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Hi, everyone. My name is an issue. Um, the medicine lead from Mind the bleep. Thank you for joining us this evening. Um, today we've got doctor Alex Kazemi from the Thinking Mind Podcast. He's also a trainee psychiatrist to talk a little bit about communication skills. Um, so we'll make a start because it's half six. So I wonder if it to him, uh, if you've got any questions or anything like that, you can pop them in the chat. Uh, and, uh, we'll get to them at the end. Is that ok? Hi, everyone. So, I'm Alex and thanks for coming. I'm a registrar psychiatrist. Uh, I always thinking Mind Podcast, just a podcast all about psychology, psychiatry, mental health. And I'm quite happy to be giving a talk to their own communication skills. And really this is very applicable, I think to being a health professional in general as I'll talk about. But also I think very helpful in people's personal life. I'm quite happy that, you know, my career in the direction it's gone. You know, aside from me, a psychiatrist, I'm also formally studying psychotherapy at the Meta Neue Institute. So I've gotten the opportunity to learn quite a lot about communication skills. As I said, I think they're very useful and they can really put people ahead of the curve if they learn them. So I'll talk about for about half an hour, 45 minutes and then as a new shed, if you have any questions, then you can pop them in the chat. So in terms of an overview of what I'm going to talk about today, I wanna talk a little bit more depth about why I think communication skills are important. They're, they've always been important. But I think with the onset of A I and things along those lines, I think they're going to become even more important. I'll talk a little bit about ways that we can think about communication that maybe are under discussed, maybe somewhat unconventional ways that we can think about communication. I'll discuss, you know, different levels of communication, variable, non, variable, emotional somatic, etcetera. I'll go through some practical steps on how you could go about communication in your day to day life in your work and talk a little about a bit about specific situations like conflict resolution, breaking bad news, um as well as a few discussion points. And then, and then I'll conclude and wrap things up and you guys can ask any questions as you want. So why are communication skills important? I mean, taking an evolutionary view on this human beings are social creature's, we've always been social creature's the reason why were the dominant species on the planet is because we can exist in a social context that's far larger than, than any other species. And so it is really our ability to communicate so effectively that makes us so dominant. We exist in a deeply social context and medicine in particular. So much of our work relies on our ability to communicate. You know, when, when you're in medical school, maybe before medical school, you have fantasies about what being a doctor is like. And you think it's all about the procedures, it's all about being clever, making the clever diagnosis, being the smartest person in the room. So I was really struck when I started at four, I, one, just how much of being a doctor, whether you're in surgery, medicine, psychiatry relied on your ability to effectively transmit and receive information and other things and communicate effectively with other people. I noticed people might be very good at procedures, but if they were bad communicators, they didn't function necessarily well within the team. And really you're only good at, you're only as good as your communications because no matter how good your other skills are, and again, in your personal life, it's extremely helpful. So I I do think communication skills are extremely important that they very much put you ahead of the curve in your career. If you take the time to learn them explicitly, of course, we mostly learn communication skills implicitly as we grow up and it's almost a bit taboo taboo to learn social skills in an explicit sense. It makes us feel like we don't get it. But taking the time to do that in our career can really put us ahead. I think with everyone's probably ahead of chat G B T by now, large language models ai and how they're probably going to take over a huge amount of online communication and online um information processing. That being the case, I think in the coming decades, what we're going to see is there's gonna be a huge premium in a person's ability to communicate effectively in a face to face situation, to communicate in an off the cuff manner, in a spontaneous manner. Not only because A I is gonna take over a lot of roles um but also because technology is so prevalent. Now, people actually losing social skills, young people now aren't as a debt that socializing and communicating. And so people who are, are once again going to be in a really, really good position. So I would urge you to take the time to learn these skills in a more explicit sense. How should we think about communication skills? I'm very lucky to have started studying psychotherapy and lend a lot of psychology, my psychiatry curriculum, the fields of psychology and psychotherapy have a lot of valuable theory and knowledge in terms of how to think about communication. Um the way I think about the person is communication is a dynamic process. As opposed to a static process, I'll expand more what I mean by uh dynamic later. And, but it's a dynamic process whereby we communicate a number of things, we communicate information. And that's normally when we think about communication, we're thinking about information, but it's so much more than information that we're communicating. We're also community, communicating mental states, um emotions. Um We're communicating a perspective. Normally, when people are talking, they're in a particular situation and they're talking about how that situation, how to deal with that situation, especially in hospital settings or clinical settings where you're in a difficult situation and, and you and a colleague or you and a colleague in a patient are talking about how to deal with it and you're each communicating your particular perspective. So one of the things I want to discuss some more detail is how actually everyone is wired differently. Everyone has different personalities. And as a result, everyone has a very particular perspective, everyone's in their own world, everyone's in their own