Emotional approach
in health communication



Communication is created by the sender’s transformation of his message to signals which are interpreted by the receiver – both processes in accordance with the image of the other person. Each signal has four levels (self, relation, factual, appeal) which have to be seen in the context to be evaluated. To grasp the emotions behind the message is of overall importance since emotions rule our decisions (amongst these compliance) and the way to do this, is to look at the world through the spectacles of the person one wants to understand. Active listening is a way of getting one’s assumptions confirmed – or denied. Words are not always preferable to silence, and shared silence may be the closest we can come to symmetry in health communication. Listening is the trump card in any kind of serious communication.

Icebergs and communication

Communication and icebergs have one important thing in common: only the smallest part of each is visible – the bulk of the subject lies below the surface. However, the difference between icebergs and communication is just as important. The concealed part of the iceberg consists of the same substance as the visible part. The part of communication which eludes us is mostly of a different nature; something you can’t see, can’t hear, and can’t grasp: emotions.

The emotional approach

The emotional approach to communication on health can be interpreted in two ways:

1)                  We are speaking about the sender’s emotions
where the aim is to gain access to these.

2)                  We are speaking about the emotions aroused
in the receiver as he or she receives a particular message.

In my lecture I will deal mainly with the point first mentioned, though I will also include some thoughts on the latter.

Communication about health is different from all other forms of communication because it concerns the most precious possession of every human being, i.e. his or her health. Nevertheless, the word „health“ could be omitted (or at least put into brackets) in the above caption because an emotional approach is the clue to any attempt at communication – if the main aim is to achieve a holistic understand­­ing of the message. If I fail to understand the emotions connected to (or behind) the message, I will as a rule miss important aspects of the message itself and crucially the underlying motive.

Example / case: Shoulder pain

A case from my own practice in Denmark: A farmer turned up in my surgery, complaining about pain in his right shoulder. It had started some months previously, the intensity and frequency had varied and was not related to known external factors. Recently there had even been occasional pain during the night. I examined him, found slightly reduced mobility in the affected shoulder joint and raised tension in the surrounding muscles.

I suggested physiotherapy, but he refused: too troublesome,  it would take too much time. So I proposed analgesics for a limited period, and again he refused: he didn’t like taking tablets. Local application of cold or heat to the shoulder wasn’t his cup of tea either.

So I rephrased the message to him as I had understood it: “You’ve told me about pain in your shoulder, pain that disturbs and bothers you and as far as I understand you want to get rid of that pain. Isn’t that so?”

His answer made me realise, that it wasn’t: “No, I can live with the pain – if you can just assure me, that it isn’t going to become so bad, that I won’t be able to work.”


Communication – the basics

At the very basic level communication is the transfer of information from one individual to another by means of signals. In fact the same principle as used in numerous systems – biological as well as technical – all over the world, e.g. in railway companies. In all systems there is a sender who transmits information via a mutually accepted signal-code and a receiver who gathers the information at the other end.

Let’s take a look at how this works between human beings:
The process begins with electrical impulses in someone’s brain, impulses which are either of sensory (e.g. pain), kinaesthetic (e.g. touch) or mental (e.g. ideas, thoughts) origin. These impulses mature into a message, and still we are at the level of electrical impulses. In order to be transmitted to another person they have to be transformed into signals which the other person can register via his senses – mainly the visual and auditory senses. The transfer tools are words, paraverbal elements such as volume, pauses, emphasis, tone of voice, mimicry and gestures. The outcome is a multitude of signals which may or may not be registered by the eyes and ears of the person on the receiving end.

Registering the signals is the first part, the prerequisite for receiving the message. The second part is as vital as the first: the interpretation of what has been registered.

This interpretation (signal -> message) is made using the recipient’s knowledge of the matter itself, his or her knowledge of communication in general and of the person sending the signals in particular.

The sender’s image, which for the recipient is formed by his or her knowledge and experience of the sender, plays an overwhelming part. However, according to Cyril Northcote Parkinson’s “Law of the Vacuum”, where knowledge and experience are lacking the ensuing gap is instantly filled with assumptions and postulations rather than being perceived as a lack of knowledge.

In most cases the outcome is something similar to what the sender meant. In some cases it will be precisely what was meant, but in others not at all. In any case the effect is the same physical phenomenon that started the whole process: a series of electrical impulses – but now in another person’s brain.

Four levels of disclosure

Let’s move back to the interface between sender and receiver, the signal.

Every signal employed in communication between two persons contains four different types of information: 1) personal information – 2) factual information – 3) relational information – and finally 4) an appeal.

