(presuppositions in NLP jargon).
- There is no failure, only feedback. (Patients respond differently to setbacks).
- The Map is not the territory. (“Science and Sanity 1933, Korzybski).
- The meaning of the communication is the response it elicits. (The success of the interaction depends on how the message is received by the listener).
- If what you are doing is not working do something different.
- Individuals have all the resources they need to achieve their desired outcomes.
- Every behaviour has positive content
Albert Mehrabian’s 1970 study
NLP and Calgary-Cambridge Framework.
CCF provided evidence base for the 5 stages of the consultation. Also showed that effective communication made a difference to clinical outcome.
Rapport and what it is
Ability to be on the same wavelength and to connect mentally and emotionally with others, building mutual trust and respect ie. to have the skills to meet people where they are.
Everyone can learn the skills and get better with practice.
- Developing and maintaining rapport is central to effective consulting.
- Means being able to enter a patients inner world sufficiently to be able to understand it.
- With some patients you’ll find it easier. Different GPs tend to attract different types of patients.
- You do not have to like a patient to enter into rapport with them.
How do you know when you are in rapport?
- Eye contact
- Mirroring: matching postures
- Simultaneous non verbal communication
- Matching movements and gestures
- Picking up and using same words as each other
- Using same type of language: visual, auditory, kinaesthetic. ( Fitting into the person’s map of the world)
Improving your consultation
- Engaging right from the beginning with smiles and eye contact.
- Genuine interest and curiosity in the patient and why they are there ( Carl Rogers: “unconditional positive regard”).
- Avoid talking about yourself or your experience.
- Watching and listening for visual, auditory and kinaesthetic cues and responding to them.
- Matching the pace and tone of the patient’s speech.
- Matching the patient’s language and representational systems.
- Maintaining awareness of your own body posture and movements.
- Matching the patients body posture.
- Not interrupting or talking over the patient.
- Leaving silent space for the patient when it is clear they are thinking and “have gone inside” ( eyes looking down and body still…”internal search”).
- Summarising back to them what they’ve just said to demonstrate that you have listened and understood.
Breaking rapport (end of consultation)
- Look at watch.
- Look at or type into computer.
- Alter body posture…no longer matching.
- Sit up straighter.
- Speak faster/louder.
- Hand over prescription.
- Stand up.
- Walk to door and open it.
- Each of us has a preferred way to process information from the outside world. What is yours?
- Clues in language content and eye movements.
- Matching language with patient’s rep system helps communication and enhances rapport.
- Medical jargon (in general) reduces rapport.
- Many patients use two two sensory modalities (v+k, v+a, a+k, etc).
- Most are visual.
- Tend to be neatly dressed, tidy, easy to picture the future, good planners, good English spellers.
- Use words and phrases like: “see”, “show”, “reveal”, “I see what you mean”, “the future looks bleak”, “I don’t see eye to eye”.
- Less concerned about the state of their immediate environment, not tidy. Tend to have internal conversations about themselves.
- Use words such as: “hear”, “talk”, “sound”, “tell”, “call”, “listen”. That sounds awful”, “ring a bell”.
- Tend to describe illness as a conversation with themselves: “ So I said to the husband “I feel right queer” and he said “ you’d better get yourself to the doctors.”
- Take in information through their feeling/emotional/physical sense…feel their way.
- Use sporting language: “tackle”, “hold”, “kick”, “grasp”, “run”, “toss”, “step”.
- Kinaesthetic words and phrases: “feel”, “touch”, “had”, “contact”, “grasp”. “I’ve got a feeling that…”, “I can’t get a grasp.” “I’ve been worried sick”. “I must tackle this”.
- Ask person: can you remember your first day at school? If they look up (usually to the left) then they are remembering pictures.
- If horizontal (usually to left): remembering sounds.
- If down (usually to right): remembering physical or emotional memory.
Listening to the patient
- Meta-modals: deletions, distortions and generalisations.
- Unconscious habitual filters for input and output.
- May change depending on context.
- Towards: towards a goal. Focuses on the positive, look for solutions. Body Language (BL): nodding, positive.
- Away from: Avoid, “steer clear of”. Tend to focus on negative, “glass is half empty”. Find obstacles. BL: shaking head.
- General: Big picture, may jump from one topic to another,with this type pf patient its important to get agenda at start of consultation. Language (L): “Generally”, “usually”, “overall”. BL: laid back, expansive, looks up.
- Specific: Detail, nitty gritty, order and sequence, present in minute detail, if interrupted go back to beginning. L: “Exactly”, “precisely”, “before”, “after”. BL: precise, finger and thumb gesture.
- Match: look for similar, matches new information with what they know. L: “same”, “similar”, “just like the last time”. BL: speak slower, less tonal variation.
- Mismatch: look for difference, how things don’t fit together, challenging, do the opposite. L: “new”, “different”, “unique”, “complete turn around”, emphasise certain words. BL: mismatch posture.
Internal/External (locus of responsibility)
- Internal: make own decisions on weighing up pros and cons. L: “I just know it’s the right thing”. BL: self assured, palm to chest when talking about beliefs.
- External: need direction and feedback. Lets others make decision ( “well, you’re the doctor, you decide!”), comply with authority, regular attenders. L: “my friend suggests…”, “I read it in the papers..”
Past, Present and Future
- Past: conservative, “good/bad old days”, depression is past oriented, L: “no future”,
- Guilty/regret re the past. Typical question: “why?”
- Present: Live for the now, if have repetitive problem behaviour such as addiction, don’t learn from mistakes (past) and don’t think of consequences (future). Typical question: “How can I….x….right now?”
- Future: Imaginative, new ideas, entrepreneurs. Anxiety is future oriented. Typical question: “What if ..x…were to happen”. Fail to notice past resources.
- Thinkers: emotionally distant, remember emotional events in a detached way, cool head, don’t panic, “cold fish”, aloof, poor at empathising,. BL: sit erect, unlikely to flush, look upwards/into distance.
- Feelers: Strong emotional responses, relive the event, hypersensitive, over-react to minor stresses, more frequent attenders. BL: likely to flush during emotion, look down and to right, wide ranging tone/speed.
- Away from +specific: look for errors all the time, critical.
- Internal +Others: always knows what is best for you.
- Feelings+ Away from: panic attacks and phobias.
- Deletions: patients leaves out information from their statement…you may be unsure at what they are getting at.
- Distortions: Patient uses language subconsciously to interpret what happened from their own perspective.
- Generalisations: All encompassing statements that are unlikely to wholly true. “always”, “never”.
- “I’m angry” ..why?, “I’m scared” ..of what? “its no better” …what?
- Simple: “He left” …where to?
- Comparisons: “she’s better than me” …in what way?
- Judgements: “He’s wrong” …is he really?
- Nomilisations: “Change is hard”…changing what is hard? ( turning a verb into a noun makes it more static…doctor converting nouns back to verbs helps in depression).
- Complex equivalence: “He didn’t buy me a Valentine’s Day cars so he mustn’t love me.” …how do you equate that?
- Mind Reading: “I know you think I am wasting your time, but…”.
- Cause and Effect: “His voice made me angry”…How does his voive make you angry?
- “I always need antibiotics when I get a cough”.
- Modal Operators of Necessity: “I have to do this.” …What would happen if you didn’t.
- Modal Operators of Possibility: “I can’t…its not possible.” …What stops you?
- Universal Quantifiers: “She never thinks about my feelings.” …Never, ever?
- “This illness will never get better.”