particular predicament. So when they're given situation, everyone's going to have their own particular take away and what you are communicating aside from the information and aside from your emotions is your particular perspective, your particular predicament. Uh And obviously, you're communicating it, you know, in a way that's somehow in your, in your contextual past and your present, your past to affect how you communicate what's happening now and to some degree, you're communicating your expectations about the future. And this is very important because our expectations really lay the groundwork for our emotional responses. One of the really interesting things about emotional responses is we tend to have them when our expectations are violated in some way. If things go, you know, the brain is kind of thought of as a neuroscientists increasingly think of the brain as a predictive machine. We're constantly basing on based on what happened previously, were constantly trying to anticipate what's going to happen in the future. And when that expectation is violated, either in a positive way or a negative way, usually as an emotional response. So you expect your partner to show up on time at the restaurant and she doesn't and then you get a spike of negative emotion or you think everyone's forgotten about your birthday and then you come home and someone's throwing a surprise party and you have a huge emotional spike of gratitude, these violation of expectations which produces emotions. And that's one of the things that you're, that you're communicating. I am a really good thing to be aware of as well as that. Communication isn't just about transmitting information you communicating your experience to other people, but it's very much about receiving as well. And we tend to overlook that a really good example of this, a really good case study of this is the psychiatrist Milton Erickson who you may have heard of Mr Nixon had polio when he was very young. So as a result, he spent a long time paralyzed and essentially bedbound. And because he was inclined to observe people when he was paralyzed and bedbound, he tended to do a lot of observing observation. And he became very, very good at observing people's nonverbal cues. And eventually he recovered from his polio and he went on to become a psychiatrist. And he was legendary in terms of his ability to read people very, very quickly to the to the point where people thought he had some sort of mind reading ability. And of course, he didn't, what he did was really to a very high level, to a level. Most people don't pursue, develop the skills of reading people in a nonverbal sense. So it's really good to think about communication as a set of skills which you can develop more and more across time. As I said earlier, a lot of discussion of communication is really limited to just discussing information, communicating, receiving and transmitting information. And that's a very limited way to discuss this topic. It's based on faulty assumptions that humans are purely rational, that we're just computers that were objective information processes that were not affected by emotions. But of course, this is wrong. You know, we, we are very much affected by emotions and we don't tend to have holistic views on situations. As I mentioned earlier, we tend to see situations, we tend to take a very narrow piece of a situation or have a very narrow perspective. It's a problem to think just about in terms of communicating information because really effective communication isn't just about communicating uh information, but you need to have emotional leverage. And the advertising industry learned this in the early 20th century that advertising products and services a lot more effective. If there's a strong emotional undertone, human beings are emotional creature's, we tend to change our behavior when we have, when there's emotional momentum. This is of course very relevant to us as health professionals. Because often the whole purpose of our communication is to get someone's behavior to change in some way, to take a particular medication, to go for a particular procedure um to change their lifestyle in some way, which are not, not easy things to do. And so to communicate the information in a dry unemotional way is often very ineffective. So it's really important to learn how to communicate in a way that leaves an emotional impact. So as I mentioned in the advertising industry, what happened was a guy named Edward Bernays came along and Edward Bernays essentially is the founder of modern public relations. And he was famously Sigmund Freud Freud's nephew. And it's actually said that he took a lot of Freud's principles from psychoanalysis, which was really understanding unconscious motivations that people have and the way that people function on a deep psychological level in order to create advertising, that was a lot more effective. One really famous example of this, there were a few but one famous example was and he wanted women to, he wanted to sell cigarettes to women. And at the time again, it's like early 20th century women weren't really smoking because it wasn't fashionable for them to do so. So what he did was at a famous parade. He got a bunch of influential socialized women to smoke and to unveil their cigarettes in a very flamboyant way. And then he marketed cigarettes to women as symbols of female independence and he called them freedom torches. So he, he was using an emotional vehicle and the possibility of the notion of female independence as a vehicle to sell cigarettes, which of course, really has nothing to do with female independence. And it's actually very harmful as we know now. But that's a really good example of using an emotional leverage, using communication, which has an emotional impact. Before that the way you would advertise is just by dryly communicating the information. So it's a very big learning point communication, of course, can be conscious but also unconscious. I would say a lot of communication is unconscious because there's so much information coming at us in a given moment, we can't process at all at a conscious level. So a person might strike us as very confident or not confident or anxious or we might really believe one person and not believe another person. But we wouldn't necessarily be able to point to why to what it is about the micro expressions or the way they communicate that made them confident or believable. And that's what we can talk about in a bit more depth later. So