KOMUNIKASI EFEKTIF

EFFECTIVE COMMUNICATION Dr. dr. Endang Basuki, MPH Department of Community MedicineINTRODUCTIONIn health care organization, communication between people poses an important role. By mastering communication it is hoped that a better communication will be created in the health care setting, there is possibility to eliminate the problems that lead to communication breakdowns and changes that can be done to make interpersonal communication more effective in professional-client and professional-professional relationship. Communication is a complex and multifaceted process. Although the word communication is often used in a general way to describe a variety of events, it is actually a term that refers to an identifiable process that has specific characteristics.DEFINITIONS OF COMMUNICATIONCommunication involves a transfer of information between a source and a receiver. Many definitions suggest that communication requires that meanings be shared between the source and the receiver based on a common set of rules. For example, a social worker and a nurse who collaborate to assure the quality of life of a person with end-stage kidney disease need to have similar understanding of quality of life. They also need to use to use a language system, or set of rules, that is common to both of them.

Incoorporating those definitions, we can state the definition of communication as: THE PROCESS OF SHARING INFORMATION USING A SET OF COMMON RULES.HUMAN COMMUNICATION

Human communication is a special case, or subset, of communication. It refers to the interactions between people. Human communication differs from some forms of communication, such as animal communication, because it involves the use of symbols and language. The ability to use symbols or other representational language is unique to the communication behavior of human beings. The use of symbolic language also accounts for much of the complexity in human interaction.HEALTH COMMUNICATION

Health communication is a subset of human communication that is concerned with how individuals deal with health related issues. It refers to any type of human communication whose content is concerned with health. In health communication, the focus is on specific health-related transactions and factors that influence these transactions. Transactions can be verbal or non-verbal, oral or written, personal or impersonal, and issue oriented or relationship oriented, to name a few of their characteristics. In general, health communication is concerned with the application of communication concepts and theories to transactions that occur among individuals on health-related issues.ELEMENTS OF COMMUNICATION Sender Message Media

Receiver

Feedback EnvironmentEnvironment

Media

FeedbackMessage:

Facts IdeasPeople talks to someone for some reasons, he or she wants the receiver knows something or makes any changes in terms of knowledge, attitudes or behavior.COMMUNICATION IN HOSPITAL OR OTHER HEALTH FACILITIES Communication between physician and patient/family Communication between physician and paramedic or other health personnels in the health facility Communication between paramedics and patient/family Communication between patient/family and other health personnels in the facilityProviders (doctor, midwife, nurse, or other personnel) expect changes in the patients, such as increment of knowledge, changes in attitudes, or changes in behavior ( takes medicine, diet and exercise regularly).Provider who expects changes in the patients will try to sent the messages in such way that could produce patients understanding relevant to his wishes.Give notice to the following examples:

Please drink a lot of water!

Take a rest, go to bed early!Provider and patient could have different perception, especially in those examples - a lot of water and go to bed early. It should be stated more clearly, that the patient should take 1.5 or 2 litres of water per day. And also the patient should have minimal 7-8 hours sleep. Effective communication happens if the message that need to be conveyed is understood by the receiver. It is the responsibility of provider to think how his messages can be understood by the patient, based on the understanding that patients come from different level of social-economy, education and cultural background.THE BENEFIT OF EFFECTIVE COMMUNICATION Increase patient/clients compliance Increase patient/clients satisfaction Reduce malpractice suits Increase providers satisfactionPATIENTS RIGHT

Patient has rights, it can be seen in several conventions such as Declaration of Helsinki 1964, World Medical Association meeting in Tokyo 1975, Declaration of Lisabon 1981.

From those documents, it is clear that patients have right to get information related to their problem, besides they also have rights to be treated respectfully, and be appreciated to share their opinion.LEVEL OF COMMUNICATIONCommunication occurs on several levels because of the perceptions of each person involved in the communication, and each level becomes increasingly abstract.

When two persons for instance a provider and a patient, are communicating, the following levels may occur:

1. This is how I perceive me. Provider is thinking only of the self while talking to the patient. Self-awareness is important but awareness must include more than that. This kind of communication will not be very helpful to the patient.2. This how I perceive you. Provider is thinking of the self but also observing the patients behavior and hearing what she/he has to say.

