Original Article

Cultivating Empathy for the Mentally Ill Using Simulated Auditory Hallucinations
William Bunn, D.O. Jan Terpstra, M.D.
Objective: The authors address the issue of cultivating medical students empathy for the mentally ill by examining medical student empathy pre- and postsimulated auditory hallucination experience. Methods: At the University of Utah, 150 medical students participated in this study during their 6-week psychiatry rotation. The Jefferson Scale of Physician Empathy, Student Version, was used before and after the experience. The auditory hallucinations were provided as part of the Hearing Voices That Are Distressing curriculum created by the National Empowerment Center, which attempted to simulate the experience of hearing auditory hallucinations. While the students were listening to the auditory hallucinations, they underwent a psychiatric interview and simplied cognitive testing and were asked to socially interact in the community. We conducted a paired sample t-test of signicance to identify pre- and postsimulated auditory hallucination changes in medical student empathy. Fifty students were randomly selected to serve as a comparison group. Results: The paired sample t-test revealed that after listening to the simulated auditory hallucinations and participating in the simplied neurocognitive testing, the students empathy score increased. Students in the comparison group had no signicant difference in their empathy scores. Conclusion: These results suggest that empathy may increase when students are given a brief glimpse into the mind of a mentally ill patient by listening to simulated auditory hallucinations. Specic interventions to increase empathy for the mentally ill can lead to a better understanding of how empathy can improve patient care, enhance the doctor-patient relationship, and direct future educational strategies.
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Received March 20, 2008; revised August 25, 2008; accepted September 11, 2008. The authors are afliated with the Department of Psychiatry at the University of Utah in Salt Lake City. Address correspondence to William Bunn, University of Utah, Psychiatry, 50 North Medical Dr., Salt Lake City, UT 84132; Bill.Bunn@hsc.utah.edu (e-mail). Copyright 2009 Academic Psychiatry

mpathy for patients is a difcult attribute to learn and plays a major role in the doctor-patient relationship. The ability to appreciate patients emotions and express this emotional awareness improves clinical outcomes, professional satisfaction, and patient adherence to medical recommendations, and is believed to signicantly improve patient satisfaction (1 6). Although the benets of demonstrating empathy for the patient have been well documented, it is troubling to note that empathy declines during the course of medical school (7, 8) and residency (9, 10). It is no surprise that the cultivation of empathy is a proposed learning objective of the Association of American Medical Colleges for all American medical schools, and many strategies have been developed to enhance empathy in undergraduate medical students. A PubMed search of primary data of educational strategies to increase empathy in medical students found several quantitative studies which used interpersonal skill workshops, communications skill workshops, and literature courses lasting from 3 hours to 16 total hours in a semester that reported increase in student empathy (1116). Six studies were found that tested groups of ve to 87 students in a variety of interventions, ranging from literature and medicine courses, attending a theatrical performance, and reective writing to participating in a student hospitalization experience lasting 24 30 consecutive hours, reported a qualitative increase in student empathy (16 21). Limitations of these studies included small sample sizes, a lack of comparison groups, and no long-term assessment of durability of effect, and the studies generally relied on self-assessment. In spite of these limitations, the studies showed that brief, targeted interventions can impact a students ability to demonstrate empathy for patients (22). One aspect of cultivating empathy that has been largely unexplored is the challenge of teaching medical students empathy for the mentally ill and the task of helping medical students understand what it is like to suffer from a
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mental illness. The object of this study was to assess third-year medical student empathy toward psychiatric patients using the validated Jefferson Scale of Physician Empathy, Student Version (JSPE-S), before and after a simulated auditory hallucination experience. The hypothesis was that after experiencing what it was like to have auditory hallucinations, the students would have increased empathy for the challenges of the psychiatric patient. Methods Participants This study was conducted at the University of Utah School of Medicine during the 20052007 academic years with a cohort of 150 medical students participating in the 6-week psychiatry rotation. Of the participants, 84 were men and 66 were women; 90% identied themselves as Caucasian, 4% as African American, 3% as Asian, and 3% as other ethnic backgrounds. Of the participating students, 65% had taken a psychology class prior to medical school, and 80% reported that they had a friend or family member with a psychiatric disorder. Procedures On the rst day of the psychiatry rotation, students were invited to participate in the research according to institutional review board guidelines. To reduce the tendency to give socially desirable responses, the aspects of the research were described and the respondents were assured of condentiality and anonymity. Participating students completed the JSPE-S, which is a self-administered, 20-item test developed by scientists at the Center for Research in Medical Education and Health Care at Jefferson Medical College (23). The JSPE-S is a specically developed and validated instrument that can serve as an operational measure of empathy for students and practitioners of health professions. Respondents indicated their agreement or disagreement to statements using a 7-point Likert scale (1strongly disagree, 7strongly agree), making the pos-

