle line:84% When you're in the corner, you're-- 01:12:06.130 --> 01:12:08.325 align:middle line:90% OK, so what do I do now. 01:12:08.325 --> 01:12:09.890 align:middle line:90% A little lie won't hurt. 01:12:09.890 --> 01:12:11.095 align:middle line:90% And you do it. 01:12:11.095 --> 01:12:12.292 align:middle line:90% Maybe it's just my-- 01:12:12.292 --> 01:12:14.020 align:middle line:84% GUEST SPEAKER 1: What you just mentioned too, that sort of 01:12:14.020 --> 01:12:15.974 align:middle line:90% like good cop, bad cop. 01:12:15.974 --> 01:12:19.140 align:middle line:84% Well, I wish we could have more of a conversation here, 01:12:19.140 --> 01:12:21.110 align:middle line:84% but security needs to put you in restraints. 01:12:21.110 --> 01:12:22.290 align:middle line:90% Security's the bad guy. 01:12:22.290 --> 01:12:24.610 align:middle line:84% When that's exactly where you want the 01:12:24.610 --> 01:12:25.801 align:middle line:90% patient to be anyways. 01:12:25.801 --> 01:12:27.486 align:middle line:84% GUEST SPEAKER 2: I'm OK, but you know Jim. 01:12:27.486 --> 01:12:28.830 align:middle line:90% He doesn't tolerate it. 01:12:28.830 --> 01:12:30.620 align:middle line:84% He's the director and he's going to-- 01:12:30.620 --> 01:12:31.910 align:middle line:90% [LAUGHTER] 01:12:31.910 --> 01:12:33.820 align:middle line:84% GUEST SPEAKER 2: Does that answer your question? 01:12:33.820 --> 01:12:34.380 align:middle line:90% AUDIENCE: Yeah. 01:12:34.380 --> 01:12:35.020 align:middle line:90% Would you-- 01:12:35.020 --> 01:12:36.270 align:middle line:90% [INTERPOSING VOICES] 01:12:36.270 --> 01:12:38.244 align:middle line:90% 01:12:38.244 --> 01:12:40.745 align:middle line:84% AUDIENCE: I guess my followup is would you ever sneakily put 01:12:40.745 --> 01:12:42.940 align:middle line:84% medicine in someone's food or do something [UNINTELLIGIBLE]. 01:12:42.940 --> 01:12:48.716 align:middle line:84% GUEST SPEAKER 2: It's not only a lawsuit waiting to happen, 01:12:48.716 --> 01:12:54.080 align:middle line:84% of a major magnitude, but I don't think it's right. 01:12:54.080 --> 01:12:58.566 align:middle line:84% Even though probably reality is that family members and 01:12:58.566 --> 01:13:01.458 align:middle line:84% sometimes even providers in nursing homes may do that. 01:13:01.458 --> 01:13:04.006 align:middle line:90% But I think it's-- 01:13:04.006 --> 01:13:07.010 align:middle line:84% GUEST SPEAKER 1: You may need to treat the person against 01:13:07.010 --> 01:13:09.450 align:middle line:84% their will, which is often meaning putting them into 01:13:09.450 --> 01:13:11.640 align:middle line:84% physical restraints, which is usually like leather kind of 01:13:11.640 --> 01:13:14.800 align:middle line:84% things, kind of a straitjacket thing, or maybe to a bed. 01:13:14.800 --> 01:13:17.480 align:middle line:84% And maybe physically inject them with something to really 01:13:17.480 --> 01:13:18.420 align:middle line:90% sedate them. 01:13:18.420 --> 01:13:20.174 align:middle line:84% But you should always be telling them what you're going 01:13:20.174 --> 01:13:20.990 align:middle line:90% to do, right. 01:13:20.990 --> 01:13:23.230 align:middle line:84% And the reason why you're doing it. 01:13:23.230 --> 01:13:24.895 align:middle line:84% Even if they don't have any choice in the matter. 01:13:24.895 --> 01:13:27.780 align:middle line:84% GUEST SPEAKER 2: And if you feel that the person is unable 01:13:27.780 --> 01:13:35.490 align:middle line:84% to comprehend, then you may need to work towards 01:13:35.490 --> 01:13:36.700 align:middle line:84% appointing a guardian who will take 01:13:36.700 --> 01:13:39.240 align:middle line:90% decisions for that person. 