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Linus Geisler: Doctor and patient - a partnership through dialogue   © Pharma Verlag Frankfurt
Active listening
Technique of "mirroring" (reflection)
Techniques for interviewing procedures in mirroring (reflection)
The best way to convince
others is with the ears:
by listening to them.
Dean Rusk
Active listening
Michael Ende describes in his book "Momo" a little girl with an exceptional ability to listen:

"Little Momo could listen in a way that nobody else could. That's nothing unusual, some might say, everybody can listen.

This is not true. There are only a very few people who can really listen. And the way in which Momo listened was absolutely unique.

Momo could listen so that inarticulate folk suddenly came out with bright ideas. It wasn't anything that she said or asked that brought such ideas out of the other person; no, it wasn't that. She simply sat there and listened with full concentration, completely involved. While she gazed at them with her huge dark eyes, others felt unique ideas (which they had never guessed were there) suddenly surfacing from deep within.

She could listen so well that restless or undecided people suddenly realized exactly what they wanted. The timid unexpectedly felt free and bold. Those who felt unlucky or depressed exuded confidence and joy. And if somebody felt that something was missing from his life, which had become meaningless (that he was only one of the teeming masses; that he could not manage and would be discarded like a broken jar) - then he would go and tell little Momo all about it. While he spoke about it, it would become clear in some secret hidden way, that he was basically mistaken; that there was only one of him, that he was unique, and because of that, he was important to the world.

How Momo could listen!"
Active and trained listening is the most important ability that the doctor should use in discussions with patients. As it is more difficult to listen than to speak, listening is also the more difficult component of discussion. A specific characteristic of the good doctor is that he has a good listening style.

Active listening means a "ready-to-receive" attitude, or "attentive behaviour". This does not only involve taking in what is said, but also developing an ear for the background, and what is not said, as well as the semi-tones or emphases.

There are 4 preconditions associated with active listening:
1.  Interest
2. Readiness to listen
3. Ability to listen 
4. To be completely present or "all there".

Additionally, it is also important that the person I am listening to, knows that I actually am listening to him. This means that he should be given a signal that readiness to listen is present. This can be achieved by the use of a non-verbal signal (eye-contact, body posture, gesture) or with a verbal utterance which encourages him, as well as by the use of complementary or explanatory statements or questions. Active listening then also involves attentiveness, signaling interest, receiving the message and assimilating the message.

Active listening is an active component of discussion and has to be present. It complements speech. Both of these factors are components of discussion, and neither can form dialogue alone. The interlacing of speech and active listening builds up true discussion.

The development of every dialogue is associated with an unhindered interplay of alternating speech and listening. Interruption is an extreme reversal of active listening, and a prime disturber of speech; it is basically the most damaging form of inattention. Listening is an active form of silence; it is a wordless expression of: "I have understood, I can appreciate what you would like to say". Sometimes silence in the form of active listening is the only form of speech which is appropriate.

Listening must be unmistakably listening, and should not arouse the impression of partial uninvolvement or disinterest. It is easy that this confusion arises, as the patient does not often receive the honour of being listened to actively.

An example which shows how little doctors have heard of active listening comes from Günter F. Gross: "I recently told a group of a few doctors: 'My doctor is an exceptional listener; I spent 5 minutes explaining something, and he did not interrupt me a single time.' The doctors looked at each other and became more and more light-hearted. One told me: 'We can appreciate that you gave him the chance, at last, to completely switch off, to relax and to think about his own problems in peace!' I still find myself wondering if that were really true."

What effect does active or ("controlled") listening have on the person I am talking with? It releases a whole series of positive factors. The other person feels that he is a real person who is accepted along with his problems. He feels relieved and reacts less emotionally. He himself can concentrate on what is most important. He needs less time to express himself clearly and is more convinced that the other is "present and thinking about him".

Comprehension is the result of the interweaving of speaking, listening, expression and observation.
Comprehension is the result of the interweaving of speaking, listening, expression and observation.
Mistakes in listening have the following far-reaching consequences for patients:
  The patient is not allowed to express himself
The patient cannot utter his feelings
The patient feels he is not taken seriously

It must be said once again, as it is of such basic importance: listening is more difficult than speaking. It requires patience, concentration, discipline, analytical thought and an awareness of semi-tones. There is an intense inner strain without a corresponding outward activity. Active, analytical and discerning listening is the highest step in an attentive attitude.
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Technique of "mirroring" (reflection)
The technique of mirroring is complementary to active listening, and an important supplement of the most important of all interview techniques. Active listening and mirroring together are the most intimately related and most productive elements of every interview.

