ACTIVE

LISTENING
SKILLS

DR. AGNES B. BAUSA-CLAUDIO

 ALS
• To understand how the patient
sees the world and how he
perceives the problematic reality
for which he is consulting
• situation
• perception
• manner of dealing
 CLIENT CENTERED
COUNSELING
• Client sets the pace and the
direction of counseling
• ability of client to come to
terms with his own problem
• counselor - help the client to
see more clearly
• provide an atmosphere of
emphatic listening
 3 IMPORTANT ATTITUDES

• Empathy
• Unconditional Positive Regard
• Genuineness
 EMPATHY

• Ability to put oneself in the

shoes of the other
• be with
• think with
• feel with
UNCONDITIONAL POSITIVE
REGARD

• There is good in a person

despite his behavior
• setting aside all our biases and
prejudices, opinions
 GENUINENESS
• Being honest and open about
one’s feelings, actions and words
• transparency
• absence of pretense
• no inner agendas, no hiding, no
defense
• self-awareness, self-acceptance,
self-expression
ACTIVE LISTENING
SKILLS
• Attending skills
• Bracketing
• Leading
• Reflecting
• Focusing
• Probing
 Attending skills
• The way we use our bodies to
communicate - non-verbal
• “I am listening to you”
• listener focus complete attention
to the speaker
•Leaning towards the patient as he
speaks
• nodding, titling head
 Attending skills
• Ranging eyebrows when patient
makes important points
• maintaining eye contact
• gestures communicate message of
openness and understanding
 Not interested
• Leaning backwards
• looking away
• no eye contact
• crossing arms

• Be aware & avoid habits of

movement
• distract patient
 distance
• Positive or negative
• too close - threat
• too far - unwillingness to get
involved
• 45 degrees angle
• allows eye contact and option to
gaze away
 bracketing
• Pay attention to what patient is
saying
• own thoughts
• own feeling
• distraction - empathy
• mental skill
 bracketing
• Setting aside feelings, thoughts
and judgements temporarily so
that there will be space in our
minds and in our hearts for what
the patient is saying
• removing our tinted lenses
• put on the lenses of our patients
• to see the world from patient’s
view point
 Leading
• Indirect lead
– open invitation to talk about
anything
– choice of what to talk about depends
on the patient

• Direct lead
– judgement call to where the patient
should go and ask him to go in that
direction
 Indirect lead
• What would you like us to talk
about?
• “Ano ang gusto mong pag-usapan
natin?”
• What can I do for you?
• “Ano ang pwedeng kong gawin
para sayo?”
• yes? ; Go on; uh-hmm; and then?
 What is your problem?
“Anong problema nyo?”

• Beware
• threatening to the patient
• two minds - hesitant
• testing - trusted with problem
RUTH SILAN 35 YRS OLD WITH BREAST
CANCER STAGE IV - FUNGATING BREAST
MASS, S/P RADIOTX, REFERRED BY MED
ONCO TO HOSPICE
HUSBAND - DINDO

• ... you see? We’ve been married for

the last 5 years and we were ok most
of the time. But since several
months ago, I noticed that she
became less talkative. Lately she has
been irritable with me, and I have a
hard time because she keeps cutting
me off and shouting at me.
 Reflecting skills
• Emotionally burdened is unable to
see himself or his situation clearly
• be a mirror
• take appropriate steps to
CHANGE his situation
• empower - take control of his life -
change for the better
 Reflecting skills
• Reflecting Content
– repackages and rephrases what the
patient says - becomes more clearer
– gives it back to the patient
– paraphrasing
– fewer and clearer words
– summarize
– allow the patient to hear
themselves & to cut thru the
confusions to have a better
understanding of what is
happening to them
 Reflecting skills
– One must be careful to capture the
essence of what the patient is trying
to say
– careful not to add to the paraphrase
what the patient has not mentioned

perception check
• if one is not sure if he understood
the patient well/correctly
• confirm
 Perception check
– Same words used, followed by
question
– Is that it?
– Tama ba?
– Orients counselor towards right
direction
– allows patient to restate in
clearer terms what’s troubling
him
 Reflecting feeling
– Patient feels a lot of emotions
and not able to clearly
articulate
– articulate the feeling for the
patient
– give a name to the feelings
– cognitive awareness of the
feeling
– patient examines - perception
behind feeling - uncovered
 Reflecting feeling
– feelings not articulated and
acknowledge - take control of
behavior
– articulate - allows patient to
take responsibility for the
feeling and for the actions that
he will make as a result of the
feelings
– feelings clearly reflected back =
patient feels understood
 Reflecting experience

