These suggestions come in two ‘packages’. The first describes various clusters of ‘mini-m.4 cues’, indicating to the doctor (if he learns to notice them) some important features of the patient’s internal processes and agenda. The second contains some communication techniques that help the doctor to ‘get through to’ the patient, or ‘get things over’ as effectively as possible.
Minimal cues – patents’ signs if internal states
(For fuller accounts, see Chapter B1, Connecting – Rapport-building skills, in The Inner Consultation; and Chapter 7, Minimal Cues, in The Inner Apprentice.)
Language can be biased in its vocabulary towards one of 3 sensory modalities – Visual (V), Auditory (A) or Kinaesthetic (K). We all have preferences for one or another, although these can vary according to context.
E.g. when learning some new ideas, we might say “That looks OK” (V), “That sounds OK” (A), or “That feels OK” (K). Or – “I’m off colour” (V), “off key” (A), or “off balance” (K). Or –“Let me make this clear” (V), “spell it out” (A), or “lay it on the line” (K).
NLP practitioners claim that each modality has its corresponding pattern of eye movements – eyes up, to left or right, for visual imagery; laterally, or down and to the left for auditory recall or speech; and down and to the right when recalling emotions or feelings.
When people are doing some serious thinking, perhaps trying to remember information stored somewhere in the recesses of memory, they exhibit a clear-cut cluster of signs called Internal search (IS). IS consists of:
- momentary ‘freezing’ of body posture, in sometimes bizarre or catatonic positions, plus
- characteristic shifts of gaze: the eyes are held either
- upwards, to the left or right,
- averted downwards, especially if emotions are being experienced, or
- straight ahead, but de-focused, looking ‘through’ rather than ‘at’ the other person.
- there are rapid eye movements, as in dreaming.
Whatever is said immediately following IS may well be of greater importance (to the speaker) than material that did not need IS to elicit it, being already in conscious awareness.
The ‘degree of energy’ in someone’s speech varies moment by moment, ranging from ‘dead calm’ – delivered in measured tones, fluently and unemotionally, to ‘turbulent’ – agitated, broken up, with erratic shifts of pace, volume and pitch. Turbulence may indicate that speaker feels vulnerable, emotionally charged or threatened by what is being said.
We have a ‘speech censor’ in our heads, that monitors what we are about to say just before we say it, in time to prevent us talking ourselves into trouble. It can sense the verbal equivalent of ‘thin ice’, and pull us back before we say something we might find unsettling.
The speech censor uses
- hesitation (playing for time),
- omissions (leaving out overly specific details,
- vaguenesses (hoping the listener won’t notice the verbal camouflage going on), and
- non sequiturs (apparent illogicalities, caused by missing out crucial but dubious steps in an account of the thought process).
Speech censoring indicates the presence of a ‘deep structure’ significantly different from the spoken ‘surface structure’ (see notes on NLP).
English vocabulary is so rich that, for most situations, words can be selected that clearly imply not only the facts but also the speaker’s associated opinions and value-judgements. E.g. “I have an enquiring mind; you are inquisitive; he is a nosey-parker!” One patient “complains” of a symptom; another “unburden” about it. One wife is “concerned” about her husband’s drinking; another “suffers from anxiety” over it; while a third “gets herself into a right state!”
By ‘tuning the listening ear’ to recognise (non-judgementally) the speaker’s value-laden words and phrases, it is possible to spot some of the maladaptive generalizations, deletions and distortions.
Handover – some ground rules and suggestions
(For a fuller treatment, see Chapter B5 – Communication Skills of The Inner Consultation.)
Observe and accept the patient’s experience and assumptive world, don’t confront it. Cultivate the skill of paying non-judgemental attention to the patient’s minimal cues without (initially) feeling obliged to challenge anything maladaptive you infer from them. Concentrate first on purely noticing. Match your comments and choice of phrase to the patient’s. During the ‘clarification’ stage of the consultation, use the Meta-Model non-confrontingly to elicit necessary detail. Even when it comes to the ‘handover’ stage of formulating and agreeing a management plan, “The patient is always right – to start with!” In NLP terms, “Match, link, lead”.
I think of this process as containing 3 elements – Negotiating, Influencing and Gift-Wrapping. The following are possibilities, not prescriptions.
The doctor usually goes first. Think aloud – you’ve nothing to be ashamed of. If you have a clear idea or firm suggestion, state it clearly. If there are real options, explain them. Ask the patient’s opinion, and offer a real choice. Remember the NLP tenet “The meaning of a communication is the response you get”. If you don’t see a “Yes”, you’ve got a “No”.
We are accountable only to our professional consciences to define the boundary between benevolent influencing and insidious manipulation.
There’s no need to be subtle or indirect if an up-front direct approach works. But many of the patient’s maladaptive mental processes will be (to him or her) unconscious, and not amenable to a ‘heart on sleeve’ approach. I believe we have a professional responsibility to be as effective on the patient’s behalf as our skills can let us be – but you may disagree!
- ‘Shingles’ technique (so named after the overlapping of roof tiles): Explanation or persuasion in the form *A leads to B; from B, it follows that C; if C, then D; since D, E …”
- Questions make good statements e.g. *What do you think would happen if you stopped smoking?” means (has the effect) “Create in your own mind a convincing argument forstopping”.
- Reframing: adjust the language of debate (its vocabulary and value associations) from negative to positive, so that the patient thinks about the old things in a new light. E.g. the pessimist’s glass is “half-empty”, but the optimist’s is “half-full”. Exchange the “jaundiced view” for “rose-tinted spectacles”. Use value-laden phrases of your own.
- Pre-suppositions: ask questions or make statements based on the assumption that the response you are looking for has already occurred. E.g. if you suspect ‘family problems’, try asking “Which member of the family do you worry most about?”, which assumes there are problems – the only doubt being with whom. Or, “Come again to see me when you have only a week’s supply of tablets left” pre-supposes that the first part of the course of treatment will have been taken.
The ‘illusion of choice’ is a form of pre-supposition, as in “Would you rather see a counsellor or a psychotherapist?, which pre-supposes seeing someone.
- ‘My friend John’: couching comments or suggestions as if they concerned a third party, (“my friend John”), rather than the patient directly. Such ‘distancing’ allows possibilities to be introduced into the patient’s mind that might not lie so comfortably if put directly. E.g. “I had another patient who …”, or “I can understand how in similar circumstances a person might …”, or “Someone less sensible than you might have been tempted to” (This last also contains a value-laden pre-supposition of ‘being sensible’.)
The art of personalising and tailoring suggestions or comments in such a way that they are understandable and acceptable to the patient, desirable, sensitively and compassionately presented.
- Cellophane: why wrap your advice in opaque paper if transparent cellophane will do?
- Delivery: How things are said is no less important than what. Pay attention to timing. Chunk large amounts of information into smaller digestible ‘chunks’. Use pauses; keep appropriate eye contact; and adjust your pace of delivery for maximum receptivity. Watch the patient’s minimal cues for signs of discomfort or incomprehension.
- How to give instructions: Remember the ‘rule of three’. Give ‘paragraph headings’ as you talk. Short words and sentences are better than long ones. Avoid jargon. Use the ‘shingles’ technique. In a list of items, the best remembered are the first and last. Write things down. Give illustrations, verbal and/or pictorial. Be specific and concrete.
- Respect the patient’s self-esteem:remember how you feel in the presence of your accountant, dentist, bank manager, garage mechanic or traffic warden.
Roger Neighbour, 1992
Roger Neighbour: The Inner Consultation (1987) and The Inner Apprentice (1992). Kluwer Academic Publishers, Lancaster.