1. BASIC ATTENDING, LISTENING AND ACTION SKILLS
CHAPTER 3 Uzm. Psk. Özlem Ataoğlu

2. What is communication?
In basics, there is a sender who sends the message and there is a receiver who receives the message
What we do or do not do is actually a communication – including sitting in silent, looking, sleeping in the class, etc.
We behave in a systematic way during the therapy sessions that gives the message that we are interested in and we care about what the patient says  attending behaviour
Attending behaviours change due to different cultural or personal backgrounds
So we need to find out the best attending behaviours (eye contact, body language, tone of voice, verbal tracking)

3. One of the most popular reasons of dropping out of the therapy is because the interviewer does not have good techniques or cannot use them properly
Regardless of theoretical background, tone of voice and good listening is the basic.
Verbal and non – verbal cues should not be contradictory. If it does, then what??

4. Positive Attending Behaviours
Positive attending behaviours start the communication, encourage the patient to open up. Negative attending behaviours inhibit them.
The way we contact to the patient change due to personal needs, motives, personality, familial, cultural backgrounds.
So if it changes depending on the individual, how can we identify them positive and negative attending behaviours?
There are a few that can be counted as universal

5. Eye Contact Some of the people feel more comfortable when the interviewer makes more eye contact, on the other hand this may make some of them feel unsafe/under threat
People who looks for approval from the therapist likes eye contact, people who are in a psychotic situation lack of eye contact
The ideal is  make more eye contact during the patient is talking and less when you are talking

6. Body Language Non – verbal communication
It includes your physical appearance (clothes, make – up, piercing, etc.), eye, face, head, hand, leg, shoulder movements, facial mimics
How does a positive body language look like?

7. Leaning toward the client
Relaxed but attentive posture
Your feet and legs should not distract the patient (unobtrusive position)
Your hand movements should be smooth
Minimize your other movements (itching, playing with your hair, etc.)
Facial expression should match with your or your patient’s feelings
Sitting approximately one arm’s length from your patient
There should be no barriers – you and the client are together

8. Mirroring is the synchrony or consistency between the therapist and the patient
Therapist’s physical movements and verbal activity should be parallel to the patient’s
Advanced body language technique  if you do not do it correctly, it will be catastrophic

9. Vocal Qualities Application  Give some feedbacks about one of your classmate’s vocal qualities (loudness, pitch, rate, rhythm, fluency, etc.)
It is not about what you say, it is about how you say it.
Why is it important?
The create a positive bond between you and the client, it will enhance rapport, communicate interest and empathy, emphasize specific issues
Your tone of voice should be parallel to client’s tone  pacing the patient

10. Speaking soft, slowly, gently, in a smooth way  emphasize the emotion
Speaking with increased rate and volume  convince them of your credibility / expertise
How do you say “I am really mad right now!!!” to convince someone that you are really mad?

11. Verbal Tracking Eye contact, body language, vocal qualities are good but not enough to show positive attending behaviours.
You need to show your patient that you are tracking what they say by using/repeating the key words or phrases.
It involves only restating or summarizing what the patient said (speech content and tone)
You do not include your personal ideas

12. Negative Tracking Behaviours
Nodding your head
Saying “Hı hı”
Eye contact
Repeating the patient’s last word
Mirroring
If you do too much of these, it will be disturbing for the patient
Folding arms
Crossing legs away from the patient
Leaning back from the waist up
Also, these behaviours are perceived as negative by the patients

13. Do not forget… Gender Social class Ethnicity Sexual orientation Age
Physical inability

14. Moving Beyond Attending
If you do not know what to say, keep silent and listen more. It is probably because you have not got enough information. You can only respond only if you listen and get the answer from the patient.
You may see some positive changes in your patient and still feel that something is missing  that is experience
Although you have enough experience, still sometimes you may not know what to say and it is pretty normal
What you reduce with experience is performance anxiety

15. Performance anxiety  anxiety about saying something wrong, saying something useful immediately
With experience (without performance anxiety), you know that “right thing to say” will come eventually
It gives self – confidence, you feel free to say “I do not know”  it will increase patient’s participation to the process
If you behave in a way that you “know” but actually not, you may direct the patient to a wrong way

16. Non – Directive Listening Behaviours
What is its purpose?
We give the patient the chance to say anything freely and open up to us
We do not direct the patient but reflect the central messages we get from the patient
We use it to make the patient talk more about specific topics. Why do we want this?
1. If we pay more attention to specific areas, we nod our head, make more eye contact, smile. This will encourage the patient talk more about these topics
2. If the patient talks about a wide range of topics at the same time we need to choose one

17. Silence It is the most basic and simple but the most effective behaviour
When do we use silence?
1. When we try to encourage the patient to talk
2. When we encourage the patient to talk about the emotions and effects
3. When we try to make the patient think about the topic in depth
4. When we want the patient digest a new information/finding
5. When we try to calm the patient’s emotion
6. When we, as therapists, try to choose a wise, conscious reaction

18. Long, silent moments are weird so you need to use them properly
It may create anxiety in your patient especially if s/he is in an emotional breakdown, psychotic state, confused moments  silence does not work
Sometimes you break the silence, sometimes your patient
If you feel that your patient is uncomfortable, ask open – ended questions: “Aklınızdan az önce neler geçti?”, “Bir şey söylemek zor gibi.”, “Bu konuştuklarımız nasıl geliyor size?”