• Patient has many gestures that

indicate underlying feeling or
perceptions
• I noticed that ……. Can you tell
me what was behind that action?
• What does that mean?
• Reflecting back the non-verbal -
done unconsciously, not aware
that they do them
 Reflecting experience
• Valuable clues on what is going
on inside the patient emotionally
• allows the patient to be aware
how he’s behaving
• once aware, allows him to
process the behavior, gain insight
on the feeling or perception
behind the gesture
• most threatening - embarrassment
• Can close up - in an effort to
defend self from embarrassing
revelation
 Focusing
– Patient’s emotional pain brings
out a lot of things one after the
other
– choose what is the most
important
– enumerate emotions and
identify which is the most
troublesome
– anger, guilt, frustration, fears
– ex. You have financial
difficulties, your wife is
nagging you, your daughter is
rebellious, your son had an
accident. That’s quite a lot. But
of these four, which one gives
you the most pressure?
 Probing
– Probing questions are asked to
elicit more information
– must be open ended to
encourage much exploration
– could you tell me more…
– could you explain….
– How..
– Could you give me examples...
 probing

– So you feel afraid, angry, guilty

and frustrated. Which feeling is
giving you the most pain?
– How does that make you feel?
Can you tell me more about the
feeling?
 Summarizing

– Packaging
– Wrapping up all
– Given back to patient
– Making aware of perceptions
and behaviors
– Total picture
 Examples
• Nasabi mo kanina na mabigat ang loob mo sa
tuwing nakikita mo ang kabit ng asawa mo. Tama
ba?
• Mukhang napakabigat ang dinadala mo at nakikita
ko sa iyong mga mata ang pagkalungkot sa
nangyari.
• Nung nabanggit ko kapatid mo, biglang may
umagos na luha sa iyong mata. Ano kaya ang ibig
sabihin nito?
 Examples
• Sabi mo naiinis ka ngayon dahil dumating
yung byenan mo, nahospital ang pangalawa
mong anak, nahulog ka sa hagdan at
kamuntik na mapilayan, mabarkada anak
mo at gabi na naman umuwi at suspetsa mo
nagda-drugs kasama barkada. Alin dito ang
pinakamabigat dalhin?
 Examples
• Nung naramdaman mo yung pagkainis, ano
ang mga naisip mo?
• Ano ang ginawa mo?
• Ano ang iniinum mo tuwing ikaw ay
nahihil?
• Sino ang doktor na nagbigay sayo nito?
CLOSING SKILLS

Agnes B. Bausa, MD, DPAFP

 OPENING SKILLS
• Concentrates on surfacing of patient’s
perception
• frame of reference
• patient’s point of view/perspectives
• to become aware of such perceptions
• make patient understand - wrong
perceptions leads to symptoms,
feelings, and behaviors
• Distorted thinking
• unproductive
• Role of doctor:
• Challenge the distortion and
incongruence
• Reality
• Move beyond limiting frames of
reference towards new
perspectives
 2nd Half of Consult

• Doctor helps the patient see the

situation -
• more realistic point of view
• more objective
• Ending - set a reasonable goal towards
the resolution of his problem
 INTERPRETATION
• Sharing “hunches” with the patient as
to what is behind the experiences,
behaviors and feelings
• Hunches are useful if accurate
• It increases patient’s awareness - self
• elicits change in behavior
 INTERPRETATIVE
STATEMENT
• I was in a party last night where I
drank too much. I broke into tears and
cried and cried. I acted like a child
who wanted to go home to mother. I
feel so ashamed.
• Paraphrase:
You drank to the point where tears
came freely. You’re ashamed now as
you talk about it.
Reflecting Feeling:
You feel very badly about what happened
last night.