01:13:39.240 --> 01:13:41.810 align:middle line:84% And it's not necessarily that the legal field has pushed 01:13:41.810 --> 01:13:43.940 align:middle line:90% itself very hard in field. 01:13:43.940 --> 01:13:46.390 align:middle line:90% But I think it's fair. 01:13:46.390 --> 01:13:48.250 align:middle line:84% You meet the person where that person is at, 01:13:48.250 --> 01:13:49.550 align:middle line:90% and try to be helpful. 01:13:49.550 --> 01:13:53.010 align:middle line:84% And I think, in my view, there is no substitute for being 01:13:53.010 --> 01:13:55.390 align:middle line:84% upfront and saying this is what's going to happen. 01:13:55.390 --> 01:13:58.490 align:middle line:84% He may not be my best friend, but he knows exactly. 01:13:58.490 --> 01:14:02.873 align:middle line:84% I'm telling the patients often ahead what's going to happen. 01:14:02.873 --> 01:14:05.010 align:middle line:84% In that sense, I'm giving them choices. 01:14:05.010 --> 01:14:07.279 align:middle line:84% So if I end up taking them to court for 01:14:07.279 --> 01:14:08.700 align:middle line:90% commitment, they know that. 01:14:08.700 --> 01:14:13.220 align:middle line:84% And you would be surprised how angry they are at the 01:14:13.220 --> 01:14:15.386 align:middle line:84% beginning and how OK they are later. 01:14:15.386 --> 01:14:18.580 align:middle line:84% And how often they come up to me and say, thank you, I was 01:14:18.580 --> 01:14:23.480 align:middle line:84% in a very bad space and I didn't want to, and I fought 01:14:23.480 --> 01:14:24.950 align:middle line:84% you all the way but I think that was the best solution. 01:14:24.950 --> 01:14:28.380 align:middle line:84% I don't necessarily do that to get that thanks. 01:14:28.380 --> 01:14:30.340 align:middle line:90% I just do it as a principle. 01:14:30.340 --> 01:14:31.820 align:middle line:90% Often it doesn't come. 01:14:31.820 --> 01:14:33.200 align:middle line:84% It's not like people are grateful. 01:14:33.200 --> 01:14:35.880 align:middle line:90% Often they leave the hospital. 01:14:35.880 --> 01:14:39.505 align:middle line:84% GUEST SPEAKER 1: Let me show a little of this training, just 01:14:39.505 --> 01:14:39.880 align:middle line:90% a few minutes. 01:14:39.880 --> 01:14:44.580 align:middle line:84% This is a project I've been working on a lot for NASA, 01:14:44.580 --> 01:14:47.920 align:middle line:84% which is basically to develop a mental health support system 01:14:47.920 --> 01:14:49.410 align:middle line:84% for the long duration space cruise. 01:14:49.410 --> 01:14:51.730 align:middle line:84% And this is kind of a whole other topic. 01:14:51.730 --> 01:14:54.880 align:middle line:84% But just one piece of this was teaching the astronauts how to 01:14:54.880 --> 01:14:58.236 align:middle line:84% manage conflict, interpersonal conflict more 01:14:58.236 --> 01:15:00.515 align:middle line:90% effectively or safely. 01:15:00.515 --> 01:15:03.370 align:middle line:90% 01:15:03.370 --> 01:15:05.810 align:middle line:84% Astronauts being a very different population from what 01:15:05.810 --> 01:15:07.762 align:middle line:90% we were talking about. 01:15:07.762 --> 01:15:42.444 align:middle line:90% 01:15:42.444 --> 01:15:45.420 align:middle line:90% [VIDEO PLAYBACK] 01:15:45.420 --> 01:15:49.636 align:middle line:84% --Welcome to the virtual space station, where you can access 01:15:49.636 --> 01:15:52.116 align:middle line:84% training and resources to help deal with the stresses of long 01:15:52.116 --> 01:15:53.356 align:middle line:90% duration space flights. 