Any of this information is occasionally sent and received consciously but for the most part it takes place unconsciously. The sequence and the intensity may vary, the strength and duration also – but you will find these elements in any message which is transmitted. Even if in most cases it is not possible to split up the individual points belonging to one or other aspect without taking into account all the levels in one holistic view, let’s for the sake of analysis focus on the levels one by one: 

1.         Self:              When sending a message the sender will always include information about him- or herself. Mostly these signals are non-verbal: posture, gestures, facial expressions, voice (sound, pitch, speed, tone) and unless voluntarily suppressed or enhanced, these will to some extent reflect his mood, attitude and emotions. When sent consciously they are almost invariably an essential part of the appeal, a part without which the latter cannot be understood.

2.         Factual:       Information about the actual issue. Facts which may be true or false and which in some cases can be proved (e.g. when the issue is the speed of light). Mainly verbal signals (words).

3.         Relational: Information about the relationship between the sender and the receiver. Mostly these are unconscious paraverbal signals like tone, volume of voice, pauses, and emphasis. In organisational meetings (including hospitals) they frequently reflect the hierarchical position of the sender and the receiver  and if used consciously they can be boosted by other signals (e.g. posture, gestures) to an extent which makes it clear to everybody that the main point is the relational dimension, diminishing the importance of other aspects. In many conversations this level discloses attitudes like respect or disrespect, acceptance or denial and esteem or contempt.

4.         Appeal:       Every signal includes an appeal from the sender to the receiver. It can be obvious, as it is when the latter is directly asked to do something. More often it is hidden to a greater or lesser extent but if you look for it, you will always find something the sender wants the receiver to do or refrain from doing: Listen, observe, pay attention to, see things in another way.
The decoding of the appeal is more often than not a case of qualified guess work and for guess work to be qualified it has to be encoded in conjunction with the signals of the other levels of disclosure.


Let’s take a very innocent example:
Imagine a couple driving their car out of town to visit some friends. He’s driving; she’s sitting in the passenger’s seat. They have both been silent for a while and now she points down the road and says: “The traffic lights down there are red.”

·        1: What is she saying about herself? It depends on the context. If he’s driving fast she could mean: “I think you’re driving too fast!” If he’s driving slowly she could mean: “I’m afraid we’ll be late.” If the silence between them was preceded by a dispute, this could be a sign that she now wants to end the tense silence and begin a conversation on a neutral subject.

·        2: The factual information: The traffic light is red. He can verify this for himself.

·        3: The relational aspect: Depends particularly on the paraverbal signs: How are the words said? Fast or slowly? In a high pitch? Does she look at him whilst she speaks? If so, how does she look at him?

·        4: The appeal: This depends on the other elements. It could be: “Drive faster!” or exactly the opposite “No need to drive that fast.” Or even: “Darling, please let’s stop arguing and start speaking again.”

So it is very seldom possible to interpret the various levels of disclosure by focussing on a single element. It is the context which contains the determining elements and it is by no means certain, that sender and receiver agree on which elements are the crucial ones. On the receiver’s side the encoding can vary depending on which “ear he is listening with”.  The same words can also take on a different meaning if he perceives them to be spoken in too high a pitch and too loudly, whilst she might consider her voice to be friendly and factual.


The importance of understanding underlying feelings is related to the role emotions play in making decisions: They are the dominating factor in every decision we make. As Edward de Bono says: “In the end all decisions are emotional.” So, unless I perceive the emotion behind a decision, I will fail to understand the motive.

When speaking about health and decisions about health these will for the most part be: “Yes!” or “No!” Yes or no being the answers to the unspoken questions: “Do you want to do what I am suggesting you do?”
“Are you going to take the prescribed medicine – or are you not?”
“Are you going to follow the advice given by the health professional – or are you not?”

Speaking about compliance this is in fact the very first question to be answered: Did the patient say – and mean – a clear “yes!” to what I proposed? Did I ask him? Did I look for signals of approval or disagreement?

Understanding the emotions behind the signals is what empathy is about. Wikipedia says about empathy: “Empathy is the capacity to recognize or understand another's state of mind or emotion.” To this I would add: “and decisions”. And Wikipedia stresses, that empathy is “not to be confused with pity, sympathy, or compassion”.  I’ll return to this difference in a moment.


The key to achieving empathic competence lies in a combination of three factors:

·        The awareness that my point of view differs from your point of view to the same extent that my frames of reference differ from yours.

·        The awareness, that even if I look at things from your point of view I will not necessarily see the same things that you see or pay the same attention to these things that you do.

·        The will to move to your point of view and see what the world looks like from there, still knowing that it is your point of view and not mine.

