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Linus Geisler: Doctor and patient - a partnership through dialogue   © Pharma Verlag Frankfurt
Discussion techniques - General principles
The 4 messages of speech
Anatomy of the signal
Metacommunication
Hearing the signal
Discussion techniques - General principles
 
One can't not communicate.
Watzlawick
The 4 messages of speech
Speaking is always more than just an exchange of information between a sender and a receiver. When I (as sender) speak, I encode my concern in a recognizable term (signal). This will be deciphered by the other person (receiver). If he has decoded my signal "correctly" (that is, what is sent is that which is received) then understanding has taken place. Talking is more than "something that happens between two computers". There are usually 4 messages contained in a signal rather than just the single piece of information. These 4 messages are:
1. Factual content (information)
2. Self-revelation
3. Relationship (contact)
4. Appeal

A simple example from daily life can be used to explain this. The mother greets her son, who does not often visit her, with the words: "It's nice that you're here again!"

Breaking down the signal soon shows that there is really more than one message hidden in the sentence.

The first message explains the facts. The fact that you are here is good. We immediately sense however that this sentence contains more than a simple statement.
The 4 messages of a signal (modif. from Schulz von Thun)
The 4 messages of a signal (modif. from Schulz von Thun)

Under the magnifying glass of the communication psychologist (a)

The 4 messages of the signal: "It's nice that you 're here again" under the magnifying glass of the communication psychologist (modif. from Schulz von Thun)

For example, it says something about the mother who is sending the signal. The mother is speaking from the heart about her feelings with the sentence: "It's nice that you're here again." She is letting it be known that she has missed her son, that she wanted to see him, and that she is pleased to see him again now. She is letting it be known how she feels. This self-revelation is the second message in the signal.

The third message says something about the relationship of the son to the mother. This message usually contains two different messages: the first expresses what the sender expects from the receiver, and the second, what the relationship (contact) is between the sender and receiver. The example "It's nice that you're here again" has an unmistakably critical undertone. The mother also wants to say: "You don't take enough care of me". By doing this, she says something about the son, as receiver of the report. At the same time, however, this sentence also implies something about the closeness and the trust of the relationship between herself and her son.

The fourth message hidden in this sentence contains a clear appeal: the mother would like to use the sentence to express the wish: "You should visit me more often!"

Whenever we speak with one another, we must be aware that the signals that we give to one another contain several concurrent messages, which can be of very different weight. Also the message which appears to be the most important (usually the information) may not be the most important at all.

This gets even more complicated by the fact that sender and receiver believe different messages of the signal report to be the most important for them. It can for example happen that the receiver believes that the factual information is the most decisive, but the sender is much more interested in the appeal or the relationship. It is clear that extensive misunderstandings can develop between the two, even though the signal which has been sent seems completely clear and unmistakable.

It may be that the son in the example given above cheerfully accepts that his mother is pleased to see him, but no more than that, and therefore doesn't bother to visit her more often in the future. This signal would then have been unsatisfactory for the mother, because her son had not "understood" the three messages which were of more importance to her (her feeling of loneliness, her mild criticism of his behaviour and her appeal that he should visit her more often).

A basic fact of communications can be deduced from this: there are usually 4 things that happen when speaking:
1. When I speak, I share a fact > information.
2. When I speak, I also say something about myself > self-revelation.
3. When I speak, I tell the other person what I think of him and how we relate to one another > relationship.
4. When I speak, I seek to have an influence on the other > appeal.

Another example from daily practice can be used to clearly demonstrate the various messages. During the morning ward round, the patient says to the doctor: "I still have bad pain."