01:15:53.356 --> 01:15:56.332 align:middle line:84% In the training simulator, you'll interact with virtual 01:15:56.332 --> 01:15:58.812 align:middle line:84% crew members to learn and practice managing some of the 01:15:58.812 --> 01:16:01.788 align:middle line:84% problems that might come up on long duration missions. 01:16:01.788 --> 01:16:05.508 align:middle line:84% The resources modules has more advanced training that you can 01:16:05.508 --> 01:16:08.020 align:middle line:84% do to learn about adapting to the stresses of living in 01:16:08.020 --> 01:16:11.055 align:middle line:84% isolation, plus interviews with long duration flyers. 01:16:11.055 --> 01:16:15.370 align:middle line:84% It also has a number of ebooks and audio books on dealing 01:16:15.370 --> 01:16:16.070 align:middle line:90% with stress. 01:16:16.070 --> 01:16:18.860 align:middle line:84% Plus survival stories about polar missions and other 01:16:18.860 --> 01:16:20.020 align:middle line:90% adventures. 01:16:20.020 --> 01:16:24.136 align:middle line:84% In the self-assessment module, you'll find questionnaires-- 01:16:24.136 --> 01:16:24.588 align:middle line:90% [END VIDEO PLAYBACK] 01:16:24.588 --> 01:16:27.760 align:middle line:84% GUEST SPEAKER 1: This is basically the whole interface. 01:16:27.760 --> 01:16:31.084 align:middle line:84% What I'll show you here is our simulator. 01:16:31.084 --> 01:16:31.512 align:middle line:90% [VIDEO PLAYBACK] 01:16:31.512 --> 01:16:33.455 align:middle line:84% --This is the training simulator. 01:16:33.455 --> 01:16:36.030 align:middle line:84% Click on the topic you would like to learn about. 01:16:36.030 --> 01:16:40.350 align:middle line:84% Then the coach or mentor for that topic will takeover and 01:16:40.350 --> 01:16:41.310 align:middle line:90% guide you through. 01:16:41.310 --> 01:16:41.790 align:middle line:90% -- 01:16:41.790 --> 01:16:42.750 align:middle line:90% This is the conflict 01:16:42.750 --> 01:16:44.190 align:middle line:90% management part of the simulator. 01:16:44.190 --> 01:16:48.245 align:middle line:84% We recommend that you do the 10 minute briefing first. 01:16:48.245 --> 01:16:49.840 align:middle line:84% After you complete each simulation-- 01:16:49.840 --> 01:16:51.090 align:middle line:90% [INTERPOSING VOICES] 01:16:51.090 --> 01:16:55.050 align:middle line:90% 01:16:55.050 --> 01:16:57.425 align:middle line:84% Here's how these simulations work. 01:16:57.425 --> 01:17:00.730 align:middle line:84% You're flight engineer one, or FE1. 01:17:00.730 --> 01:17:04.440 align:middle line:84% Your crew mate, Chuck, is flight engineer two. 01:17:04.440 --> 01:17:08.030 align:middle line:84% We'll be giving you three choices of what to say or do. 01:17:08.030 --> 01:17:11.050 align:middle line:84% You can roll your mouse over them to hear how they're said. 01:17:11.050 --> 01:17:14.660 align:middle line:84% Even though some options are more likely than others to 01:17:14.660 --> 01:17:17.360 align:middle line:84% reduce the conflict, I recommend that you try out 01:17:17.360 --> 01:17:19.648 align:middle line:84% options you might not choose in real life. 01:17:19.648 --> 01:17:22.680 align:middle line:84% That's because all paths in these simulations lead to 01:17:22.680 --> 01:17:24.210 align:middle line:90% teaching points. 01:17:24.210 --> 01:17:27.835 align:middle line:84% You can click the backup button anytime if you want to 01:17:27.835 --> 01:17:29.650 align:middle line:84% change your choice and go down another pathway. 