CASE STUDY:
Conversation
Mrs. Raymond: (deep sigh) George has been sick for so long, sometimes I wonder if he’s ever going to get well. I don’t know if I can keep my spirits up much longer.
Jeff: Now, of course George is going to get well and you can keep your
spirits up. You’ve been so strong about it.
Mrs. Raymond: But it’s been so long. It seems that Dr. Johnson should be getting George well pretty soon.
Jeff: Now, you know Dr. Johnson is a good doctor and you shouldn’t be questioning his care of your husband. It’s important to trust your physician.
Mrs. Raymond: Well, he’s certainly not getting anywhere with George!
Jeff: How long has it been now that George has been sick?
Analysis:
Placating response:. Mrs. Raymond’s reaction to this might be “How can he be so sure George will get well? And he thinks I’ve been so strong: He has no idea how terrified I’ve been most of the time.” Mrs. Raymond seems to be protesting Jeff’s glib response that she has nothing to worry about.
Judging response:. Mrs. Raymond’s response to this might be “Of course, he’d stick up for the physician. And it isn’t really that I question his treatment of George. I’m just discouraged and no one understands that.” Quizzing or probing response:. Having this bit of information at this point is probably not as important as focusing on Mrs. Raymond’s feelings.
Contrast the above exchange with the following between Mrs. Raymond and Bill Reynolds, another pharmacist.
Conversation
Mrs. Raymond: Thirteen months.
Jeff: Sometimes these things take time. Maybe you just need to get away more. I think it would do you good to have someone come in and stay with George, say one day a week, so you can get out more.
Mrs. Raymond: I don’t want to get out more. I want George to get well.
Jeff: He will, believe me. He is getting the best care possible.
Analysis:
Advising response:. While this advice may be reasonable, the fact that Jeff offered this as a quick solution may outrage Mrs. Raymond. It’s as if he can presume to tell her how to cope with the situation when she has been coping with it for thirteen months.
If anything, she could probably teach him a thing or two about coping.
Conversation
Mrs. Raymond: (deep sigh) George has been so sick for so long, sometimes I wonder if he’s ever going to get well. I don’t know if I can keep my spirits up much longer.
Bill: It must be heartbreaking to see George so ill.
Mrs. Raymond: It is. I sometimes feel that it’s hopeless.
Bill: You seem discouraged.
Mrs. Raymond: (Head nod and nonverbal struggle to control tears)
Bill: (after long pause) Is there something I can do to help?
Analysis:
Understanding response:. Bill shows that he recognizes the stress that Mrs. Raymond has been under.
Mrs. Raymond confirms that Bill is accurate in his understanding and goes on to reveal a little more about her feelings. Often the response to an accurate understanding will not be further exploration of feelings. The fact that someone has listened and understood may be all she needs at the time. Bill lets her decide how much she wishes to reveal by leaving the door open without forcing disclosure through probing.
A patient who feels discouraged or angry often needs simply to know that others understand. Mrs. Raymond is not “blaming” Bill or the physician but is lashing out because of her own frustrations and feelings of helplessness. Rather than placating her (“He’s getting the best care possible”) or judging her feelings (“You shouldn’t be questioning his [physician’s] care of your husband”) the pharmacist can be helpful instead by showing concern and understanding.
We try in various ways to get patients to stop or change their feelings. We may feel uncomfortable in dealing with expressions of emotion, so, to protect ourselves, we cut off patients’ communication of feelings. We may try to distract them by changing the subject; we may try to show them that things are not as bad as they seem; or we may direct the communication to subjects we feel comfortable with, such as medication regimens. These responses tend to convey to patients that we are not listening and, perhaps, that we do not want to listen. Yet it is a gratifying experience for a patient to feel that someone has listened and, to a large extent, understood feelings expressed.
As a pharmacist, monitoring how well you are listening to patients is as important as carefully choosing the words you use in educating them about their medications.
Conversation
Mrs. Raymond: Sometimes it helps just to be able to talk to people.
Dr. Johnson always tells me not to worry. How can I help but worry?
Bill: It sounds as if people try to cheer you up instead of understanding how painful it is for you.
Mrs. Raymond: I don’t blame Dr. Johnson. I know he’s a good doctor. But sometimes I get frustrated by how long it’s taking.
Analysis:
Problems:. Yet the emotional concerns patients bring to you along with their physical problems cannot be “cured” or “treated” in that way. This does not mean that you have no help to provide; it does mean that you must define “helping” in a new way.
In addition, with empathic communication, it is not sufficient to feel that you understand another person—empathy requires that you effectively convey to the person that you do, in fact, understand. How can this be done? One approach is to briefly summarize or capsulize what you understand the person’s feelings to be.
In the conversation between the second pharmacist (Bill) and Mrs. Raymond, Bill said “You seem discouraged,” which captured the essence of what Mrs. Raymond had been communicating and served to convey to her that Bill had heard and understood her concerns.
The ability to capsulize the essence of a patient’s feelings and convey this understanding back to the patient involves what is called “reflection of feeling.” Reflection of feeling has been defined as restating in your own words the essential attitudes and feelings expressed by the patient. Reflection of feeling is not simply a repetition of what the patient has said; instead it conveys your attempt to grasp the meaning of the patient’s communication. It further implies that you are checking to make sure that your understanding is accurate.
In this sense, the reflection of feeling is not a bold, declarative statement but rather a tentative and provisional one.