sible range of resulting scores 20 140 (higher score signifying a higher degree of empathy). Upon completion of the JSPE-S, the students listened to a 40-minute simulated auditory hallucination presentation on individual headphones. This presentation was created by Patricia Deegan, Ph.D., of the National Empowerment Center, Inc., as part of the Hearing Voices That Are Distressing curriculum and was designed to mimic the experience of auditory hallucinations. While the students listened to the presentation, they participated in simplied neurocognitive testing. The students were asked to follow written directions to construct various geometric designs with wooden toothpicks and participate in a modied Mini-Mental State Examination, which assessed memory, concentration, fund of knowledge, and abstraction ability (24). Once the tasks were completed, the students were encouraged to walk around the medical center while listening to the simulated auditory hallucinations and to interact with their peers as they would normally. After listening to the auditory presentation, the students were asked to complete another JSPE-S. Fifty students were randomly selected for the comparison group and completed the same procedures as the test participants, including the JSPE-S and neurocognitive testing, but without listening to the simulated auditory hallucinations. Results Results of the paired sample t test (Table 1) revealed that after listening to the simulated auditory hallucinations and participating in the simplied neurocognitive testing, the students empathy score increased, with an average difference of 2.65 (t3.44 [SD7.6, p0.004]). Prior to the simulated auditory hallucination experience, the average JSPE-S score for the group of 100 students was 111.1. Mens and womens scores were similar and the average post-experience JSPE-S score for the group was 113.8. The comparison group was evaluated with the JSPE-S and with neurocognitive testing, but did not listen to the simulated auditory hallucinations. The results of the paired

TABLE 1. Results of the Paired Sample t-Test Among Test and Comparison Students
Pre-Experience Average Test students (n100) Men Women Total Comparison students (n50) 111.1 111.2 111.1 111.8 Post-Experience Average 113.9 113.7 113.8 111.9 Average Difference 2.8 2.5 2.65 0.1

t 2.58 2.26 3.44 0.049

SD 8.1 6.8 7.6 5.5

p 0.006 0.014 <0.001 0.48

95% CI 2.602.73 2.432.56 2.582.67 0.020.165

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sample t test (Table 1) revealed no signicant difference in their empathy score, with an average difference of 0.1 (t0.049 [SD5.5, p0.48]). The empathy score distribution (Figure 1) demonstrated a wider range of scores in the pre-experience group than in the post-experience group, with the highest concentration in the 110 115 range. Post-experience JSPE-S score distribution demonstrated no students in the lower scoring ranges and the highest concentration of scores in the 110 119 range. Discussion Results indicated that the students who listened to the simulated auditory hallucinations had an increase in their overall empathy score as measured by the Jefferson Scale of Physician Empathy, S-Version, while students who did not listen to the simulated auditory hallucinations had empathy scores that remained unchanged. These results suggest that empathy may be increased when students are given a brief glimpse into the mind of a mentally ill patient and allowed to articially experience what some people with mental illness experience daily. The study demonstrated little difference between empathy scores of men and women on the JSPE-S, which is a departure from the results of several authors who noted that women students scored higher on empathy scales than their male counterparts (15, 16, 2527). The empathy score distribution (Figure 1) demonstrated a shift in the disbursement of scores throughout the lower ranges to a more concentrated disbursement in the higher ranges, which may signify that, although the average empathy score change was 2.65 among test students, the

group scores underwent a concentrating effect in the higher ranges. In addition to the group effects noted, the effect of the hallucination experience on the individual student should also be appreciated. Students commented that after their participation in the research, it was easier to understand the behavior of their patients with mental illness. One student reported, You learn about the features of schizophrenia but when you put it together with the hallucinations, it really helps you understand why patients behave the way that they do. Another student said, I just could not stop talking about it. I called my family to tell them about the experience. I feel like I know how to better understand my patients. The results of this study are limited to one school and cannot necessarily be generalized. Also, as a self-report, the JSPE-S suffers from the same difculty as many selfassessments of not necessarily correlating with behaviorbased measures (28). Future studies may use standardized patients to measure the patients perceptions of medical student empathy before and after a simulated auditory hallucination experience and the effectiveness of the student empathy. Perhaps combining the JSPE-S with the Mercers Consultation and Relational Empathy Measure (29) would help researchers discover what components of medical student empathy most improve patient satisfaction, clinical outcomes, and physician well-being (30). Larger studies are needed with appropriate controls to see if the changes in empathy are maintained over time. As medical schools begin to adopt strategies to enhance empathy in undergraduate medical students, specic interventions like participating in a simulated auditory hallucination experience can be a valuable tool to help students increase their empathy for the mentally ill. This interven-

FIGURE 1. Empathy Score Distribution for Test Students (N100)

70 60 Test Students 50 40 30 20 10 0 <80 8089 9099 100109 110119 120129 130140 Range of Scores (inclusive) Pre-experience score Post-experience score

JSPE-SJefferson Scale of Physician Empathy, Student Version

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tion can lead to a better understanding of how empathy can improve patient care, enhance the doctor-patient relationship, and direct future educational strategies.
At the time of submission, the authors declared no competing interests.

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