01:17:29.650 --> 01:17:32.760 align:middle line:84% You can click on the fair fighting manual at any time to 01:17:32.760 --> 01:17:34.560 align:middle line:90% read some tips. 01:17:34.560 --> 01:17:36.220 align:middle line:84% You'll also find this manual in the 01:17:36.220 --> 01:17:38.573 align:middle line:90% resource module's library. 01:17:38.573 --> 01:17:41.860 align:middle line:84% Now as you go through the simulation, I'll be right here 01:17:41.860 --> 01:17:44.240 align:middle line:90% coaching you along the way. 01:17:44.240 --> 01:17:45.040 align:middle line:90% OK. 01:17:45.040 --> 01:17:47.193 align:middle line:90% Back to the simulation. 01:17:47.193 --> 01:17:50.990 align:middle line:84% It's four months into your mission, with five and a half 01:17:50.990 --> 01:17:51.820 align:middle line:90% left to go. 01:17:51.820 --> 01:17:54.790 align:middle line:84% So far, the mission's been going pretty well. 01:17:54.790 --> 01:17:58.750 align:middle line:84% But you're both tired, having had to sleep shift last night. 01:17:58.750 --> 01:18:03.205 align:middle line:90% 01:18:03.205 --> 01:18:03.700 align:middle line:90% -- 01:18:03.700 --> 01:18:06.530 align:middle line:84% Is your display getting squirrelly? 01:18:06.530 --> 01:18:08.580 align:middle line:90% Shoot, mine too. 01:18:08.580 --> 01:18:11.108 align:middle line:84% Damn, I think the whole system's down. 01:18:11.108 --> 01:18:12.972 align:middle line:90% It was the wrong cable. 01:18:12.972 --> 01:18:16.360 align:middle line:84% When I was installing the recorder I 01:18:16.360 --> 01:18:18.350 align:middle line:90% disconnected the A10 cable. 01:18:18.350 --> 01:18:21.433 align:middle line:84% I fixed it right away but I think it screwed 01:18:21.433 --> 01:18:22.390 align:middle line:90% up the whole system. 01:18:22.390 --> 01:18:25.260 align:middle line:84% Look, if ground calls, don't tell them about the cable. 01:18:25.260 --> 01:18:29.555 align:middle line:90% 01:18:29.555 --> 01:18:29.960 align:middle line:90% -- 01:18:29.960 --> 01:18:31.782 align:middle line:84% Ah, this is a tricky situation. 01:18:31.782 --> 01:18:35.149 align:middle line:84% You believe it's important to tell the ground what happened. 01:18:35.149 --> 01:18:38.690 align:middle line:84% At the same time, you don't want Chuck to get in trouble. 01:18:38.690 --> 01:18:41.630 align:middle line:90% What's your response? 01:18:41.630 --> 01:18:42.030 align:middle line:90% -- 01:18:42.030 --> 01:18:44.110 align:middle line:84% They'll spend hours trying to figure this out. 01:18:44.110 --> 01:18:45.185 align:middle line:90% We got to tell them. 01:18:45.185 --> 01:18:47.520 align:middle line:84% What's wrong with telling the ground. 01:18:47.520 --> 01:18:47.790 align:middle line:90% -- 01:18:47.790 --> 01:18:48.070 align:middle line:90% You're saying make a choice. 01:18:48.070 --> 01:18:48.405 align:middle line:90% -- 01:18:48.405 --> 01:18:50.740 align:middle line:84% OK, but you're putting me in a bad position. 01:18:50.740 --> 01:18:51.240 align:middle line:90% -- 01:18:51.240 --> 01:18:51.740 align:middle line:90% I know. 01:18:51.740 --> 01:18:53.740 align:middle line:84% But thanks you're a real friend. 01:18:53.740 --> 01:18:55.740 align:middle line:90% I owe you big time. 01:18:55.740 --> 01:18:59.240 align:middle line:90% 01:18:59.240 --> 01:18:59.740 align:middle line:90% -- 01:18:59.740 --> 01:19:00.985 align:middle line:90% Houston, this is FE2. 01:19:00.985 --> 01:19:02.235 align:middle line:90% Go ahead. 01:19:02.235 --> 01:19:04.300 align:middle line:90% 01:19:04.300 --> 01:19:04.580 align:middle line:90% No. 01:19:04.580 --> 01:19:04.860 align:middle line:90% Negative. 