3. This is how I perceive you seeing me and hearing me. At this level, provider is aware of how the patient might be perceiving her/him in addition to being aware of what both she/he and the patient are saying, doing and feeling. Thus she/he can better consider the effect of her/himself on the patient and the behavioral cues from the patient, and respond to them. In addition she/he may ask for validation of personal perception-whether or not the patient is actually perceiving her/him as she/he believes.4. This is how I think you see me seeing you. To achieve this stage, provider must be very alert, feeling energetic and atuned to the situation. Provider should consider how the patient thinks she/he is perceiving the patient her/his feelings and attitudes toward the patient as the patient perceives them. Level 4 takes considerably empathy, but will allow provider to be most udeful in communicating with the patient.

These levels increase in complexity with increasing numbers of people. If you understand the levels of communication, you anticipate the communication process, hear hidden meanings, and recognize your impact upon the process.

To achieve the best results in communication, one should have 3 kinds of communication skills; verbal communication skills, non-verbal communication skills and observing clients communication skills. These skills are need to be practiced everyday, every occasion, and with everybody we met.STEPS:

1. Self awareness, we should aware that we are communicating with somebody, and are ready to practice interpersonal communication2. Realizing that persons who communicate with us maybe have never been studied or understood about how to communicate well; so just ignore the way they communicate with you. The important thing is that we try to communicate based on our knowledge. 3. By practicing everyday it is hoped that all FKUI alumni will become good communicators INTERPERSONAL COMMUNICATION INTERACTION BETWEEN SOMEONE WITH ONE ANOTHER BOTH VERBALLY AND NON-VERBALLY, SHARING FEELINGS OR INFORMATION. INTERPERSONAL COMMUNICATION COULD ALSO HAPPEN BETWEEN MEMBERS OF SMALL GROUP.INTERPERSONALCOMMUNICATION SKILLSInterpersonal communication skills are those skills which one needs in order to communicate effectively with another person or a group of people. The key element of interpersonal skills is self-awareness, and this dilters through every single micro-component of person tp person relationships. These components include warmth, acceptance, genuineness, empathy, listening, attending and responding. We can summarize the skills into 3 basic skills:

Verbal communication skills Non-verbal communication skills, including paralanguage Observation of patients verbal and non-verbal communication skillsVERBAL COMMUNICATIONVerbal communication is quite important in health care. Provider should learn how to use verbal communication so that he or she can communicate effectively with the clients. A good verbal communication will benefit the doctor-patient relationships, while bad verbal communication will harm the doctor and patients relationships. In general, according to my experience, verbal communication can be implemented in these 6 kinds of activities which are very important while engaging with patients. Making patient/client feel comfortable Raising questions (open questions, closed questions, in-depth questions, raise questions one by one) Active listening (reflecting content, reflecting feelings, summarizing, showing empathy)

Giving information Responding (asumption, evaluation, interrupting, soothing, appraising)

Encouraging patient to speakMAKING PATIENT/CLIENT FEEL COMFORTABLE Greets patient kindly Ask patient to have a seat Building rapport, you can use phatic communication (small talk e.g. about the wheather or transportation to come to the clinic ,etc) Explain authority and responsibility of the provider Invite patient to speak freely, in terms of raising questions or bringing up opinion

RAISING QUESTIONS

The purposes of questioning are (and listening too) are :

Encourage patienst to talk

Show our interest and attention to patients Increase our awareness to clients feelings

Get information

Give direction of the conversationWhat kinds of information that we can have by asking? General condition, by raising question such as: May I know what do you want to talk about?"

Facts, by asking: What happened? Client or patients feelings, by asking: How do you feel about undergoing the radiotherapy?"

Reasons, by questioning: Why havent you started exercising regularly?There are 3 kinds of questions

1. Open questions

2. Closed questions

3. In-depth questions

Open questions do not restricts clients responses. They allow clients to give extended and unlimited answers. Open questions are often used in therapeutic interviews as the primary means of encouraging clients to explore their personal thoughts and feelings. For medical patients, open questions are a means of getting patients to tell their story of what is wrong with them and to freely disclose about their situation. Open questions are illustrated in the following examples: You seem upset. What are you feeling right now?

Describe what you think is going to happen.

How did you feel when you first learned of your diagnosis?

Open questions are advantageous and essential in health care interviews. Clients have a sense of control because they have the freedom to answer in whatever way they choose. In other words, clients can select what they want to say, how much the want to say, and how they want to say it. Open questions are also valuable because the interviewer obtains more information and description from the client.