Carl Rogers and Reinhard Tausch are the originators of the mirroring technique. However, even Sigmund Freud said: "The doctor, like a mirror, should not show anything other than what he is shown".

The principle of this reflection is based on the fact that the doctor should give back to the patient whatever he has heard and understood; that is, what he thinks he has understood. This mirroring takes place in an empathetic setting with emotional warmth (see chapter on empathy link). Here is an example: Patient: "I'm getting less and less enthusiastic about life. He gets home so late every evening, and he is always tired. He doesn't talk to me, or show any interest in me. I sometimes cry the next morning and that helps a bit. I seem so empty. What can one do to change it all?"

The doctor reflects: "Your marriage seems to be hollow and meaningless at the present time. You feel desperate and don't know how to react?"

This example shows how the doctor uses the mirroring technique to play-back the present internal world and the feelings of the patient in his own words, making her feel accepted and understood.

Mirroring then involves putting into words what the other cannot express easily. This initially imparts a feeling of comprehension and acceptance. The most important effect lies in the fact that mirroring helps the patient to gain more insight into his own world of experience, his feelings, moods, presumptions, behaviour, desires and goals. Mirroring encourages self-exploration or self-study on the part of the patient. It leads the patient to "explore his own emotional preconceptions, and judgements, his objectives and desires, and becomes more clear about some of them, or attempts to become clearer" (R. Tausch 1970).

This again makes it clear that understanding discussion is a procedure in which diagnosis and therapy are closely intertwined: in as far as I help my patient to gain more insight into his feelings and conflicts, I create for him at the same time the conditions under which can come to terms with them constructively. Mirroring therefore is in the first place "the verbalization of emotional contents of experience" (R. Tausch, 1970).

People react far more emotionally and far less rationally than they would like to believe. As the head (mind) finds arguments for ways of acting and behaving which come from the "heart" (emotional world), we are strengthened in our belief that we are acting rationally. Psychologists know well enough that most (and probably all) of the "life decisions" of a person are taken emotionally and not rationally. The philosopher Blaise Pascal once said: "The heart has reasons which are not known to the mind." Many studies have shown that mirroring makes it possible for constructive changes in personality, especially in cases of psychoneurotic-tinged ways of behaving.

Mirroring affords the doctor the opportunity to signal his understanding, and to put it into words without the danger of interpretation, judgement or advice. It is also important that he can express that he understands the patient without his implying an immediate agreement with the contents. A comment which starts: "I understand that you..." is usually unfavourable as this easily releases the feeling of agreement with a certain attitude or way of behaviour of the patient. This can be avoided if the doctor expresses his understanding with: "Apparently the mess your son made of things left you so angry that you felt you had to fetch him one...".

The decisive advantages of mirroring are (mod. acc. W. Weber):
  The patient feels that he is accepted and understood.
This means for him that he receives partnership and tolerance.
It allows the patient to get a grip on his internal experiences, his feelings, attitudes, ways of behaviour, desires and objectives, and to manage them better.
For the doctor himself, mirroring is a methodical and clear form for leading patient-centered interviews.
It allows the doctor to choose the correct distancing or closeness to his patient.
Mirroring is the most impressive way of signaling to the patient that the doctor is listening to him actively.
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Techniques for interviewing procedures in mirroring (reflection)
There are three discussion techniques with which the doctor can mirror:
1.  By repeating the words of the other.
2. By repeating what he has heard and understood in his own words; this technique is called paraphrasing.
3. By striving to grasp the emotional contents of the experience of the patient in words; this is called verbalization.

Obviously all three methods demand too much of the doctor at one time. However it is important to recognize the possibilities, the value and the dangers of these three techniques.

The simplest of the three is the repetition of the words (perhaps somewhat more briefly); this does not require the doctor either to work on the formulation of his words or take the trouble to go deeper into his understanding of the patient. For example: Patient: "It was so horrible last night; I felt as if I was going to suffocate. I never ever want to experience that again." Doctor: "It was horrible for you last night." This response will do little more than let the patient know that the doctor heard what he said, but it remains in doubt whether he can really appreciate the fear of suffocating in such an asthma attack. This is a technique which should only be used sparingly as there is a very real danger that the patient experiences the doctor's responses as "parroting".