01:19:04.860 --> 01:19:07.904 align:middle line:90% I have no idea. 01:19:07.904 --> 01:19:08.790 align:middle line:90% Yeah I know. 01:19:08.790 --> 01:19:12.351 align:middle line:84% I already got the reboot started. 01:19:12.351 --> 01:19:17.420 align:middle line:84% No, I guess it's too early to say what the impact is. 01:19:17.420 --> 01:19:17.905 align:middle line:90% Roger that. 01:19:17.905 --> 01:19:20.060 align:middle line:84% I'll let you know if it happens again. 01:19:20.060 --> 01:19:21.310 align:middle line:90% FE2 out. 01:19:21.310 --> 01:19:24.156 align:middle line:90% 01:19:24.156 --> 01:19:24.640 align:middle line:90% -- 01:19:24.640 --> 01:19:27.890 align:middle line:84% You're feeling very anxious having just heard Chuck lie to 01:19:27.890 --> 01:19:28.970 align:middle line:90% the ground. 01:19:28.970 --> 01:19:33.152 align:middle line:84% You're worried that this might backfire on you, if the ground 01:19:33.152 --> 01:19:34.960 align:middle line:84% finds out that you knew what happened. 01:19:34.960 --> 01:19:37.090 align:middle line:84% This makes you very angry at Chuck. 01:19:37.090 --> 01:19:39.450 align:middle line:90% How would you like to respond? 01:19:39.450 --> 01:19:39.930 align:middle line:90% [END VIDEO PLAYBACK] 01:19:39.930 --> 01:19:42.440 align:middle line:84% GUEST SPEAKER 1: The reason I'm showing you this is that 01:19:42.440 --> 01:19:44.820 align:middle line:84% this is one approach that I've taken to teaching how to 01:19:44.820 --> 01:19:47.410 align:middle line:84% handle an interaction with somebody through sort of a 01:19:47.410 --> 01:19:47.880 align:middle line:90% simulation. 01:19:47.880 --> 01:19:49.750 align:middle line:84% Now this is obviously not a game. 01:19:49.750 --> 01:19:50.170 align:middle line:90% There's no score. 01:19:50.170 --> 01:19:51.220 align:middle line:90% There's no time limit. 01:19:51.220 --> 01:19:54.060 align:middle line:84% It's more of an interactive movie. 01:19:54.060 --> 01:19:57.570 align:middle line:84% But with the teaching points here, just like what Cesar's 01:19:57.570 --> 01:20:00.870 align:middle line:84% given you is, we can give this to an astronaut and they'll 01:20:00.870 --> 01:20:04.050 align:middle line:84% read it in 5-10 minutes and say, yup, got it, what's the 01:20:04.050 --> 01:20:04.760 align:middle line:90% next thing. 01:20:04.760 --> 01:20:06.820 align:middle line:84% That doesn't mean they actually can use it, remember 01:20:06.820 --> 01:20:09.420 align:middle line:90% it, absorbed it. 01:20:09.420 --> 01:20:10.745 align:middle line:84% and I'm not saying that this is the way they 01:20:10.745 --> 01:20:11.600 align:middle line:90% should do your games. 01:20:11.600 --> 01:20:17.395 align:middle line:84% But that this is one approach that we've taken to try to get 01:20:17.395 --> 01:20:20.730 align:middle line:84% them more involved with the material in more of a 01:20:20.730 --> 01:20:21.910 align:middle line:90% simulated way. 01:20:21.910 --> 01:20:24.500 align:middle line:84% We can just do maybe one or two more of this. 01:20:24.500 --> 01:20:25.890 align:middle line:84% What would you like to do here? 01:20:25.890 --> 01:20:26.340 align:middle line:90% [VIDEO PLAYBACK] 01:20:26.340 --> 01:20:26.750 align:middle line:90% -- 01:20:26.750 --> 01:20:29.130 align:middle line:84% Chuck, we need to talk about this. 01:20:29.130 --> 01:20:29.610 align:middle line:90% -- 01:20:29.610 --> 01:20:31.540 align:middle line:90% What is there to talk about? 01:20:31.540 --> 01:20:33.840 align:middle line:84% Ground doesn't need to know every single 01:20:33.840 --> 01:20:35.184 align:middle line:90% little detail, alright? 