Closed questions are questions that limit and restrict clients responses to specific information. The most common type of closed question is one to which the client is asked to answer yes or no. In health care, closed questions are used more frequently in information-sharing interviews than in therapeutic interviews. By using closed questions, the interviewer controls the direction of the conversation. The following examples are illustrations of closed questions: Do you think your breathing is better, worse, or about the same as yesterday?

Are you feeling anxious about what the laboratory reports reveal about your condition? Do you have a history of heart problems in your family?

How old are you?

Clients could respond quickly to each of the preceding closed questions with straightforward and specific answers. The main advantage of closed questions is that they can be used by professionals to get quick answer. They are efficient. Closed questions do not allow the client to explain feelings or emotions or give additional information. Thus, closed questions inhibit client communication and may lessen the clients sense of control.In-depth questioning is used when the clients response was not clear or complete, and the interviewer needs more elaborate information to get to a conclusion. This type of questioning is also called as clarification. Asking clarification or indepth-questioning helps the provider to understand the client more clearly and helps the client to understand his or her own thoughts and feelings better.Several examples: Client: I cant ever get along with him. (shakes head)

Provider: Who do you have trouble getting along with? (looking at the client)

Client: I urinate frequently.since several weeks ago.

Provider: Frequently..could you explain what do you mean by frequently? Could you mention for how many weeks it had lasted?

Questions also should be raised one at a time, so client can answer one by one. According to my experience, some doctors raised 2 or 3 questions all at once. The example:Provider: So Mam, do you urinate frequently, drink a lot, and always hungry.? Patient will get confused, which question need to be answer first, and also if the patient say yes, then the doctor will also get confused, to which question the reply is directed. Overall, the conversation becomes inefficient, the consultation will last longer because there must be a repetition of questions.

ACTIVE LISTENINGThese following communication skills included in the area of active listening :

1.Reflecting of content (paraphrasing or restating)

2.Reflecting of feelings 3.Summarizing4. Showing empathy

Information exchange and showing our attention to clients are included in the consultation process between doctor and patoents. Thats why how we talk and listen are as important as what we said.Listening is an important skills and need to be rehearse continuously. Summarizing the essence of sentences that were stated by somebody is a good exercise of listening. This skills will help ensure clients that they are heard and understood. Listening is one type of empathy that we need to perform. Dos and donts: Give attention Concentrate to your client Do some reflection, summarize Do not interrupt Do appropriate non-verbal behavior (eye contact, nodding, smile when needed, lean your body towards client) Ask for clarificationPerforming correct reflection, and respecting clients feelings become very important things in the consultation process. Before ready to listen to the doctors offers to overcome their problem, and starting to decide their choice, clients should believe that the doctor listens and understands their feelings, need and concern.1. Reflection of content (paraphrasing or restating) The activity of revealing or giving inputs to the client about the essence of his or her utterances by shortening or explaining the sentences. Reflection of content is not similar with echoing, because in this case we use our own words. Echoing merely repeating clients words.By makjng restatement we will have several advantages such as:

1. Reduce vagues especially for clients who do not speak clearly, because provider verifies the problems 2. Clients will trust the provider because their complaints are heard and verified.

3. Both provider and clients agreed upon the matters

2. Reflection of feelingBy observing and listening provider can understand clients feelings. Provider should reflects clients feelings. When a provider notices that the client gets confused, he or she should say : You look confused.. The purposes of this task are:

1) By doing that, client will think about her or his feelings and why he or she has that feelings;

2) Provider wants to know whether the client really in confusion; and

3)If there is a confusion, the provider and the client will work out hrough a discussion.

Sometimes this skill is known as reflection.3. Summarizing Summarizing need to be done after the conversation were lasted for several minutes and covers some information conveyed by the clients. It can be used before moving to other topic, or while discussing the clients problem which is considered complicated.

Provider: Well, so you had been urinated 5 to 6 times during night, always hungry and lost your weight for the past 3 months. You are worried of having malignancy Okay let me examine you and make several laboratory tests. 4. Showing empathy

Of all the variables that comprise health communication, empathy is regarded as one of the most essential and at the same time one of the most complex variables operating in the communication process. Empathy is believed to affect communication outcomes in all types of relationships--from our everyday social relationships to intense therapeutic encounters. It is well established that empathy plays an important role in effective, interpersonal communication.

