PATIENT-CENTERED

FAMILY- FOCUSED
COMMUNITY ORIENTED
ž If we understand that we do not see or hear
those which we are not trained to see or
hear, we begin to focus our attention in
listening.

ž It is important to hear both cognitive and

affective components and respond to each of
them.

ž To address both, it is important to listen

more and can be accomplished with the use
of ACTIVE LISTENING SKILLS.
ž GENUINESS- being honest and open about
feelings, needs and ideas

-a genuine person can be himself with another

so they know him as he truly is

- a genuine person is aware of his innermost

thoughts and feelings, accepts them and whenever
appropriate, shares them responsibly

- 3 ingredients: self-awareness, self-

acceptance and self-expression
ž UNCONDITIONAL POSITIVE REGARD- choose to
believe that there is something good in a
person regardless of the external qualities

- involves accepting, respecting and

supporting another person
- non-possessive love, willed love
ž EMPATHY- ability to put oneself in the shoes
of the other

- to be with, feel with and think with the

other

- ability to really see and hear another

person and understand him from his
perspective
OPENING SKILLS
1. Attending
2. Bracketing
3. Leading - Direct and Indirect
4. Focusing
5. Probing
6. Attentive silence
7. Reflecting
a. reflecting content- paraphrasing
and perception check
b. reflecting feeling
c. reflecting experience
1. ATTENDING SKILLS- involves the listener
giving his/her physical attention to the
speaker.
- it includes:
a. attentive, open, posture
b. appropriate body movement
c. appropriate eye contact with speaker
d. open and receptive facial expression
e. establishing a non-distracting
environment
2. BRACKETING- form of psychological
attending.

- it is a mental skill involving suspending

own judgement and feelings and then
setting them aside for a while in order to
listen more fully to the patient.
3. LEADING SKILLS
a. Indirect Lead- open invitation by the
MD to the patient to talk about whatever
concerns him.

-includes verbal and non-verbal

encouragers which are used to show that
the listener is listening and following
what the speaker is saying

- encourages the speaker to continue

talking
a. Indirect lead examples:
“What can I do for you?”
“What would you like to talk about?”

verbal: “yes”, “go on”, “and then”, “I see”

“Uhmmm”
non-verbal: nodding, smiling, eye contact
3. LEADING SKILLS
b. Direct lead- the MD chooses the direction
where the conversation should go.
- oftentimes it is based on the disease
entity that the MD is considering
- it is also worthwhile to choose
basing it on what is most emotionally
disturbing for the patient

- eq.: “Tell me more about…”

“Let’s talk about…”
4. FOCUSING- patients in emotional pain
sometimes brings up a lot of things one
after the other.

- in such cases, ask the patient to do the

choosing of what is most important to him
5. PROBES- are questions that the MD asks in order to
find more about how the patient is reacting to
the illness

- ask open-ended questions not answerable by

yes or no
- avoid “WHY” questions
- use HOW, WHAT, “could you please explain”

- between probing an event and probing a

feeling, it is better to probe the feeling
6. ATTENTIVE SILENCE- one of the hardest skills to
master, as people often feel uncomfortable
with silence and feel the compulsion to jump in
and fill in the silence.

-there are times when silence is the most

appropriate response, as when:
-the speaker is searching for a response
-the speakers is emotionally distressed,
silence allows the person to experience
distress, regains composure and continue
the communication
7. REFLECTING SKILLS- facilitates the attempt of the
listener to communicate that s/he understands
the perspective of the speaker

A. Reflecting Content
1. Paraphrasing- listen for the basic
message of the patient; restate to the patient a
concise and simple summary of the basic
message; don’t add anything which the patient
did not mention
A. Reflecting Content
2. Perception Checking- paraphrase
what you think you heard; ask for
confirmation directly from the
patient about the accuracy of
your perception; allow the patient
to correct your perception if
inaccurate
B. Reflecting Feeling- empathic responses
facilitate and deepen communication by
focusing on the speaker’s feelings rather
than content details.

-involves expressing in fresh words

the patient’s essential feelings, stated or
strongly implied.

-eq.: “it sounds as if you felt…”

“As I understand it, you seem
to be feeling…”
C. Reflecting Experience- oftentimes, the patient
has a lot of non-verbal or gestures which
reflect some emotional state but the feeling
is not articulated.

-the MD can mirror the non-verbal

behavior back to the patient and ask for
clarification as to what the behavior means
EXAMPLE REFLECTING SKILLS: Post MI husband
“ I really love my wife. She does many
things for me constantly. She reminds me of my
medicines, she sees to it that I get to sleep early,
she fusses about my food, she keeps tract of where
I am all the time because she said that she is
worried about me. Sometimes though, I can’t
breathe because of all these things.”
PARAPHRASE: “You appreciate all these things
that your wife is doing for you, but it kind of
suffocates you.”

PERCEPTION CHECK: “You appreciate all these

things that your wife is doing for you, but it kind of
suffocates you. Is that right?”

REFLECTING FEELING: “You appreciate your wife’s

attentiveness, but it somehow irritates you,
doesn’t it?”