Under the magnifying glass of the communication psychologist (b)
Breakdown of the signal: "I still have bad pain" under the magnifying glass of the communication psychologist (modif. from Schulz von Thun)
It is not obvious that this apparently simple statement contains several messages: Everybody understands the message "I have bad pain" (factual content or information). The second message is one about the speaker herself (self-revelation). We could presume that the patient would like to express that she is disappointed about the experience she has had so far with her treatment, perhaps also losing courage or feeling confused. The fact that she is approaching the doctor says something about her relationship with the doctor who is treating her. This is something like: "I am telling you that I have bad pain, because you are the only one who can do something about it." However in this message is also something about her attitude to the doctor: "I am approaching you, because I trust you." The relationship message therefore not only contains a statement about what she thinks of him, but also how she relates to him. One cannot miss the 4th message, the appeal: "You should help me!"

This means that when somebody speaks to me and I would like to grasp all of the messages of this statement, it works best if I answer the following 4 questions:
1. What is the factual content of the report?
2. What is this telling me about the other person?
3. What does the other person want me to know about myself and about our relationship?
4. What does he want to achieve?
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Anatomy of the signal
The signal in interpersonal communication is the sum of the messages, which the sender sends across to the receiver. It is a "complete many-faceted packet, including both verbal and nonverbal components" (F. Schulz von Thun).

The extent of this signal can vary considerably, and there does not have to be a form correlation between the extent and the amount of information it contains. For example the information contained in the one word: "Help!" shouted by a drowning man is far greater than that in a page of a circular letter covered with words from a German electricity company, announcing in effect, that there will be a small increase in the price of electricity in the following year.

Even silence (as a particular sort of not speaking) is a form of communication. Silence is not just "not speaking", but can involve consciously refraining from to speaking, even though I should speak or somebody is expecting it from me. This is the extreme of the basic principle of Watzlawick (1969) summed up as: "One can't not communicate".

The message given by silence is inevitably very difficult for the receiver to interpret as it can mean so many things. How should one interpret the patient who, when asked how he is, turns towards the wall and does not reply. Perhaps the self-revelation part of the message is: "I feel so sick that I can't even say it". The relationship part of the message is perhaps: "You are not the person that I want to talk to about it", or "I don't trust you", or "I am so disappointed with results of treatment so far, that I don't want to tell you how I feel". The appeal is probably: "Leave me alone!". "Don't talk to me!".

In order to understand the message, it is important to determine whether it contains an implicit message as well as the explicit one. Something is expressed directly with the explicit message, whereas the implicit message expresses it indirectly. In addition, this is made more complicated by the fact that there are explicit messages which may be actual or apparent.

For example, the explicit message: "I'm going to bed now" cannot be misunderstood. The signal: "It's nearly midnight" probably contains the same message, namely "I would like to go to bed". Perhaps the receiver took this at face value, whereas the sender possibly would like to express something completely different i. e. "It's is nearly midnight, but I am working so well that I want to carry on".

All messages in a report can be explicit or implicit, which means that there is a great danger of misunderstandings in the field of implicit messages. It can be very instructive to examine any everyday conversation for the implicit and explicit messages that it contains. Usually it will be found that the proportion of implicit messages is much higher than one would expect.

One of the basic abilities in successful communication is to determine which is the true major message of a signal. Is it factual information which has been expressed or described, or is the real request hidden in the implicit message?

Not recognizing implicit messages in discussions between doctors and patients can lead to profound disorders of communication. The patient who says: "I get such a bitter taste in the mouth from the red pills" could be taken as a purely explicit message with a clear factual content (subjective drug intolerance). The implicit messages, which this report (probably) contains as well or even first and foremost are more difficult to identify. Perhaps the patient was trying to say: "I think medicines are poisonous", or "I don't want to take these tablets any more, as they don't suit me". "I doubt if these are the right tablets for me", "Perhaps these tablets taste so bad because the diagnosis is not correct", "I don't really believe that your treatment will work", "I don't want you to treat me" or "Nothing can help me now!".

What possibilities are there to determine whether a signal contains implicit messages?

One of the basic prerequisites is active listening (see Chapter on this subject link). A further way is that of systematically listening out for implicit messages: this means putting out a "second internal antenna" to pick up the implicit messages of the signal. In other words, it is a matter of consciously remembering that a high proportion of signals contain implicit messages along with the explicit message. The third method is a very careful observation of non-verbal parts of the signal, which involves the analysis of movements, gesticulations and phonetics.