Rogers defines empathy as a process that involves:

Rogers contends that empathy is one of the core conditions of successful psychotherapy and one of the major elements in establishing a helping relationships.

According to Rogers, empathy involves 3 components:

1. cognitive, involves observing a clients behavior and processing the obtained information

2. affective, involves being sensitive to a clients feelings and

3. communication, focuses on the language and responses of the listener.Several works of other experts support the multidimensional view of empathy which was posted by Rogers:EMPATHY:

1. Involves trying to to feel what others feel (affective component)

2. Trying to adopt their point of view (cognitive component), and

3. Communicating this understanding to others (communicative component)

Empathy is indeed complex and may occur at several points within the communication process. Because of this, many qualitiesobservational skill, communication skill, perceptual skill, emotional sensitivity, and caring, to mention just a few-- are needed by those who are asked to exhibit empathy.Application of empathy in health care

Understanding is achieved through empathy. In fact, it is an essential factor in effective interpersonal communication. For clients, empathy is important because illness is confusing and frightening, and being understood helps clients cope with these emotions. For professionals, empathy is essential because it helps professionals to understand clients and their problems, as well as to understand other professionals and themselves.

The clients perspective

One of the strongest needs of the patients is the need to be understood. The availability of time, staff shortages, demands for efficiency are among others that could prevent providers from fully attending to clients. When providers express empathy, it will help clients satisfy their need for understanding. Showing empathy produces positive therapeutic outcomes for clients, it reduces clients feelings of alienation and of being all alone with their predicament. The professionals perspective

Empathy has also an impact on health professionals, who, like clients, have a need to be understood. Health professionals desire understanding because they desire to be more effective helpers to clients and also to have better interpersonal relationships with co-workers. Empathy assists professionals to see the problems of clients and other professionals more clearly.Some examples of reflecting of content and feelings 1. Patient: Actually I plan to use birth control pills, but my neighbor said that pills made people becomes fatter and acne,whereas I am fat enouh nowI dont know..

Provider :

Reflection of content:Mam, you heard several side effects of pills.

Reflection of feelings:You are worried of using pills, because of its side effects.

2. Patients wife: Doc, I do not know what to do, my husband was diagnosed having diabetes mellitus, but he eats a lot, does not take medicine regularly.and does not exercise at all. He just ignores my advice, even though everyday I try to remind him.. I fed up.

Provider :

Reflection of contentYour husband does not comply to medical regimen...

Reflection of feelings :You are annoyed of his behavior.

GIVING INFORMATIONINFORMATION THAT CONVEYED TO PATIENTS OR CLIENTS SHOULD: Using simple words. Simple language means that it should be inderstood by the patients or clients. Try to speak in clients daily language, do not use difficult or medical terms. Honest. The information that we give to patients should be honest information. There is no information hidden by the provider. Correct. Provider should be able to provide correct information. Provider should update his or her knowledge by attending seminars, workshops or reading journals related to his or her area of expertise. Remember, one thing that is considered correct at this time, maybe will be considered wrong in the next 5 years. Complete. Give complete information to the patient or the family, for instance facilities to get the procedures and its requirements, cost estimation, etc.

RESPONDING TO CLIENTS/PATIENTSHow do we respond to our patients? Suppose they want to convey their problems, complaints or rumors that they have heard. Have we respond correctly? Patients will be disappointed if we respond inappropriately. What kind of words that we should avoid or what kind of behavior that we should do or should not do?Behavior that need to be avoidedA. Verbal

Interrupting clients utterance. In general people do not like to be interrupted. Scolding clients. Patients similar to other people, do not like to be scolded. Asumption, in this case provider make a conclusion without evidence Evaluation, provider does not believe to what client saidExamples of the negative verbal responses: Assumption and evaluationIn communicating with other people, often we receive negative responses. We call them negative responses because they harm the relationship.

Consultation between provider and client is also a form of interpersonal communication, so negative response could happen too. Verbal responses which need to be avoided are making assumption and evaluation.AssumptionResponse classified as assumption if the provider made conclusion without the supporting evidence. In other words provider anticipates the patients answer.Example of assumptionClient: Doc, lately I am losing weighturinate frequently.could not sleep well, feeling weak, .I am afraid that...

Provider: You mean .you get cancer.?.

What the provider said was something that was unspoken. If a provider often make assumption will ruin the relationships. Patients feel ignored, provider will make conclusion based on his or her own frame of thought.