19. If you feel yourself uncomfortable, remember: THIS SESSION IS NOT FOR YOU TO PROVE YOUR EXPERTISE, IT IS FOR PATIENT’S EXPRESSION.
Try to relax and use your attending behaviours
Watch the silence moments from the therapy sessions  how long does it take, who breaks the silence, how do you feel at those moments, ask your closed ones about their feelings of silence

20. Paraphrase It is a verbal listening technique
When do we use it?
When we try to tell the patient that we get the main idea, if there is a misunderstanding, we reduce it
When we want to give a feedback about how other people perceive their speech
When we are reflecting, we do not change what has been said by the patient, do not comment
It should be short and clear

21. The Simple Phrase
We reflect what the patient said in simple words, repeating
Patient: “Hep aynı şeyler oluyor. Ne zaman bir arkadaşımı arasam işi olduğunu söylüyor.”
Therapist: “Çoğu zaman arkadaşlarınızın işi olduğundan görüşemiyorsunuz.”

22. 2. Sensory – Based Paraphrase We use what the patient uses to experience the world (visual, auditory, tactile, kinesthetic systems) Use what the patient prefers to use  it will make you seem you are empathetic, gives trust Patient: “Tam bir başarısız olduğumu hissediyorum.” Therapist: “Pek çok alanda istediğiniz noktada olmadığınızı hissediyorsunuz.”

23. 3. Metaphoric Paraphrase Generally we use it for kinesthetic sentences but it suits them all Patient: “Aslında böyle davrandığımda üzülen yine ben oluyorum.” Therapist: “Yani aslında bu davranışla kendi kalenize gol atıyorsunuz.”

24. 4. Intentionally Directive Paraphrases When the patient talks about a past event that is negative, traumatic, generalizations, we use this kind of paraphrase Patient: “Geçmişte hiçbir istediğim karşılanmadı, bu benim önemsiz olduğumu gösteriyor.” Therapist: “Geçmişte çoğu zama isteklerinizin karşılanmadığından dolayı önemsiz biri olduğunuzu düşündünüz.”

25. Clarification Clarify what you have been through during the session both for yourself and for the patient
How to do it?
Tell what the patient said in a different order (P: Karım ayrılmak istediğini söylediğinden beri çok mutsuzum. T: Mutsuzluğunuzun başlangıç sebebinin karınızın boşanma isteği olduğunu söylüyorsunuz, doğru mu?)
Present choices for clarification (P: Sınıfta yapamayınca çok üzüldüm. T: Sizi üzen yapamamak mı? Yoksa bunun sınıfta olması mı?)
Sometimes you do not understand at all. ASK! (Tam anlayamadım. Tekrar eder misin?)

26. Sometimes we do not understand the patient, that’s OK, you can ask
Sometimes the patient is confused, does not know how to explain  help the patient for clarification
Sometimes you, both, do not understand. Try to explain what the patient said, get the feedback, ask for reexplanation

27. ACCEPT that sometimes while you are talking about something totally different, a thing a patient said may confuse your mind
ASK FOR EXAMPLE Sometimes patients do distortion (“Zaten beni hiçbir arkadaşım istemiyor.”, “Zaten hiçbir şeyde başarılı olamayacağım.”). In order to prevent this, try to collect the thoughts and ask for concrete examples
If the topic is irrelevant to your therapy goals, try not to talk about them. Use silence or talk about the previous important topic or go back to the previous session
If the issue seems important however the patient is not able to explain, let the patient try to explain then you can use clarification

28. Reflection of Feeling (Non – directive) By doing this, you show that you are sensitive and empathetic to your patient. Your patient’s emotion dictionary develops. You encourage emotion reflection.
Even if you have a guess/interpretation, you only reflect what you have heard, not your theory
Emotions are very subjective so when you use reflection your patient may get angry. Try to use as ambiguous words as possible (Sıkıntılı, zor gözüküyor, iyi hissetmemişsiniz gibi duruyor, memnun gözüküyorsunuz, vb.)

29. Summarization At the end of your session OR at the end of a topic, make a summary
It gives the chance to go through the important and main/key points and the client give a meaning to his/her messages or clarify them
Although it seems so easy, you should wrap up and not miss the main points, at the same time not waste time talking about unimportant things
Do not trap yourself by putting barriers
Try to progress this phase by talking to your patient, get approval
This gives the responsibility to your patient to remember the important points, you do not have to memorize and gives the message that “We are on this together, it is not ONLY my job to success – it’s ours.”