01:20:35.184 --> 01:20:38.285 align:middle line:84% Plus if we do tell them, next thing you know we're going to 01:20:38.285 --> 01:20:38.530 align:middle line:90% be all over the news. 01:20:38.530 --> 01:20:38.970 align:middle line:90% -- 01:20:38.970 --> 01:20:40.360 align:middle line:90% This was a good choice. 01:20:40.360 --> 01:20:44.135 align:middle line:84% Even though Chuck seems exasperated, you know what's 01:20:44.135 --> 01:20:45.290 align:middle line:90% going on in his mind. 01:20:45.290 --> 01:20:47.970 align:middle line:84% Understanding what each other is thinking goes a long way to 01:20:47.970 --> 01:20:49.383 align:middle line:90% solving conflict. 01:20:49.383 --> 01:20:52.855 align:middle line:84% Chuck is concerned about the ruckus this might cause about 01:20:52.855 --> 01:20:54.480 align:middle line:90% negative media attention. 01:20:54.480 --> 01:20:56.320 align:middle line:84% But now you have something to work with. 01:20:56.320 --> 01:20:58.316 align:middle line:90% What's your next move? 01:20:58.316 --> 01:21:02.308 align:middle line:90% 01:21:02.308 --> 01:21:02.810 align:middle line:90% -- 01:21:02.810 --> 01:21:03.590 align:middle line:90% I know you-- 01:21:03.590 --> 01:21:05.780 align:middle line:84% you've been doing excellent work so far. 01:21:05.780 --> 01:21:07.753 align:middle line:84% I can see you're really scared of them. 01:21:07.753 --> 01:21:11.134 align:middle line:90% 01:21:11.134 --> 01:21:15.108 align:middle line:84% I know you don't want to draw a lot of attention. 01:21:15.108 --> 01:21:16.599 align:middle line:84% What'll you think will happen if they figure it out? 01:21:16.599 --> 01:21:17.096 align:middle line:90% -- 01:21:17.096 --> 01:21:17.593 align:middle line:90% OK. 01:21:17.593 --> 01:21:19.084 align:middle line:90% You got a point. 01:21:19.084 --> 01:21:19.581 align:middle line:90% I'll get fried. 01:21:19.581 --> 01:21:24.205 align:middle line:84% Especially if it looked like I was trying to cover it up. 01:21:24.205 --> 01:21:27.790 align:middle line:84% You know, this really is a team issue. 01:21:27.790 --> 01:21:30.961 align:middle line:90% 01:21:30.961 --> 01:21:31.420 align:middle line:90% -- 01:21:31.420 --> 01:21:34.670 align:middle line:84% On one hand, you seemed to get Chuck to come around to your 01:21:34.670 --> 01:21:35.500 align:middle line:90% perspective. 01:21:35.500 --> 01:21:38.560 align:middle line:84% But the ground really needs to know what happened. 01:21:38.560 --> 01:21:40.940 align:middle line:84% On the other hand, he's asking you to share the 01:21:40.940 --> 01:21:44.350 align:middle line:84% responsibility, even though it really wasn't your fault. 01:21:44.350 --> 01:21:45.810 align:middle line:90% You have mixed feelings. 01:21:45.810 --> 01:21:48.810 align:middle line:84% You don't want to be blamed for a mistake you didn't make. 01:21:48.810 --> 01:21:51.360 align:middle line:84% But you're concerned about keeping a good relationship 01:21:51.360 --> 01:21:52.225 align:middle line:90% with Chuck. 01:21:52.225 --> 01:21:53.525 align:middle line:90% How are you going to respond? 01:21:53.525 --> 01:21:56.106 align:middle line:90% 01:21:56.106 --> 01:21:56.490 align:middle line:90% -- 01:21:56.490 --> 01:21:57.360 align:middle line:90% I'm sorry, Chuck. 01:21:57.360 --> 01:22:00.900 align:middle line:90% But this was your mistake. 01:22:00.900 --> 01:22:02.150 align:middle line:90% [INTERPOSING VOICES] 01:22:02.150 --> 01:22:16.265 align:middle line:90% 01:22:16.265 --> 01:22:19.758 align:middle line:90% [LAUGHTER] 01:22:19.758 --> 01:22:20.260 align:middle line:90% -- 01:22:20.260 --> 01:22:21.430 align:middle line:90% Houston, this is FE2. 