The crucial difference between empathy and sympathy is: in sympathy you try to participate in the emotions of the other person in order “to feel as he or she does”; in empathy you register these emotions – but you remain detached from them in order to understand the other person’s perspective. Sympathy is an emotional process – empathy a mental one.


The process of empathic understanding can be described as a journey, a journey in three stages:

a)      The first stage is moving from where I am to where you are.

b)     The second stage is looking at the world from that perspective.

c)      The third is going back to where I came from – now knowing how things look from the other perspective.

Moccasins and spectacles

Much has been said about this process. Many metaphors have been created. To me one of the most beautiful ones is: “Don’t condemn a man before you have walked for a month in his moccasins”.

Another one is “to see the world through other glasses”. The sharpness of an image on my retina depends on the type of glass (convex or concave) and its strength – but what is “the correct type and strength”? It differs from one person to another depending on the eye behind the spectacles.

The colour of the glasses determines the colour of what is seen. You “see things through rose-coloured glasses” and if they are dark grey the world you see will not be so bright.

What should we focus on when we put on someone else’s spectacles? We are in the surgery sitting with our patient. Time is limited. We have to make priorities and decide what direction to look in. 

·        The family situation: married, single, children?

·        Financial resources: Poor? Wealthy? Or neither?

·        Health situation apart from the actual disease, complaints, diagnosis?

·        Network(s) and its (their) resources? Will their be somebody at home for the patient to speak to after this consultation?

·        Paradigms and frames of reference. General, habitual mood?

·        Balance between what he or she wants to do and what they are able to do.

Every single thing we think we see “through the patient’s glasses” might well be “wrong”, might be different from what the patient in fact sees – but it is the best we can do. Only in this way can we reach a qualified idea of what the other person is experiencing. The alternative is no more than a wild guess.

In my book „Das schwere Gespräch” (the English translation would be: “The  Hard Consultation”) which is at present being translated into Korean, I  mention my general preparations before seeing the patient for a serious conversation, for example where the topic is an incurable cancer. A few minutes are used for my own mental preparation: to make sure once more of the exact diagnosis, to make sure again that this is the patient in question – and then to move into his moccasins and see what the world looks like to me from that perspective.

From what I learn here I have to arrive at my interpretation of the patient’s signals, at the same time knowing and being conscious of the fact that they are still interpretations and not “the truth”.

Correct interpretation and active listening

The next step will be to make sure that my understanding is correct.

The most straight forward way to do this is to describe the message as understood and then ask the sender whether this is right or wrong.

A more precise way is “active listening”, a concept developed by Thomas Gordon. In active listening the point is, that the interpretation focuses on the feelings behind the signals, and that the outcome is described in the form of a question where the supposed underlying feeling is named. This question is sent back to the sender for confirmation or denial. This was the case in the afore- mentioned consultation with the farmer about his shoulder pain. “You’ve told me about the pain in your shoulder, pain that disturbs and bothers you and as far as I have understood you want to get rid of that pain. Isn’t that so?” The fundamental points are the feeling (“disturbs and bothers you”) and the desire (“get rid of”). Both these elements are essential to understanding. Just to make it very clear: The main point in active listening is not understanding the message itself, but merely understanding the underlying feelings.

“To understand” always requires getting in touch with the emotions contained in the message. Just think of yourself: When do you really feel understood? When somebody is getting the point of what you are saying – or when he or she finds out why you are saying it?

Feelings / emotions

If I were to ask you how many different emotions you can name, I guess most of you would be able to name between four and eight off the cuff. In general we are not good at making verbal distinctions between emotions and many feel somehow embarrassed or incompetent when speaking about them.  And yet the range of emotions is considerable, and we prefer to wrap them in non-verbal expressions. Not because we lack the words. They are there: grief, joy, hate, disappointment, insult, indignity, love, fear, anger, worry, pride, sorrow, inferiority etc. etc., but we feel uneasy when speaking about feelings and some of them are difficult to handle.

Let me focus on anger for a moment, because it is a familiar emotion frequently experienced by everybody. Not as a primary feeling, but as a secondary one. A primary feeling is an emotion directly connected to something, e.g. sorrow when a beloved one dies or embarrassment when your 14-year-old son listens to his IPod at high volume in church. If we are unable to express the primary emotion (for example because we just don’t know how to do so adequately) we transfer it to another, secondary feeling which we have more experience of, and one of the feelings we resort to most frequently in this context is anger. Thus anger may in many cases be a substitute for some other feeling, which is just not named.