Interpretative Statement:
You feel badly that you lost control of
yourself last night.

Alternative Interpretation:
You drank until you lost control of your
feelings. As you look back on the evening now
you want to punish yourself for acting in that
childish way.
 INTERPRETATIVE
QUESTIONS
• Interpreting done in a form of
questions
• tentative than declarative
• less risky
• Example:

Doc: When are you going to be

concerned about yourself too?
Pt: That’s selfish attitude.
• So what’s wrong with that?
• Pt: I don’t like selfish people.
• Doc: Because ….?
• Pt: Selfish people aren’t so popular.
• Doc: (IQ) So popularity is important to
you; and if you are self-centered,
people wont like you. Is that getting
close to where you are now?
 FANTASY OR METAPHOR

• Introduce an idea in a form of a

fantasy(daydream) or a metaphor
(words denoting one kind of idea
in place of another to suggest
likeness between them)
Fantasy
“I have a fantasy about what you have said.
I picture you walking down the path in the
woods, coming to a fork in the path, and
being undecided which one to choose. You
unconcernedly flip a coin and run joyfully
down the path chosen by the coin. How
does this fit?”

Metaphor
“Most of the time I perceive you as a great
big soft teddy bear who stays in any
position he is placed.”
GUIDELINES: INTERPRETATION

1. Look at the basic message of the

patient.
2. Paraphrase it to them
3. Add your understanding of what the
message mean to him in terms of your
theory or your general explanation of
motives, defenses, needs and styles.
3. Keep the language simple and the level
close to the patient’s message. Avoid
wild speculations and statements in
esoteric words (mysterious/secret).
5. Introduce your ideas with statement that
indicate you are offering tentative ideas
on what their words and behaviors
mean.
6. Solicit patient’s reactions to your
interpretation.
7. Teach the patient to do his own
interpreting. Remember, you cannot
give insight to another, patient has to
make the realization himself.
 CONFRONTATION

• Skills which enables the doctor to

challenge the discrepancies, distortions,
smoke screens & games that patient is
using
• blocking/clouding the patient to see his
problems clearly
• getting in the way of solving the
problem (problem-managing actions)
• Challenge conflicting behaviors
• examine behaviors that can be
detrimental or harmful to the patient
• Warning: Confrontation is done only
when there is already GOOD
RAPPORT (patient-doctor relationship)
• Offensive - defensive
• Argumentative behavior
• Non-compliant patient
• Loss of practice (loss of patients)
I. CHALLENGING DISCREPANCIES

• Discrepancies between what patient

thinks or feels
• what he says and what he does
• what he is and what she wishes to be
• what are his expressed values and his
actual behavior
• “You said you have been dieting, but so
far you have failed to show any weight
loss. Perhaps we need to examine your
daily eating record.”
• “You say health is important to you, but
you have not been in for a check-up in
five years. Let’s talk about it…”
II. CHALLENGING DISTORTIONS

• Twist out of shape, out of condition,

out of true meaning
“Nancy sees herself as a sexual victim,
but this is only partially true because
she flirts and seduces.”
Challenge: “Nancy, I realize that the
sexual demand made on you by your
boss have a profound impact on you,
but your continuing to put most of the
responsibility for your sexual problems
on others seems to self-defeating. It
also seems to be convenient.”
 III. FEEDBACK AND OPINION

• Feedback from the doctor

• statement about his own reaction to the
therapeutic interchange or about his
own perception of some dimension of
the problem
• Guidelines:
A. Give feedback only when the patient
is ready.
B. Describe the behavior before giving
your reaction to it (sharing) your
feelings).
 Feedback and Opinion

• “We have been talking about your

problems in getting along with people.
You may be interested to know that I
have been increasingly irritated with
your persistent quibbling almost
everything I say. I sometimes feel that I
don’t want to listen to you anymore. Do
you think my reaction to you is typical
of those of other people you know?”
 Guidelines….