01:22:21.430 --> 01:22:21.925 align:middle line:90% -- 01:22:21.925 --> 01:22:22.915 align:middle line:90% Go ahead, FE2. 01:22:22.915 --> 01:22:23.410 align:middle line:90% -- 01:22:23.410 --> 01:22:25.760 align:middle line:84% Houston, I think we found the problem. 01:22:25.760 --> 01:22:28.360 align:middle line:84% The instructions you sent up for the recorder had some 01:22:28.360 --> 01:22:30.020 align:middle line:90% serious problems. 01:22:30.020 --> 01:22:33.125 align:middle line:84% When you follow the recorder connect procedure, you can end 01:22:33.125 --> 01:22:35.105 align:middle line:90% up disconnecting A10. 01:22:35.105 --> 01:22:37.454 align:middle line:90% It may need to be validated. 01:22:37.454 --> 01:22:37.941 align:middle line:90% -- 01:22:37.941 --> 01:22:38.915 align:middle line:90% Copy that, FE2. 01:22:38.915 --> 01:22:40.863 align:middle line:84% The procedures team ran through this in the mock-up, 01:22:40.863 --> 01:22:43.298 align:middle line:84% but they can give it another look. 01:22:43.298 --> 01:22:43.785 align:middle line:90% -- 01:22:43.785 --> 01:22:49.060 align:middle line:90% In any organization [LAUGHTER] 01:22:49.060 --> 01:22:51.700 align:middle line:84% Sometimes this can help to create a bond within the 01:22:51.700 --> 01:22:54.502 align:middle line:84% workgroup, because everybody has a common enemy. 01:22:54.502 --> 01:22:58.041 align:middle line:84% But, even though scapegoating the ground may keep the crew 01:22:58.041 --> 01:23:03.288 align:middle line:90% unified for a while, 01:23:03.288 --> 01:23:03.764 align:middle line:90% [END VIDEO PLAYBACK] 01:23:03.764 --> 01:23:04.520 align:middle line:90% GUEST SPEAKER 1: OK. 01:23:04.520 --> 01:23:07.825 align:middle line:90% You kind of get the idea. 01:23:07.825 --> 01:23:10.240 align:middle line:84% We'd like to be available by email, in case you guys have 01:23:10.240 --> 01:23:11.590 align:middle line:90% any questions. 01:23:11.590 --> 01:23:15.500 align:middle line:84% PROFESSOR: I'll sent out some tech information to the class 01:23:15.500 --> 01:23:18.930 align:middle line:84% list and we're probably going to spend the rest of this week 01:23:18.930 --> 01:23:20.110 align:middle line:84% being around all of you so we're not quite sure yet 01:23:20.110 --> 01:23:21.360 align:middle line:84% exactly what we're going to do yet. 01:23:21.360 --> 01:23:24.745 align:middle line:90% 01:23:24.745 --> 01:23:25.995 align:middle line:84% Hopefully [UNINTELLIGIBLE PHRASE]. 01:23:25.995 --> 01:23:29.850 align:middle line:90% 01:23:29.850 --> 01:23:32.580 align:middle line:84% I just have a couple more [UNINTELLIGIBLE] things to do. 01:23:32.580 --> 01:23:35.610 align:middle line:84% I wanted to thank you guys first of all. 01:23:35.610 --> 01:23:40.450 align:middle line:90% [APPLAUSE] 01:23:40.450 --> 01:23:42.430 align:middle line:90% So let's see. 01:23:42.430 --> 01:23:45.290 align:middle line:84% On next Wednesday, which is the Wednesday right before 01:23:45.290 --> 01:23:49.040 align:middle line:84% Thanksgiving, I think a couple of folks are probably going to 01:23:49.040 --> 01:23:50.290 align:middle line:90% be getting out-- 01:23:50.290 --> 01:23:54.020 align:middle line:90% 01:23:54.020 --> 01:23:57.970 align:middle line:84% because I've been hearing some daffy stuff about what the TSA 01:23:57.970 --> 01:24:00.095 align:middle line:84% might be doing, and what people have been doing in 01:24:00.095 --> 01:24:01.540 align:middle line:90% response to TSA [LAUGHTER]. 