communication is happening at different levels simultaneously. Again, a lot of people think just about the information which is really in, in the verbal and verbal realm, but there's all sorts of levels which communication is happening at simultaneously. The verbal is the most obvious. I do think it can be underrated. And there's a really common meme, you know, 93% of communication is nonverbal. I'm not sure if you can actually, you know, empirically assigned percentages, verbal communication is really, really important, especially when you're discussing ideas and you're getting into the nuances of those ideas. Just think, you know, if you're seeing two characters on your favorite sitcom and you compare watching a scene between them, talking with your ability with sound on versus sound off, obviously, you're getting so much more information with sound on. I'm not sure it's fair to say that 93% of communication is nonverbal. Verbal is really, really important. But verbal is the one that's discussed the most. And I think verbal is the one that lends itself most to our education and how were thoughts at university and up to university. So I'm not going to discuss it in that much depth. I think everyone really grasped the principles of good verbal communication. Let's talk about nonverbal communication. So there's all sorts of ways that you're commenting, communicating nonverbally facial expression is probably the most obvious and it's worth, you know, stopping and reflecting on facial expression. It is really a magnificent part of being human. I think that we have this system of musculature around our face that can contort itself in all sorts of different ways, so many different ways. And if you watch carefully, you really can't tell what, you know, as long as they're not trying to cover it up, you can tell a huge amount about what someone's mental state is like or what kind of emotions someone might be experiencing. I think facial expressions are really good example of a phenomenon where we just really don't pay attention that much. And I would urge you in your practice even in your personal life, maybe even if you're out in public people watching just taking time to look at the different expressions that people make with their faces. And just to remark just how much you can tell about what state of mind someone is in when, when their faces in, when you, when you observe their facial expression, when you choose to pay attention. And i it's been strange, you know, people think when you, when you become more observant as a person, people really notice I give them in my life, I might be talking to my friend and I say, well, you, you look like you're really mulling something over, like you're really worried about something and, and kind of like the Milton Erickson things. They'll be like, what are you like a mind reader? It's, it's not that exactly, it's just, it's, it's remarkable how hard it is to be, to actually sit and, and get out of your own self consciousness and be observant. And it's remarkable how much you can pick up really fast. And so facial questions are a really good example of that. And tone of voice is obviously extremely important, how hesitant or sure how deep someone's vocal tone is, or you can tell how when people are anxious, the vocal tone actually gets a lot more stifled and high pitched. And another interesting aspect aspect of vocal tone that is simple and to point out is that's kind of like three ways vocal tone often manifest itself in speech and those three different ways communicate, things are quite different. So something that's quite popular on the internet now is that the idea of up speak and that's when you communicate in an upward vocal tone. And when you, it's when you like finish your sentences though, you're asking a question. So it's like if you finish your sentence as though you're asking a question that's very common. It's common even when people aren't asking questions and what, what it communicates is a lot of uncertainty So that's an upgoing vocal tone. When people communicate in a kind of neutral tone, they're not communicating very much at all. And then the third way is a downgoing vocal tone. So that's more like this as opposed to more like this and what you communicate with the downward vocal tone is certainty. So when you see politicians giving a speech, they're almost always go down because the downward vocal tone community congruence, I believe what I'm saying. And you should also believe what I'm saying. So vocal tone can be very powerful in that way and it can really change the favor of your consultations. When you pay attention to that, you see it a lot of times when medical students that, that the vocal tone will naturally go upwards, it's, it's a really quick fix that can add a lot more confidence to the way that you're communicating. Uh Somatic communication is very important how a person holds themselves and how a person sits, how a person makes use of a chair, even how a person shakes hands can communicate a lot. One of the kinds of therapy I studies gestalt psychotherapy, which is one of the first kinds of psychotherapy to really pay attention to the body in a big way. And you would observe a lot in gushed out how a person holds themselves. So for example, I might have one client to really, they're able to relax into a chair and they're able to really let the chair support them and that communicates one thing about them or you have another client that, that really holds themselves up high like this with a lot of tension with very high shoulders and they're actually not reliant on the chair for support at all. Now, obviously, these things would mean different things depending on the psychological context, but it's all, it's all valuable later and all things you should be paying attention to in your patient consultations. Another example is I might, I've, I've had a client before in psychotherapy. He was very, had a very calm demeanor, very calm facial expression. But when I looked at his hand, he was gripping the armrest like this, like he was holding on to dear life, so very calm facial expression, but a lot of tension in his hand. So it's really worth paying attention to the body as well, what the body is doing and really worth paying attention to what your body is doing because that's gonna communicate different things. It's always important to have an awareness of what emotions people are communicating, what emotions you're communicating. The harsh truth of it is that people