Evaluation

Response classified as evaluation if the provider doubts clients answer. In other words provider does not believe clients utterance.Example of evaluation:Provider : Mam, anybody in the family has the same symptoms like you?Client : No, I dont think so?

Provider : Really, nobody has the same symptoms.are you sure?Making evaluation is also need to be avoided. Patient will feel uncomfortable because they think the doctor distrust them.B. Non-verbal

Frowning. Frowning means that we do not agree with the clients answer or utterance. Avoid this behavior. We have to accept clients as they are. Showing an expression of frightened or shocked. This behavior will make client more worried. Remember we have to make clients feel save talking with us. Be careful of your smile. Sometimes we respond clients who raise questions about rumors with smiles. This should be avoided. Be careful to respond with smile. In that case we had better just listen to their utterance, with a neutral facial expression and give full attention. Soothing and appraising clients are positive behaviors in communication process. But be carefull in soothing the clients. Some of the providers often say dont worry or do not be afraid. We can not change the clients feelings only by saying those words. We have to explain the reasons why they do not have to be afraid or worry. Appraising clients opinion could increase clients attraction to provider, and also trust, because they feel respected and appreciated.ENCOURAGING CLIENTS TO TALKSometimes clients do not want to talk or they do not talk fluently for several reasons. Worried and frightened of the disease, the cost of the medical treatment and culture or social gap with the provider are among the reasons. It is providers responsibility to make the clients talk and share their problems so that providers could construct the correct diagnosis or therapy.Dos and Donts:

1. Encourage clients by saying: What else..and then what happened ?2. Sometimes providers need to stop speaking for a while (silence) to allow clients to think or concentrate so that they can give their opinion.3. While performing 1 and 2, do not forget to use appropriate non-verbal behavior, make eye contact, do not do other activities such as sending SMS, or tidying up your desk etc. These tasks will give impression that you ignore them. You should show your patience while waiting for their reply, and soften your voice.4. Show your interest and attention to clients5. Avoid asking questions all at once6. Use more open questionsNON-VERBAL COMMUNICATIONNon-verbal communication has special relevance in health care primarily because patients pay close attention to the non-verbal communication of the professionals, and professionals, likewise, rely heavily on the non-verbal communication of the patients.

Non-verbal communication is communication without words, includes messages created through body motion, the use of space, sounds and touch.

Purposes of non-verbal communication

Non-verbal communicaton performs several identifiable functions in the process of communication, including (1) the expression of feelings and emotions, (2) the regulation of interaction, (3) the validation of verbal messages, (4) maintenance of self-image. Voice (intensity, pitch height, and extent), called as paralanguage or paralinguistic Facial expressions (happiness, sadness, surprise, fear, anger and disgust) Gaze, how individual use their eyes in the communication process to give information to others, receive information from others and establish relationships. Gestures, one of the most obvious and commomn forms of non-verbal communication. Touch, is a particular type of non-verbal communication. Touch can take a variety of forms and it can convey a variety of meanings. Non-verbal communicarion usually supports the verbal communication. Non-verbal communication is not less important than verbal communication. OBSERVING VERBAl AND NON-VERBAL COMMUNICATION OF THE CLIENTS OR PATIENTSPatients problem can be identified easily if the provider: Listen carefully to the clients complaints Observe clients behavior both verbal and non-verbal Perform effective questioningOBSERVING CLIENTS BEHAVIOR1. Non-verbal Facial expressions Sad

Angry

Worry Confused Disappointed Bowed Happy

Satisfied

Gaze

Eye contact No eye contact Gestures Restless Not patient, looking at watch several times Hands make certain movements2. VerbalGive attention to clients remarks or utterances and expressions, to find out whether there is worry, dissatisfaction or anger and sadness. Provider need to observe clients verbal and non-verbal behavior to identify clients message.BARRIERS IN INTERPERSONAL COMMUNICATIONSeveral problems could hamper the effectiveness of interpersonal communication.1. The receivers problem Feelings, thoughts, or suspicion, distrust to the sender Do not concentrate to the sender Not a good listener Problems of five human senses2. Message Not clear, vague3. Sender Not clear, vocal, volume, pronounciation Having problem with the receiver4. Environment Comfortable room, quiet Tidy room Provider and patient sit facing one another, do not put the desk between the provider and the patient. Not allowing other provider enter the room, unless for conducting a special task in helping the patient ordered by the doctor. Sufficient consultation time Providers dress neatly, do not dress up5. Media Inappropriate choice of mediaCONCLUSIONHere are some reminders which are written by Tate: The patient is more frightened than you are Most of them want to be involved in their own treatment Most of them want to understand what is going to happen to them

They come to you not merely because of the disease,but because of their beliefs about, their expectations of and the effects of their oreceiced change in health

Whenever possible be emphatic

The patient is probably afraid of you, they tend to be passive and not say very much much, but they want to know.

