Communication Revisited

Week 5

Context

This week we revisit communication skills as these are the cornerstone of good support in mental health and mental illness. We start by reflecting on the communications seen in the video episodes so far, and then explore the communication skills mental health care workers require to be effective in giving support. "Communication is functional behaviour, motivated by a hierarchy of needs, beginning with primary needs, such as food and fluids, up to more complex needs such as forming and maintaining relationships (Hurst-Brown & Keens, 1990).

Introduction

This week runs from 20th to 26th October. You will need to:

Complete this section
Complete the Communication Skills (Advanced) section if appropriate to your level of skills and knowledge
Complete the Self Awareness (Advanced) section if appropriate to your level of skills and knowledge
Watch the interview with Video Interview: Clinical Expert: Dr Russell Razzeque Crisis Management
Watch the Video: Journey: Episode 4: Crisis Point video
6. Complete the task with the video

Content

Reflection

We are over half way through the course. We would like you to take a little time to reflect on the following before you move on to the rest of this week's materials:

Whilst watching Carols interactions with people, what have you noticed or observed about how she interacts with people in her family
What have you noticed about how Carol communicates non verbally
Who in the different episodes has the most effective means of communicating with Carol, what constributes to this do you think?

Good Communication

What things do you think promote positive communication?
What factors might inhibit communication?
What elements of these last two have you observed in Carol’s storyline?

Follow this link to the Google Docs Links to an external site. section where you will find a document that you can add your ideas into. You might find other people editing the list at the same time as you, so don't be surprised if things move around!

Everyone is unique

Communicating with people means adapting and engaging in a two way process, tailored to each individuals different situation. Consider how you talk to close friends and family, then compare this to how you talk to someone who you have met for the first time. "Objects of reference" are the objects that have special meanings attached to them, which can help someone understand what is being discussed quickly, or anticipate an event or activity about to occur. "Objects of reference are items such as toys, clothes, jewellery or other everyday objects that have a special meaning for somebody. For a child, a cuddly toy may represent comfort and safety. An older person may treasure their photographs because they represent and provide memories of family, friends and relatives. Objects of reference, such as photos or toys might be used ... to stimulate communication and interaction with individuals ..." ()

Consider all the symbols you see around you, and what attached meanings these have for you. Would other people recognise these?

Effective communication relies on a number of interlocking factors, skills and expertise:

Active Listening

Active listening helps patients clarify and articulate their inner process (Friedman, 2000). For a patient, being carefully listened to can be a moving and profound experience, one that transforms the relationship between patient and carer. Active listening is particularly relevant in a hospital setting, where patients often report that they feel isolated and invisible. It can make a difference in rebuilding a patient's sense of self. It can also be rewarding for the carer.

Listening to people involves more than just hearing what they say. To listen well you need to be able to hear the words being spoken, thinking about what they mean, then thinking what to say back to the person. You can also show that you are listening and what you think about what is being said by your body language, facial expressions and eye contact. By yawning or looking at your notes when someone is talking, you give the impression of being bored by what is being said. By shaking your head and frowning you are showing that you disagree with, or disapprove of, what they are saying. The process of active listening involves:

allowing the person talking time to explain and not interrupting
giving encouragement by smiling, nodding and making encouraging remarks
asking questions for clarification, such as, ‘Can you explain that again please?’
showing empathy in your comments
looking interested by maintaining eye contact and not looking at your watch
not being distracted by anything else, such as an interruption on your mobile – switch it off or say you will ring back
summarising to check that you have understood the other person.

Making Listening Therapeutic

Listening acts as positive encouragement to the speaker. To listen actively, you should help the other person speak, using attentive body language, and encouraging words and movements. When the person is uncertain, supporting them with encouraging nods, smiles, maintaining eye contact, and raised eyebrows in anticipation can all be very effective responses Listening attentively, can in itself be therapeutic. Listen for total meaning – listen to both the content and also for any underlying emotions. Respond to feelings – sometimes the real message is in the emotion, rather than the content of what is being said. In such cases, you can respond to the emotion. For example; that must have been really upsetting for you. Only use this response when you have paid attention to all the communication clues… ie verbal and non verbal messages. Listen to your own responses, thoughts, feelings, reactions, as a way to understanding empathetically (which literally means, being in someone else’s shoes)

Use of pause and silence

Try to tolerate pauses, and silence, which are most often kept to a minum when in normal conversation. However, when affectively listening, and communicating therapeutically, the emphasis is on the speaker. Therefore, take time to consider what is being said, and allow the person time to think about what they want to say.

Using questions to understand meaning and improve communication

Questions can be used to help identify what is actually being said, rather than accepting the immediate response to verbal and non verbal communication. Questions are important in seeking to understand another persons situation and can be therapeutic when asked to help the other person gain insight. There are different types of questions and it is important to understand the difference, and when to use the different types.