like to be around people who can provide good emotions, especially in a difficult setting, like a hospital or a busy clinic. And people don't like being around people who are continuously providing negative emotions. That doesn't mean you can never have negative emotional responses to things. But it means it's something you should be mindful of that whenever you're talking to someone, whenever you're interacting with someone, being a colleague, a superior patient, you're gonna be communicating to some kind of emotion. Even if that's apathy and that's gonna have an impact, it's gonna have an impact on how people see you and how people perceive you. So, an important thing to keep in mind, emotions tend to affect each other. Emotions are often contagious and even mental states are contagious. And we know that because there is a phenomenon called the psychological epidemic, which is actually when dysfunctional psychological states actually spread very widely. And we know lots of um mental health phenomenon, mental conditions have a contagious like quality to them. Self harm is a good example. Uh eating the solar behavior is another example. Um they're, they're issues which often spread amongst tightly tight groups of type of people. So you notice how when you start to pay attention to this, lots of things are being communicated. At the same time, you're communicating, let's say you're talking to a patient, you're communicating information, but you're also communicating how confident you are on that uh information, you're communicating a level of certainty or uncertainty or level of anxiety or self assuredness. And all of this is going to have an impact on, on what you're trying to communicate. You might put a greater emphasis on some information than others. Think about how important lifestyle advice is becoming a medicine, we are increasingly understanding how important nutrition and exercises in people's health. The amount of emphasis you put on that will have a huge impact on whether the patient even takes seriously or not. So if you say no to a patient, your hypoglycemic medication is extremely important, really, really important. But also think about that and exercise, you've communicated the information, but you put much more emphasis on, on the medication. Whereas if you take the time to like your hypoglycemic medication is really important. But also it would be very regretful if I didn't also inform you about exercise, which is super important and nutrition, which is extremely important for your health as well. You're putting equal emphasis on all of those different components of the management. And so the patient is automatically gonna take it a lot more seriously. So the way we communicate is a lot, often as a health professional, you're going to be expected, whether consciously or unconsciously to really transmit an atmosphere of calm and confidence and relative certainty in a situation which is anxious and uncertain and sometimes, you know, my on cause it's been remarkable how much people want that even in the absence of a definitive solution or or a clear, definitive way of getting out of the problem, how much as, as long as you can provide an atmosphere of calm, people are come away from the situation reassured. And people feel like as a group you're managing the problem in the best way that you can, we're obviously on the informational front were expected to distill very complex situations into very simple digestible information patient's come to us with. You know, they might be experiencing a presenting complaint, a particular symptom, let's say they're experiencing back pain and for them back pain could represent anything from a musculoskeletal problem to cancer too. Everything between it could be 100 different problems for them. And they're coming to us so that we can contextualize it, distillate, simplify it into maybe two or three possibilities and communicating that in a simple way that they can understand is we're seeing very important. So how should you go about communication? The first thing to note is that communication is a goal oriented process like any kind of any other human behavior. And often we stumble into so complicated social interactions without being mindful of what that goal is a really good example is when you end up in a fight with your friend, we started a conversation about something that becomes a discussion that becomes a debate that becomes a very heated argument. And what you realize is somewhere along the lines, you started from a conversation that was just trying to figure out the truth, but then you ended up trying to win or both of you ended up trying to win. So those are very different goals for uh conversation to take place. One goal is about actually trying to find out the objective reality of the situation. One goal is to get one over on your friend and those different goals are going to have a very different outcomes. Uh Your, your, when it comes to your behavior, aim is everything. So once you have your aim in line, everything else follows. So whenever you're having a complicated interaction at work, again, whether it's a, a colleague, a superior junior, a patient, you need to understand if it's a tricky situation, what what am I trying to achieve? That might be trying to get the best history possible. It might be trying to communicate something difficult to a colleague. Um It might be trying to communicate difficult information to a patient or to a patient's relative, but very much be mindful of the goal. And that will allow everything else to fall in line in terms of how you communicate. A very good maxim from a very classic self help book called The Seven Habits Of Highly Effective People is seek first to understand such the receiving parts of communication and then to be understood, that's more the transmitting part. So thinking about the first aspect, seeking first to understand in psychotherapy and psychiatry, we have a phrase which is called active listening. Listening really is an active skill. It sounds like something that's easy, it's not easy. Most people are very bad at listening, I would say. And so listening is a really scarce commodity. This is why therapists same business because they're very good at listening. And as I'll talk about later, actually, people love to be listened to so active listening means putting yourself and whatever you think about the situation aside for the moment and really proactively focusing all your attention on the person in front of you and