Paraphrasing means that the doctor replays what he has heard in his own words, at the same time attempting to express what he believes he has understood. For example:

A patient who has had many courses of chemotherapy says: "If it carries on like this, I can't take any more." Doctor: "Do you want to finish the treatment then?" It is important that the doctor has formulated his mirroring statement as a "floating question ". He has given back what seems to him the most likely interpretation of what the patient said, but would like to leave it completely free, and available as a point of discussion, in case the patient meant something else instead. In fact "what is meant" by what the patient says can be something completely different i. e. "The treatment up to now has not helped much ", or "I can't cope unless you help me", or "I am at my wits' end" etc. From this it can be seen that paraphrasing has the basic difficulty that we can only give the patient one of the very many options of interpretation, which is what we ourselves presume to be the most likely.

Verbalization is the best method of getting in touch with the experience and feelings of the patient. For example: The patient says: "I don't know if I can manage more chemotherapy."

Doctor: "You are anxious that it could get too much for you?" Here again the doctor has responded with the method of the floating question, but this time focusing the discussion on the likely predominant feeling of the patient, which is that of anxiety. Here it is also clear that this statement permits many other interpretations on the level of feelings. Probably the feeling of anxiety is overshadowing true feelings of helplessness, despair, anger, hopelessness, as well as aggression against the doctor. The method of verbalization includes the major danger of misinterpreting the emotional experience, as well as a tendency to judgement and interpretation.

W. Weber goes on from the suggestions of Tausch to give the following concrete suggestions for the procedures of discussion technique by mirroring:
 I should mirror first and foremost the following contents. 
- emotional statements
- desires and objectives
- presumptions and emotional judgements
technically I should mirror: 
- all important statements as soon as possible after they have been uttered
- briefly and concretely
- clearly and vividly
- what the patient is experiencing and feeling in the "here and now" and
- make the attempt to work out the meaning for the patient. 
For example: "I wonder what this means for you?" "I am trying to work out what is happening inside you"
- use the term "you" ("you have the feeling that...", "you would like that..."), rarely or never the words "I", "We" or "one".
- try not to mirror mechanically, as a façade or by echoing.

If I am not sure whether I have understood the patient, it is important that I mention it, for example, by interjecting: "Is that right?", "I'm not completely sure if I have understood you"? or "It seems as if I could understand you better if this point were clearer".

As the doctor should use his own words for replaying, it is especially important for verbalization of emotional experiences that he deliberately broadens his own vocabulary. Synonyms, or words that tend to express the opposite meaning such as antonyms should be studied. If for example the doctor picks up the statement of the patient that he "feels alone", he could use the following synonyms for reflection: "You have a marked feeling of loneliness", or " It seems to you, that you have been abandoned". On the other hand, formulation with antonyms would be: "You have the feeling that nobody is there for you", or "You do not feel as though there is any loving concern for you at the moment" etc.

Active listening and understanding mirroring, especially with the verbalization of emotional experiences, work together like cogs in a gear: this interaction of understanding listening and expressing comprehension is the ideal engine for every understanding discussion. The ability to listen actively and to express that which is heard and understood so that the other feels that he is understood, extends his view of himself and completes the higher levels of interview technique. Typically this form of discussion does appear to be a work of art in its effect but a "normal" discussion in its form. This is not new as is clearly shown by the following lament of J.K. Lavater (1741-1801):

"If you can discover a person
who is peaceful,
without affectation
who, with presence of mind,
with true involvement,
can quietly listen to needs,
who does not interrupt, who does not pose two questions at the same time,
who waits for the answer and grasps it all,
who does not peer into the future or past,
who does not fix you with a studied look, and put you down,
who does not avoid your gaze, looking upwards or downwards,
who is as prudent as he is at ease, then -
then you will think that you have found treasure in a field,
then you will think that you have found a pearl".
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Acceptance does not mean much if 
it does not include understanding.
C.R. Rogers
Empathy is one of the fundamental components in communication between doctor and patient. In the widest sense of the word this means "to involve one's self in understanding". To achieve a sympathetic understanding is very near to that of "empathy", but is not identical, meaning more "experiencing the feelings of the other for oneself, and to share it with him (to see with the eyes of the other and to hear with the ears of the other)" (Dahmer and Dahmer). Rogers (1959) defined empathy as follows: "This condition of feeling (or to feel for oneself) consists of accepting the internal environment of the other with regard to his relationships in such a way that encompasses the associated emotional components and significance's as if one were in fact the other, never however abandoning the "as-if" status. This means that one can experience the pain or the joy of the other, in the same way that he feels it; one can recognize the reasons for the emotions in the same way that he perceives them but one never ever loses sight of the fact that it would be "like that if" I were to be hurt or if I were to be joyful...".