01:24:01.540 --> 01:24:04.420 align:middle line:90% 01:24:04.420 --> 01:24:07.250 align:middle line:84% Getting to the airport early, if you are flying out, might 01:24:07.250 --> 01:24:08.890 align:middle line:90% be a good idea. 01:24:08.890 --> 01:24:12.120 align:middle line:84% Because if everybody decides to refuse the bag scanner 01:24:12.120 --> 01:24:15.430 align:middle line:84% scans and the body searches, then we're talking about some 01:24:15.430 --> 01:24:15.910 align:middle line:90% real delays. 01:24:15.910 --> 01:24:17.170 align:middle line:90% Anyway. 01:24:17.170 --> 01:24:21.090 align:middle line:84% So I think what I'm going to do is [UNINTELLIGIBLE] 01:24:21.090 --> 01:24:22.340 align:middle line:90% this class. 01:24:22.340 --> 01:24:25.590 align:middle line:90% 01:24:25.590 --> 01:24:28.525 align:middle line:84% If there are teams who are really wanting to do a live 01:24:28.525 --> 01:24:31.550 align:middle line:84% action game, and they want to get a head start on that, talk 01:24:31.550 --> 01:24:32.560 align:middle line:90% to me directly. 01:24:32.560 --> 01:24:37.150 align:middle line:84% And maybe what we can do is, meet up with you as a team. 01:24:37.150 --> 01:24:40.220 align:middle line:84% And try to get some of ideas across. 01:24:40.220 --> 01:24:43.450 align:middle line:90% Do a brainstorming with me. 01:24:43.450 --> 01:24:46.610 align:middle line:84% I will also get into talking about live action games the 01:24:46.610 --> 01:24:47.907 align:middle line:90% following week. 01:24:47.907 --> 01:24:50.769 align:middle line:84% I'll schedule one of the classes for that. 01:24:50.769 --> 01:24:54.130 align:middle line:84% So we're not going to miss that topic. 01:24:54.130 --> 01:24:56.880 align:middle line:84% I just worried that if we get to it too late, and you are 01:24:56.880 --> 01:24:58.470 align:middle line:84% making live action games, then you don't have enough material 01:24:58.470 --> 01:24:59.720 align:middle line:90% to work with. 01:24:59.720 --> 01:25:06.590 align:middle line:90% 01:25:06.590 --> 01:25:10.520 align:middle line:84% Finally, about this assignment, if the subject 01:25:10.520 --> 01:25:16.436 align:middle line:84% matter is at all uncomfortable for you to work with, and you 01:25:16.436 --> 01:25:22.620 align:middle line:84% can't really find something in this fairly large topic that 01:25:22.620 --> 01:25:25.531 align:middle line:84% you will be comfortable working with and you can't 01:25:25.531 --> 01:25:28.720 align:middle line:84% find a team, talk to me directly. 01:25:28.720 --> 01:25:31.950 align:middle line:84% And we can work out some other assignment. 01:25:31.950 --> 01:25:34.270 align:middle line:84% I can't say that I have an assignment in my back pocket 01:25:34.270 --> 01:25:37.930 align:middle line:84% all ready to go, and more likely than not, I'm 01:25:37.930 --> 01:25:40.799 align:middle line:90% half-assing it too. 01:25:40.799 --> 01:25:45.629 align:middle line:84% I would much prefer folks to work on this problem that I 01:25:45.629 --> 01:25:46.595 align:middle line:90% think is fascinating. 01:25:46.595 --> 01:25:50.459 align:middle line:84% And a pretty big problem that you can find some small 01:25:50.459 --> 01:25:51.425 align:middle line:84% project that you're comfortable with. 01:25:51.425 --> 01:25:56.080 align:middle line:84% But if you are, I don't want to make anyone uncomfortable 01:25:56.080 --> 01:25:57.580 align:middle line:90% due to [INAUDIBLE]. 01:25:57.580 --> 01:25:58.830 align:middle line:90% So just talk to me. 01:25:58.830 --> 01:26:04.956 align:middle line:90%