Patients are just people like you. They deserve respect, need to be informed, and they need to consent. REFERENCES

1. Badan Keluarga Berencana Nasional BKKBN/Johns Hopkins University/Population Communication Services. (1997), Pelatihan Keterampilan Komunikasi Interpersonal/Konseling: Kurikulum dan Modul untuk Provider di Klinik. Pegangan Pelatih.2. Basuki, E. Komunikasi efektif. Diktat Modul EBP3KH Semester 1, Fakultas Kedokteran Universitas Indonesia; 2005.

3. Brock, CD, Salinsky, JV. Empathy: An essensial skill for understanding the physician-patient relationship in clinical practice. Fam Med 1993; 25:245-248.

4. Kerlinger FN. Asas-asas penelitian behavioral. Yogyakarta: Gajah Mada University Press; 1986. p. 786-822.

5. Murray R.Therapeutic communication: Prerequisite for effective nursing. In: Murray R, Zentner J, editors. Nursing concepts for health promotion. Englewood Cliffs (NJ): Prentice-Hall Inc; 1975.p 44-72.

6. Northhouse LL, Northouse PG. Health communication: Strategies for health professionals. Stamford (Co): Appleton & Lange; 1998. p.1-78.7. Samil RS. Etika Kedokteran Indonesia. Yayasan Bina Pustaka Sarwono Prawirohardjo, Jakarta, 2001.

8. Rungapadiachy DM. Interpersonal communication and psychology for health care professionals: Theory and practice. Oxford: Butterworth-Heinemann; 1999. p. 55-65.9. Tate P. The doctors communication handbook. Radcliffe Medical Press. Oxford and New York, 1995.CHECK-LIST OF PROVIDERS BEHAVIOR

I. MAKING CLIENT FEEL COMFORTABLE

SKILLS YESNO

Greet friendly

Invite client to have a seat

Introduce him/her self

Rapporting

Asking client to speak freely

Face: friendly

Smile

Paralanguage : pitch, intonation, clear, vocal, pace

Body language

Maintaining eye contact

II. RAISING QUESTIONS

SKILLSYESNO

Using open questions

Using appropriate close questions

Raise questions one by one

Raise in-depth questions

III. ACTIVE LISTENING

SKILLS YESNO

Reflecting content

Refkecting feeling

Showing empathy

Summarizing

IV. GIVING INFORMATION

SKILLS YESNO

Giving correct information

Giving information in a simple language

Give complete information

Give honest information

V. RESPONDING

SKILLSYESNO

Praise client

Evaluating client

Make assumption

Cutting clients utterance (interrupting)

Criticizing client (physically, or the opinion)

Tolerant in listening to client

Soothing client

Responding client appropriately

VI. ENCOURAGING CLIENTS PARTICIPATION

SKILLSYESNO

Showing interest and attention (eye contact, friendly face, friendly voice)

Sometimes keep silent to give client to concentrate to give the opinion

Do not cut clients utterance

Saying the words: and then.or hm.hm., or what else?

Sometimes nodded head to show understanding

CHECK-LIST OF PATIENTS BEHAVIOR

BEHAVIORYESNO

PATIENTS FACE

Sad

Disappointed

Worried

Confused

Bowing head (no eye contact)

Angry

Maintaining eye contact

Happy

Satisfied

GESTURES

Restlessness

Looking at watch

Kneading hands

BEHAVIORYESNO

PATIENTS VOICE

Speak in hesitation

Speak fluently

Unclear

Clearly heard

Message

Sender

Receiver

entering the private world of the other and becoming thoroughly at home in it.It includes communicating your sensings of his world as you look with fresh and unfrightened eyes at elements of which the individual is fearful.It means frequently checking with him as to the accuray of your sensings and being guided by the responses you receive

To be with another in this way means that for the time being you lay aside the views and values you hold for yourself in order to enter anothers world without prejudice. (Rogers, 1975)

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