Clarification questions

When someone stops talking, clarify you have fully understood what they were saying, to ensure you have received their message accurately, "So, what you are saying is ….". Listen to the tone and volume of what and how the person is speaking. Wait and watch for facial expressions, eye movements, body language – this can all help you to understand what is really being said. Clarifying enables clear and effective understanding. Some examples include: "What does this mean?", "How does this relate to what we have been discussing", "Can you give me an example?", "Can you help me understand exactly what you mean when you said …", "Are you saying …", "Can you rephrase that for me please?", "Have I got this right when you say….".

Closed questions

A closed question can be answered quickly, and with a single word (yes/no) or short response, for example: "Have you eaten today?", "What is your name?", "Are you taking any medication?", "Did you sleep well?".

Open ended questions

An open question is likely to allow the person to respond in full. Open ended questions are more effective when trying to understand a person and their particular situation. for example: "Tell me more about …", "What do you think about …", "What did you mean by …".

Funnelling and Tunnelling

Tell me about … is the entrance to the funnel, getting to the heart of the matter under discussion. What? and How? questions are the most useful when wanting to elicit facts. These can be used to tunnel into the subject matter. When? Where? and Who? are also tunnel questions, that help gather supplementary information.

Why questions?

Why? is the least useful question in effective communication, because when asked too early, and too often, it can confuse and puts people on the defensive –
If you have inquisitive children, you will know how frustrating being asked Why? all the time can be! However, when asked at the most appropriate time, it can help to surface motivation, underlying reason and emotional responses… this takes skill in your own active listening and level of awareness in terms of the purpose of your communication, and where you are in the relationship with the person you are talking with.

Socratic Questioning

Socratic questioning is a dialectic method of inquiry, that uses cross-examination of someone's claims and premises in order to reveal a contradiction or internal inconsistency among them. The basic form is a series of questions formulated as tests of logic and fact intended to help a person or group discover their beliefs about some topic, seeking to characterise the general characteristics shared by various particular instances. Aristotle attributed to Socrates the discovery of the method of definition and induction, which he regarded as the essence of the scientific method.

Padesky (1993) using socratic questioning in mental health and mental illness, believed that it "involves asking the client questions which:

a. the client has the knowledge to answer;

b. draws the client's attention to information which is relevant to the issue being discussed but which may be outside the client's current focus;

c. generally move from the concrete to the more abstract, so that ...

d. the client can, in the end, apply the new information to either re-evaluate a previous conclusion or construct a new idea".

This can be achieved by asking: concrete questions, which are structured information gathering questions … eg. "How long have you …"; empathetic questions to elicit emotional understanding, and show active listening; summarising, feeding back to clarify or reiterate a point; and, synthesising or analysing questions; encouraging expansion of an idea, or refinement of key information.

Reflecting feelings, content and meaning

When you reflect what you hear back to the person, you are demonstrating that you have heard what they said, and have clarified meaning
Reflect back what you hear, not by using exactly the same words (parroting), use instead your own words to rephrase what they said. A good way of doing this is to summarise what they have said in fewer words. Some argue that using the persons own words, does enable them to hear what they have just told you, and this helps them check whether that is actually what they meant.

Consider the consequence

What was the intention behind the therapists encouraging Carol to have tea with her neighbour?
What do you think is the purpose of undertaking ‘homework’ ?

Empathy and Body Language

Empathy and body language are both important components of effective communication. It is not just about what or how we say something, or how well we listen. We communicate messages in many other ways at the same time.

Empathy involves helping yourself and the other person, by making sure you are sat somewhere comfortable. Find somewhere that has the least distractions. Sit squarely (both feet on the ground), facing the person, giving them your full attention. Think about what is must be like for them, in their situation, and take time to also think about how you feel as they speak. Body language accounts for up to 50% of a communication, yet it can be very subtle and very easy to misunderstand. One method of reading body language is to watch for changes that correlate with specific events. Body language is the most difficult for people to control, as we literally have hundreds of muscles in our body, many of which are outside of our conscious control. Consequently, body language can be the most reliable indicator of what other people are really thinking and feeling, despite what they might be saying.

Examples:

Aggressive body language: showing physical threat. In the video episodes so far, have you seen Carol or any others showing aggressive body language?
When Carol throws the book down, in her front room, what does this mean in terms of how she is thinking and feeling at that time?

Attentive body language: showing a real interest to what is being said. Who in Carols story, shows they are interested in her and what is happening. What body language did you observe? When Carol is found on the bridge, what do you notice about the neighbours body language?

References

Epstein, RM. Borrell, F. & Caterina, M. (2000) Communication and mental health in primary care. In New Oxford Textbook of Psychiatry (Eds. Gelder, MG. López-Ibor, JJ. Andreasen, NC.), Oxford: Oxford University Press

Friedman, N. (2000) Focusing: Selected Essays 1974-1999. Xlibris Corp

Horowitz, S. (2012) The Universal Sense: How Hearing Shapes the Mind Links to an external site.. USA: Bloomsbury

Hurst-Brown L, Keens A (1990) Encouraging a Natural and Better Life Experience (ENABLE). Forum Consultancy, London

Padesky, C.A. (1993). Socratic Questioning: changing minds or guiding discovery? Links to an external site. A keynote address delivered at the European Congress of Behavioural and Cognitive Therapies, London, 24 September.