Naming an emotion is a way of showing the patient, that he is not alone with it. The more precise you are in your description, the more the patient will feel that he is understood. Naming a feeling means accepting it – but it is not necessarily the same as accepting the behaviour which arises from the feeling.

An example:  You are in a conversation with a patient. Maybe the tone is a little  tense, and then, all of a sudden your patient bursts out: “You are a bad doctor!” If your next question is “Do you really think I’m a bad doctor?” you are barking up the wrong tree. Active listening (getting to the emotion behind the verbal and non-verbal signals) could produce the question: “It sounds as if you are very angry at me?” And even better might be: “Did I disappoint you badly?” (In this case anger is likely to be a substitute for some other feeling, for example disappointment). In both of the latter questions you are opening up the possibilities for speaking about what the patient wants to speak about – namely his feelings, and certainly not your competence as a doctor. His “You are a bad doctor!” is just his way of expressing his emotions, and at the moment he can’t find a better way to do it.

The reason could be that he can’t find the proper words to express what he feels. Perhaps because he is not aware of the primary feeling. It could also be that the distance between you and your patient has become so great, that it is necessary to shout to be heard.

Asymmetrical communication

In general the rules of every day communication and communication on health matters are the same. Or perhaps to put it more correctly: When communicating on health issues the general rules of listening, speaking and mutual silence are particularly valid. This applies to any form of asymmetrical communication.

Communication on health is asymmetrical communication. On one side you have the health professional who has knowledge about diseases and how to cure them – or maybe the knowledge that they cannot be cured. On the other side you have the patient who knows how it feels to be ill through personal experience – and is dependent upon the will and the skill (and even the will to use the skill) of the health professional to change that situation.

This is and will remain asymmetrical communication. You cannot change that. But being aware of it gives you the chance to narrow the gap between you and your patient instead of widening it by using unnecessary words or phrases.

Words and silence

Words are not neutral – it makes a difference which words and phrases are used, and being aware of that is a part of empathic communication. “You have to…”, “You should…” and even “You could…” are different from the question “Could it be an idea to…?”

An Arab proverb says:
“If you choose to speak, your words ought to be better than silence“.

Communicating with patients suffering from incurable disorders not infrequently forces us into situations, where we just don’t know what to say. If you don’t know what to say, then don’t say anything. There are situations where there is no hope – and to pretend solutions in these cases is to treat your patient with contempt.

Shared silence is, perhaps, the closest we can get to symmetric communication.

Preparations for the hard consultation

I have already mentioned some points for preparation.  Knowing about the diagnosis as well as about the patient are two. Making sure that we will be undisturbed and in appropriate surroundings are others. I should also assess the relationship between myself and the patient in the past. Likewise I should also make myself fully aware of my own present physical, mental and emotional state. When all of these “external” preparations are complete there is still one thing left. Some seconds or even a minute of silence. Silence, just silence, no reading, no writing, no listening apart from listening to my own inner voice and thinking about what is going to happen when this silence is over.

Surgeons wash their hands before entering the theatre. No matter how far he is behind with his schedule, no surgeon would even think of walking into the operating theatre without first washing his hands.

To me these seconds or this minute of silence is my mental “hand washing” in preparation for any conversation of a very serious nature.


I have left till last the most important aspect of understanding and giving the feeling of being understood.

It is listening. It is said, that God gave us two ears and one mouth so that we should listen twice as much as we speak!

I can listen to you in many ways:

I can listen in order to reply.
That is what most people do. But strictly speaking this is not listening but merely a pretence, a way of getting one’s own opinion broadcasted; prescribing my own glasses for you, putting you into my frames of reference.

I can listen in order to understand; getting the factual idea of what you mean.

I can listen actively in order to comprehend your emotions and motives.

And – I can listen empathically.
Empathic listening is more than listening in order to understand, more than listening in order to comprehend feelings and motives. When I listen empathically I do not seek to gain anything. I am merely telling you: “Look, here are two big, big ears – and you can tell them whatever you want. You can rest assured that I will not criticise you and I will never pass judgment on you. Ears, two of them – just for you. They are yours.”



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De Bono, Edward

Atlas of Management Thinking, London 1981

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Geisler , Linus

Arzt und Patient - Begegnung im Gespräch,
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P. E. T. Parent Effectiveness Training, USA 1981

Parkinson, Cyril Northcote

The Law or Still in Pursuit, London 1979

Rosenberg, Marshall B

Nonviolent Communication, USA 2004

Thun, Friedemann Schulz von

Miteinander reden: Störungen und Klärungen,
Reinbeck bei Hamburg 1982



active listening, communication, decisions, emotions, empathy, interpretation, levels of disclosure, listening, transformation