Empathy should not be confused with fellow-feeling, sympathy or "infectious feeling". It also does not correspond to identification, from which the "as if" characteristic is the most important difference. If the "as if" is missing, there is identification but no longer empathy.

Sympathy is "an appraising agreement with the feelings, ideas and the tastes of the other". As with all judgmental forms of behaviour, it should not characterize discussions between doctor and patient. Biermann-Ratjen underlines the importance of the "as if" characteristic of empathy: "Empathy means to so completely and so closely follow the experience of the other as if it were one's own, but to never ever leave the "as if" state".

Empathy should also not be confused with "being full of understanding in the sense of a humane attitude". Obviously it is an ethically desirable form of behaviour to be "full of understanding", but this is not an indispensable condition for interview techniques. Although I do have to have the ability to feel for him in order to be able to communicate about his problems, it is not necessary that I am personally upset or involved. It can be said with some reserve that involvement is more likely to impede free communication between doctor and patient than facilitate it. Stated simply: a basic condition of doctor-patient discussion is that the doctor is prepared to work towards understanding: sympathy and compassion lie at another level of relationship. Empathy is not only the ability to follow the feelings of the other. The emphasis lies not so much on the term "feeling", but more on the ability of entering into the world of experience of the patient. Rogers did not refer to feelings, but more to the personal "perceived world" of his clients.

Doctors vary in their extent of empathetic behaviour, as the ability to empathize depends on certain conditions:
  The basic ethical attitude of the doctor to his profession and his social involvement
His ability to be moved emotionally, and his experience of coping with his own sensitivities
His ability to perceive the quality of his relationships with patients and to influence it (M. Geyer, 1985)

There are two requirements which can greatly impede the development of empathy: one is the need for emotional neutrality and the other the need to dominate. The desire to be empathetic is usually the reason for choosing medicine as a profession. However most of the medical training is concerned with understanding somatic disorders. Empathy is not required here. This may also be stifled by defense mechanism against personal anxieties and guilt, as well as experiences with pushy or clinging patients who cannot be managed with an "empathetic approach". A need for emotional neutrality can develop from this, which leads to an "ethically questionable distancing from the human reality of the patient" (M. Geyer).

So the doctor also has to know his own need for emotional neutrality and he has to integrate it deliberately in his empathetic attitude. Only then he will be able to form both distance and closeness to the patient according to his personality and to remain susceptible to the patient's problems at long sight. The doctor who tries to dominate the patient - mostly because of a lack of self-confidence -, will misunderstand the patient's need for information and his attempts to create a partnershiplike relation with the doctor and he will confuse them with know-all manner and impeachment of the doctor's role. This conflict makes it harder for him to behave empathetically (M. Geyer). Extensive studies showed that the ability to develop empathy is facilitated by certain features of the personality. These are: composure, good fellowship, the ability to reflect and to be self-critical, general psychical stability (M. Geyer).

Ultimately, the doctor should be able to signal his empathy and appropriate understanding towards the patient either directly or indirectly. The course of a discussion which is characterized by involved understanding is often enough of an indication of the doctor's empathy. If the patient finds that he can "get through" with his problems or requests, and that these are interpreted in the same way that he sees and experiences them, the doctor does not necessarily have to reaffirm his understanding.

However, if the doctor gets the impression that the patient is unsure that he has really been understood, comprehension should be clearly affirmed. This can be done in two ways, either directly by a verbal confirmation: "I can well understand, how you felt at that moment...", "I know that this condition can be very unpleasant..." The second possibility lies in indirectly implying that I am prepared to involve myself and to understand by trying to describe his situation or experience in my own words: "I think that you would like to tell me, that you can't understand how it is that other people can laugh."

Empathy is the bridge which leads from one's own reality into that of the other, and makes it possible to determine a common reality. Empathy permits sorting out the various problems that a patient has, not only in the abstract, but also to do something about them. As a result one can understand that the otherwise apparently inadequate reactions and behaviour of the of the patient are in fact perfectly appropriate from his point of view.

Empathy is the key to understanding the way in which a patient works through his experience of illness. It is a precondition that doctors and patients really mean the same thing when they discuss an illness. It is a prerequisite for a doctor-patient relationship which is characterized by warmth and mutual acceptance, and of a doctor being perceived as open and "real" (in other words he is what he makes himself out to be). Empathy does not only mean that one has to be prepared to put oneself into the patient's position for a short period, but also to sense what the patient thinks of him (Dörner and Plog, 1980).

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Linus Geisler: Doctor and patient - a partnership through dialogue
© Pharma Verlag Frankfurt/Germany, 1991
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