It is the non-verbal components of the signal which "qualify" the messages. If there is congruence between them and they both point in the same direction, the report is "true". There are contradictions between verbal and non-verbal messages in an incongruous report.

For example: the young girl who turns her cheek away from her lover's kiss with the words: "No, because I don't love you" is sending a congruous signal. However an incongruous signal is sent by a cyclist after a fall from his bike, who when asked if he is alright replies: "Life is wonderful" with pain written all over his face.

Unfortunately it is not always as easy to spot congruence and (what is far more important) incongruent as in these examples. The contradiction between verbal and non-verbal parts of a signal can be relatively small and may not reveal the full extent of the incongruence.
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Metacommunication
It is inevitable that communication always runs on two levels: that of the actual communication and on the level of metacommunication. The phenomenon of metacommunication again clearly shows just how complicated the course of sending information between people has become.

Metacommunication means communication about communication, or "to unravel the way in which we deal with each other and about the way in which the report we sent is meant, as well as sorting out the signal we receive, and how we react." (F. Schulz von Thun).

Metacommunication can also run explicitly or implicitly. In the true sense of the word, metacommunication is explicit communication. I. Langer used a picture to try to make the concept of metacommunication easier to understand. The discussion partners agree to move to a hillock to get away from the hustle in which they were tangled up. At this vantage point, sender and receiver make the manner in which they are dealing with each other the subject of their discussion. Explicit metacommunication which is used economically can be an excellent method of re-establishing mutual understanding by consciously analyzing and talking about the factors which are disturbing conversation. Parallel to the communication on the level of a signal, there is always communication on the meta-level in the sense of implicit metacommunication. This is the "this is meant" part of every signal. Thus the messages at both levels "qualify" each other. J. Haley (1978) differentiated 4 possibilities by which the signal could be qualified in either a congruent or incongruent way: qualification by context, the way of formulation, by movements and gesticulation as well as the tone of voice.

When the Countess in Tolstoi's "Anna Karenina" dismisses the young Ljewin in a cool and dry tone to the words: "We shall be pleased to see you", then such parting is experienced by the one leaving as a classical example of implicit metacommunication. He was aware that the factual content of the signal ("We shall be pleased ...") was a polite but empty phrase, as the true message was expressed by the tone of voice. The correct decoding of a signal is also bound up with the ability to recognize the metacommunicative content. The nature of implicit metacommunication can be summed up briefly as: "When I send a signal, I also send (whether I want to or not) a message about how this signal is meant to be received" (F. Schulz von Thun).
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Hearing the signal
It is almost a coincidence if the sender correctly codes the signal to say what he would like to say and if the receiver in turn decodes it as the sender meant it, even though it is presumed to happen all the time in the course of communication between people.

The mere recognition that each signal contains 4 messages, which can be in turn either congruent or incongruent, explicit or implicit, and that there is metacommunication in addition, raises reasonable doubt whether talking to one another and understanding one another is as simple as it is made out to be.

The complexity of this procedure becomes even more obvious when we realize that the correct decoding of the signal by the receiver means that he has to have a particular ear for each of the messages of a signal; in other words, he has to have "four ears". He needs a factual ear, a relationship ear, a self-revelation ear and finally an appeal ear (see figure).

Correct understanding requires the receiver to have 4 ears
Correct understanding requires the receiver to have "4 ears" a) Factual ear b) self-revelation ear c) relationship ear d) appeal ear (mod. from F. Schulz von Thun)
The factual ear checks the signal with the question: "How is the factual information to be understood?". The self-revelation ear would like to hear something about the person opposite: "What sort of person is this?" The relationship ear (which is often very sensitive) is used by the receiver to ask himself: "What relationship does he think he has with me? What does he think of me?" And with the appeal ear, he poses the question: "What does the sender want to achieve?"

The completely different ways in which the signal can be "taken" are shown in the following simple question, asked by a husband during breakfast: "Where did you buy this bacon?"