REFLECTING EXPERIENCE: “While you were talking

about your wife, I noticed that you were clenching
and unclenching your fist. What do you think that
could mean?”
ž FIRST
HALF OF THE PATIENT-DOCTOR
ENCOUNTER THE MD:
¡ Brings out the patient’s perceptions and frame of
reference
¡ Sees the situation from the patient’s perspectives
rather than from his own
¡ Helps the patient become aware of his
perception
¡ Helps the patient to understand how such a
perspective results in the symptoms, feelings and
behaviors which the patient experiences
ž However, very often the patient’s point of
view is not enough; his perceptions and
perspectives may in some ways be distorted
and unproductive.

ž Itis the role of the MD to challenge the

distortion and incongruence with reality.
CLOSING SKILLS
1. Interpretation
a. Interpretative statement
b. Interpretative question
c. Fantasy or Metaphor
2. Confrontation
a. Challenging discrepancies
b. Challenging distortions
c. Feedback and opinion
3. Summarizing
4. Goal setting
1. INTERPRETATION
-involves sharing your “hunches” with
the patient as to what is behind the
experiences, behaviors, and feelings.

-the goal of all interpretative effort is

increasing self-interpretation by the patient.

-the more the patient knows about

him/herself, the more he will be able to
change his behavior.
 Forms of Interpretation:
1. Interpretative statement- declarative
statement about your hunches
2. Interpretative question- makes interpreting
less risky
3. Fantasy or Metaphor
Guidelines for interpretation:
1. Look at the basic message(s) of the patient
2. Paraphrase.
3. Add your understanding of what the messages
mean to him in terms of your theory.
4. Keep the language simple and close to the
patient’s messages.
5. Avoid wild speculations.
6. Offer tentative ideas on what their words and
behaviors mean.
7. Solicit patient’s reactions to your
interpretation.
8. Teach the patient to do his own interpreting.
2. CONFRONTATION
-enables the MD to challenge the
discrepancies, distortions, smoke screens and
games that the patient is using, knowingly or
unknowingly, to keep himself and others from
seeing his problems clearly, thus getting in the
way of problem-managing actions.

-an invitation to examine behaviors that

may be self-defeating or harmful to self or
others.
-an invitation to change behavior.
2. CONFRONTATION
-may be perceived as offensive and may
lead to: defensive behavior
non-compliance
loss of the patient
loss of practice
Forms of Confrontation:
1. Challenging discrepancies
-between what the patient thinks or
feels and what he says
-between what he says and what he does
-between wheat he is and what he
wishes to be
-between his expressed values and his
actual behavior
Forms of Confrontation:
2. Challenging distortions
- some patients cannot face the situation
as it is so that they distort it in various ways.

3. Feedback and opinion

-MD’s reaction to the therapeutic
interchange, his own perception of the
problem.
Guides in giving feedback:
1. Patient must be ready
2. Describe the behavior before giving your reaction
to it, which may be thru sharing your feeling.
3. Give feedback about the behavior rather than
judgment about the person.
4. Give feedback in small amounts so that the patient
can experience its full impact.
5. Feedback should be a prompt response to current
or to specific behavior, not unfinished emotional
business from the past.
6. Give feedback on the things the patient can change
7. Give positive feedbacks.
8. Ask for reactions to your feedback.
3. SUMMARIZING
-involves tying together into one
statement several ideas and feelings at the end
of a discussion or interview.
-broader than paraphrase.
-gives focus or direction to counselling
process
-help clients view their situation in a
more focused way, clarify and begin to set
goals.
Guide for SUMMARIZING
1. Attend to the various themes and
emotional overtones as the patient speaks.
2. Put together key ideas and feelings into
broad statements of their basic meanings.
3. Do not add new ideas in the summary.
4. Decide if it would be more helpful to let
the patient summarize for you.
4. GOAL SETTING
-most important part of the session since
it ties all the processes together.

-Characteristics:
1. specific and measurable
2. realistic
3. hierarchical
4. desired by the person
5. tailored to him
6. frequently evaluated
Steps for GOAL SETTING
1. Identify and affirm strengths

2. Discuss resources
3. Identify the needs/wants in terms of
behavior one would like for himself or from
others.
4. Help patient decide which alternatives he
would like to try.
LATTER HALF OF THE CONSULTATION PROCESS:
ž MD helped the patient to see the situation
from a more realistic point of view

ž MDhelped the patient to set reasonable

goals toward the resolution of his problem
ž INFORMATION GIVING
1. Advising- based on experience
2. Informing- based on expertise
**MDs should not pretend to know everything

ž Guidelines:
1. Clear and relevant
2. Do not overwhelm patients
3. Do not push your own values
4. Be informed
5. Phrase advise in the form of tentative
suggestions
ž HELPER SELF-SHARING
¡ Doctor reveals something about his own personal
life

ž Guidelines:
1. Selective and focused
2. Not a burden to the patient
3. Done sparingly
ž Communication flows out of basic attitudes
as well as through specific methods and
skills.

ž The person who has mastered the skills but

lacks genuineness, love and empathy will
find his expertise irrelevant.