C. Give feedback in a form of opinion

about the behavior rather than
judgement about the person.
“I don’t like the way you constantly
interrupts me”

“I don’t like you because you constantly

interrupts me”
D. Feedback should be given in small
amounts so that the patient can
experience its full impact.
E. Feedback should be prompt response
to current and specific behavior, not
unfinished emotional business from the
past.
F. Feedback about things that the patient
has the capacity to change.
G. Give positive feedback whenever
possible.
“You have shown awareness of your own
feelings, though they have changed.
This helps me believe that, given time,
you can find a way through this
struggles.”

H. Ask for reactions to your feedback.

 SUMMARIZING
• Tying together into concise statements at
the end of the interview
• Broader than paraphrasing
• Help patients view their problematic
situation in a more focused way
• Places patients under pressure to clarify
their problems more fully and to begin to
set goals
• Used during long discussions, too many
information given, exhausted,
overwhelming info - gives focus or
direction
 SUMMARIZING
• After a patient has talked about his life
experiences and the vague feelings of
inadequacy running through all of them;
• Summary:
“From your talk about family, school, and
now your new job, you appear to have
experienced feelings of personal failure in
all of them.”
 SUMMARIZING
Guidelines
1. Attend to the various themes and
emotional overtones as the patient speaks
2. Put together the 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 state
your summary or ask the patient to
summarize it for you
 GOAL SETTING

• Both patient and doctor-counselor have

acquired a clearer picture of the problem
and their possible solutions.
• As a result of 3 processes (interpreting,
confronting, summarizing)
• Most important part of the session
 Goal setting - characteristics...
1. Specific and Measurable
- assist the patient to state the
counseling goals in terms of behavioral
change
2. Realistic - factors - potential and
environment
3. Hierarchical - prioritization
4. Desired by the patient and tailored to him
- unique to patient
5. Frequently evaluated - progress can be
gauge
 Goal setting - Steps
1. Identify and affirm surviving strengths
despite the problem situation to help in
coping- inner strength, family, friends,
spiritual resources
2. Identify the needs, wants in terms of
behavior one would like for himself or
from others
3. Contracting - help the patient to decide
which alternatives he would like to try
now or would want to do between now
and next session to meet his identified
needs
 Goal setting
A. Advice giving
B. Experiential sharing

- both content comes not from the client but

from the doctor-counselor
- not “client-centered”
- culture and profession - patients look up to
doctors with “high regard”
-patients would tend to solicit direct advice
- “there is a place for the judicious use”
 Goal setting
1. ADVISING
- giving suggestions and opinions based
on experience (should have sufficient
expertise and experience)
- appropriate in crisis situation
- family reorganization, hospitalization of
a family member
- beneficial when several people must
cooperate to prepare the patient for major
readjustment in his life circumstances
- inappropriate when dealing with major
personal/individual choices
 Goal setting - Steps

• career
• choosing the person to marry
• choosing friends
• personal choice - limitation (patient may
not follow advice)
• patient may follow advice and fail
• end up putting blame on the doctor
• making patient depend on the doctor, thus
putting the responsibility on the MD
 Goal setting

2. INFORMING
- giving of valid information based on
expertise
- correcting misinformation
- ex. Chemotherapy in Lung Cancer
patients
Surgery (amputation) of diabetic foot
 Goal setting
• Guidelines
– 1. It should be clear and relevant to the
problem
– 2. Do not overwhelm clients with
information
– 3. Do not use information giving as a
subtle way of pushing your own values
– 4. Be informed, know the sources of
your area of expertise
– 5. Phrase your advice in the form of
tentative suggestions.
 Goal setting

B. HELPER SELF-SHARING

• enables the doctor-counselor to share his

own experience with the patient both as a
way of modeling non-defensive self-
disclosure
• reveal something about personal life
• as a way of helping the patient see the
problem more clearly
 Goal setting

• Guidelines
– 1. Sharing should be selective and
focused
– should be towards the target goals and
should not distract patient from looking
into his own problem
– 2. Sharing should not be a burden to the
patient
– 3. Sharing should be done sparingly