If the wife receives this signal with the factual ear, she will reply: "In the supermarket". If she hears it with the excessively sensitive relationship ear, she will take the question as a criticism of her housekeeping, and reply: "You can eat breakfast in the canteen at work if you like". However if she picks it up with self-revelation ear, then this might be one more confirmation of her husband's nosiness, and release the reaction: "Do you have to know everything?". If the wife understands this as an appeal, she would reply: "I can buy it from the butcher instead of the supermarket next time".

Obviously the receiver receives all 4 messages of the signal at the same moment, filters them to a greater or lesser extent, and hears with more than one ear. One of the fundamental problems of communication is that the reaction of the receiver to the signal depends on whether he is aware or unaware that he is more likely to hear with one ear.

The trained receiver must have the ability to receive the signal that the sender is transmitting with all 4 ears. Major disorders of communication can arise if he only hears with one "ear" (for example, with the factual ear or the relationship ear, because he has consciously or unconsciously closed the other ears).

For example, men who tend to take up technical or academic careers choose to hear with the factual ear, and receive no other message apart from the factual content. On the other hand, marriage partners, particularly when they are under stress, only receive in the relationship ear, and are unable to pick up a factual statement. They are "lying in wait for one another".

A well-trained self-revelation ear is very important for the doctor, as this is his diagnostic ear. He uses this to sift out whatever can lead him to understand his patient. Even when the patient has an emotional outburst, his self-revelation ear allows him to have a better attitude to the patient than if he were using only his relationship ear.

Of course this does not mean that the doctor should "switch off" the relationship ear completely, and listen only with the self-revelation ear and the factual ear, as this would result in the patient being observed as a diagnostic object, and rob the doctor of the ability to be affected or involved.

Schulz von Thun has pointed out the additional danger of "psychologization", which results if the self-revelation ear alone is used (or rather misused). The factual content of a signal is ignored, and the signal only examined under the aspect of what kind of person is hidden behind this signal. The receiver judges all of the statements of the other under the motto: "He only says that because he is made up in that way."

A well-trained self-revelation ear is vital for active listening. It allows us the possibility of sensing the thought and affective world of the other, and not to regard him as just an object, or to continue to judge him from a human point of view.

The appeal ear also plays an important role in discussions between doctors and patients. If the appeal ear is not tuned in, many requests, desires, hopes and expectations of our patients would be ignored, as analysis of the factual content of their signals would leave them unheard.

A particularly ominous example is that of "overhearing" (in the sense of "overlooking") the intent to commit suicide. This may be considered to be the final appeal to those around, and can probably only be picked up with a very finely-tuned appeal ear, which warns us about cries for help made with faintly-transmitted signals during the course of discussion.

The appeal ear can also be used diagnostically when we need to review, and ask about the objective of a statement or way of behaving. It was Alfred Adler who employed the method of the "what purpose does it serve" question, such as for example: "What advantage do you derive from your migraine?"

If a problem in communication has arisen, the receiver should go through the following check-list:
1. What are the messages in the signal?
2. Which was the main message?
3. Does the signal also contain implicit messages?
4. Was the signal congruent or incongruent?
5. What was expressed on the level of metacommunication? (the "that-is-what-is-meant" part of the signal)
6. Have I picked up the signal with 4 ears or with only one?
The content of the signal which is transmitted by the sender, is not (as in a postal package) identical to the content which "gets to" the receiver.

What somebody says is simply not identical to that which the other hears. We call it misunderstanding, and tend to look for blame instead of for the cause. Understanding, as well as misunderstanding, are part of the nature of every communication.
The knowledge that each signal contains various messages, as well as the ability to receive signals with 4 ears, are the best guarantee that misunderstandings can be minimized in communication between people.
 

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Linus Geisler: Doctor and patient - a partnership through dialogue
© Pharma Verlag Frankfurt/Germany, 1991
URL of this page: http://www.linus-geisler.de/dp/dp06_speech.html
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