1. DEVELOPING GREATER SENSORY AWARENSS OF MINIMAL CUES BY WHICH PEOPLE SIGNAL THEIR THOUGHTS AND FEELINGS Adapted from www.bathgptraini ng.co.uk

2. Rapport What is it? Why is it important? How and when do we achieve it? How do you know that you have achieved it? Why and how to break it?

3. W AYS OF COMMUNICATING Verbal Speech (tone, rate, pitch, volume) Content Non verbal Olfactory BODY LANGUAGE (posture, gestures, facial expression, eye movements) Patients rarely ever tell you EXACTLY how they feel and what they want you to do about it....

4. G AMBITS AND C URTAIN -R AISERS GAMBITS ‘ the rehearsed opening moves’ planned by the patient, usually refined in the waiting room But they often change once they enter the consulting room. These CURTAIN RAISERS often betray their state of mind and feelings towards you. N.B. Curtain raisers will only happen if the doctor allows them to happen - and doesn’t smother them with... “Hello Mrs X, come in what can I do for you”

5. M INIMAL C UES Non verbal messaging outdates formal language on an evolutional scale Minimal CuesVerbalSpeech Content Whats said/ not said Speech QualityIdiomsAuditoryNon Verbal Representiational Systems Visual- eyes face Kinaesthetic- posture, gesture. mobility

6. R EPRESENTATIONAL S YSTEMS Brain encodes all experience into information Visual Auditory Kinaesthetic- feelings arising from skin/ proprioception Olfactory We all have a preference for one of these modalities Can be used to connect and empathise with a patient

7. Types of language used Visual people – “see, show, reveal, appear, colourful” etc Auditory people – “hear, tell, listen, sounds good/awful, he/she said…., sounds good/awful” etc Kinaesthetic people – “I feel, my guts tell me, I just can’t get hold of it, I don’t know why but it feels….”etc

8. Which type of person am I?

9. Using this to build rapport Adapting your language so it mimics the style of the patient may help them feel that they have a better connection to you

10. V ISUAL C UES Facial expression- mood, variability, appropriate Gaze- at you, downward, objects, flirty, cold Eye contact- good, poor

11. E YES People glance upwards when remembering/Imagining a VISUAL image Glance to the side when remembering/ imagining an SOUNDS or WORDS Glance downwards when experiencing/remembering a feeling

12. Visual Constructed Visual Remembered Auditory Auditory Remembered Constructed Kinaesthetic Auditory Internal Dialogue

13. AUDITORY CUES FROM THE PATIENT Pace- fast or slow Pitch- high or low Volume- quiet loud or comfortable Rhythm- regular and rhythmic, broken up Modulation- how much do the other qualities vary Matching of tone, pace and inflexion Picking up and reflecting back the same words

14. T HE IMPORTANCE OF WHAT IS NOT SAID Hesitations, omissions and vagueness imply that speech is being censored Aim would be to help the patient to find a way of expressing what is not being said as May be important clinically Patient will find a sense of relief, and contributes to rapport building

15. S PEECH CENSORING Key features Hesitating Omitting details Vague in descriptions Raising sensitive issues by hinting and implication Skipping from one idea to another without obvious link Associated with quiet voice, nervous clearing of throat, poor eye contact, restless, posture withdrawn

16. K INAESTHETIC C UES Posture- open, slumped, lean in/out, matched Distance- too far/close Touch- Accepted/ welcomed Gesture- which part of body is most expressive Mobility- stationary or moving- high energy or low Muscle Tone- Relaxed or tense Breathing- rate depth

17. M AKING THE MOST OF M INIMAL C UES Three groups Speech censoring Internal Search Acceptance Set

18. I NTERNAL S EARCH Key features- Lengthy pause Immobility Eye movements Gaze far away Do not interrupt! You may destroy a productive line of thought. The end will be apparent- respecting privacy of times of internal search is a powerful aid to rapport

19. A CCEPTANCE S ET Although a patient may sound like they are verbally in agreement with you, their non verbal cues may tell the other story! But big variation though in physical signs Mmm, mmm Face looks blank Lack of eye contact Vs Steady eye contact Attentive posture Echoing words Nodding

20. R APPORT Match your language and non verbal cues to those of the patients

21. Now watch the videos Play I Spy minimal cues Share what your saw in small groups Re-run the video step by step and see how many more you can identify Then use the scoring sheet looking at the first four COT competencies

22. Where do I go from here? Read Liz Moulton’s book! The Naked Consultation