30. Guidelines for Summarizing
Informal “Kaygılıyım mı demek istediniz, emin olalım ne demeye çalıştığınızdan.” Try to avoid using sharp sentences
Collaborative After your summary sentence(s), pause and make eye contact. Your patient may wait or approve or correct the misunderstanding. Resummarize and ask for approval again. Ask for the important points according to him/her
Supportive While you are asking for a summary, say something supportive “Çok önemli şeyler söylediniz.”, “Pek çok yoğun duygudan bahsettik.”, “Hayatınızın gidişhatını etkileyen olaylardan bahsettik.”
Summarization may change due to theoretical backgroung – psychoanalytic: childhood traumas, cbt: maladaptive thoughts, solution – focused: positive thoughts.

31. Reassurance The patient will wait for assurance and support.
“Ne kadar iyi olmuş, değil mi?”, “Haksız mıyım?”, “Siz olsanız böyle yapmaz mıydınız?”
Answering these questions is NOT assurance and support.
It means that you give this in the right time, place and dose. ONLY say that you believe that these circumstances will change and you will reach different solutions.

32. Directive Listening Behaviours
The therapist controls the session
Being directive is more risky – you need to have a clinical sense, know the pathology and diagnostic criteria very well
We can use this when the patient needs consultation or more directive behaviours

33. Feeling Validation It is different than reflection of feeling.
The therapist sees the RIGHT feeling and asks for approval. What is the point?
The patient will agree that these feelings are a piece of normal progress
When you give support, s/he will open up more freely and feeling more comfortable  “My therapist understands me.”
We especially use these when someone feels guilty about own feelings  we try to change this

34. You should not use this technique very frequently because this may lead your patient to ask for approval and assurance all the time.
What we are trying to say is “Your emotions are fair enough under these circumstances and you have a right to feel in this way. Some emotions SHOULD be experienced.”
You can open up yourself to your patient if you have a therapeutic relationship.
You can give the message that these feelings are universal.

35. What can be the effects or risks?
Enhance rapport
Increased or decreased client exploration of the problem or feeling
Temporarily, reduction of anxiety
Temporarily, enhanced client self – esteem or feelings of normality
Increased likelihood of client – therapist dependency

36. Interpretive Reflection of Feeling Reflecting the patient’s feelings by interpreting, telling the unexplained
This gives the chance to develop insight (since the patient has a partial insight)  for instance, anger is a secondary feeling of disappointment, resentment, feelings of obstruction, etc.
What can be the risks?
You are telling the unknown by the patient, deeper, buried feelings. If you do it on a wrong time, it will damage your therapeutic alliance

37. But, if it is done on time, it will strengthen your relationship
It is directive because we, as therapists, give the idea/direction by considering the sentences, body language, tone of voice, etc.
In order to develop your relationship, do it on time, by using FIRST feeling validation THEN interpretive reflection of feeling
Always avoid sharp words and sentences

38. Interpretation Our goal is to make our patient to have an insight
It is an unconscious process  we make it conscious
What we are trying to say is “Görünen aslında senin bu konuda yanlış bir başetme yolu kullandığın.”

39. 1 Classical (Psychoanalytic) Interpretation We make the emphasis on unconscious conflicts, patterns and make our patient develop awareness/insight. Insight does not mean change of behaviour Show the similar patterns: “Aslında eşiniz size yapamazsın dediğinde hissettiğiniz kaygı duygusu, babanız bunu söylediğinde hissettiğinie benziyor.”

40. If you are doing the right interpretation, your patient will reference past times (artık, eskiden, o zamanlar, vb.) The chain should be: Feeling validation  Interpretive reflection of feeling  Interpretation The timing is too important otherwise you break the relationship and the thing you have done will not have a point

41. 2. Reframing Our goal is to create a different perspective
Instead of grumbling, change the situation or your way of interpretation
You have to find fair, alternative thought
“Okulun çok zor olduğunu ve başaramadığını söylemiştin fakat ödevleri yapmadığını, derse gitmediğini söylemiştin. Aslında başarısızlık değil de denememiş olmandan kaynaklanabilir mi?”

42. Confrontation We want our patients to understand themselves because no one can be objective to themselves
Body language, tone of voice and the words should be in a harmony. If not, then the patient ignores or refuses the situation/feeling
Do not confront your patient at time time you have found this disharmony
Do this if you have enough concrete information and your relationship is ready

43. If your patient does not talk about something at all, there should be something really important. You can say “Oğlunuzun şehir dışına taşınmasından hiç bahsetmediniz. Ne düşünüyorsunuz?”
Tough/Harsh/Aggressive confrontation can be done if you are sure of your alliance otherwise resistance may develop
Harsh confrontation is not preferable – there is no evidence that it works better, especially for alcohol/drug addiction patients (actually motivational interviewing works best for them)

44. You should be more gentle at the beginning and can move to more harsh confrontations
The important thing here is to give the message that a behavioural change is a MUST
You are not trying to prove that your patient is wrong!