putting your attention on them in a very holistic way as I alluded to earlier, not just listening to the words that are coming out of their mouth, but also paying attention to their, what their eyes are doing, the facial expression, their body and taking it all in as a kind of whole picture. What you find often when you do this is you start to do the right things kind of naturally. But those right things are, for example, adopting a stance that's calm, that's empathic, you know, really occupying their view, which is different from a sympathetic point of you being sympathetic is taking their side, whereas being empathic is merely putting yourself in the shoes. So you want to become you be empathic and really what helps is to be curious to generally want to know what the other person's predicament is. And again, as a goal, this helps everything else fall into line. So you come, you're curious, your empathic, you usually as well all learn in medical school with history taking, you tend to start a very open questions and then you go for more closed questions later. It really is valuable if you think an interaction is be going to be complicated or difficult to give someone what we call that golden minute, which is really a minute of just letting them talk on uninterrupted. Most people never have people let them talk for a minute, uninterrupted and it feels like a really long time. But actually, it's not, it's just a minute. But usually if you give someone a minute of talking uninterrupted, they really already will start to feel like you're a good listener with that. Uh starts of being calm and curious. You're naturally, you're gonna ask clarifying questions. You might even point out contradictions in the way that they're expressing themselves. You said A but you also said B and A M B can't both possibly true. And people really love that because that's, that's a good sign that you're, that you're listening with another very useful technique to adopt is when someone's finished to summarize or paraphrase what they've said back to them and then to check that you, they've on that, that you've understood them correctly. You can really think about active listening, kind of like being a syringe, like you're creating a vacuum into which they can express themselves. You can use silence strategically. People are often afraid of silence and in social interactions. But the interesting about thing about silence is really silence is a form of social tension. And what you communicate. Why by being able to tolerate a silence is actually that you're more confident that you're more calm and it's also a communicator of status because it means you can tolerate tension. And also when you, when you create silences, people tend to eventually fill them. What you start to notice when you employ all of these different techniques is people will start to talk in a way where they learn things about themselves as they talk. So one of the really interesting things about spontaneous speech is when people engage in, in it. And this is really one of the founding principles of psychoanalytic therapy. When people engage in spontaneous speech, they start to access what they're not necessarily conscious of day to day and they start to learn things about themselves. And of course, you're learning about them as well, which is, which is the whole goal. And when people feel like they can learn about themselves by talking to you, then they know you're a really good listener and they start to gravitate towards you. So that's the active listening component. Then you want to transmit what you think your take on the situation, your perspective, your predicament. So this is being understood, you want to express yourself with confidence, but you also want to have some humility in that confidence. Um You don't necessarily want to portray your view on the situation like it is the view or the truth. Um But you also want to have that confidence that this is how you see it and you want to express yourself and as clear, as simple way as they can, you want to communicate in a way. It's really helpful, just as your empathic. When you're listening, it's really helpful to communicate in a way which forces the person you're talking to, to be empathic. So you might use phrases like you would understand if I was in the situation then. So you're kind of forcing them to take your point of view, um which can be helpful because people aren't always naturally, very empathic. So you calmly and clearly explain your predicament. It's really helpful to be transparent about your motivations and what you're trying to achieve in the situation. So even in a patient consultation, even saying something explicitly, like I just want your quality of life to be better or I would just like your symptoms to be relieved as much as possible. You know, if things get heated or difficult, it's a really good way of building rapport. It's a really good way of uh engendering trust. You know, one of the huge sources of conflict between people, both in professional and personal life is when people make assumptions about each other and they tend to fester and they tend to grow into resentments by showing a willingness to explain your motivations as clearly as possible. But also asking about other people's motivations, it shines a lot of light on things and it tends to allow those assumptions to, to melt away. So it's a, it's a huge way to get rid of unnecessary conflict. Now, you can't get rid of all conflict and you don't want to. Some conflict. Health conflict is important. And there's also an idea that whenever you're dealing with someone you want to get to crucial disagreements or important disagreements because that's usually the foundation of progress. But a lot of conflict is unhealthy and can be done away with. And that's, that's a really good way of doing that. As I said at the beginning, it's really important to understand that communication is a dynamic process. So what I mean is, it's not, not too static entities, transmitting information to each other as a result of communication, you're going to learn something and be different as a result of the interaction. And so is the other person and even within the interaction itself, the way you communicate your first question or the first thing you say will change the way, the way you communicate, the second thing and the third thing and it's a constant back and forth like a tennis match. That's why you can't just get report most of the time just like that. But it has to be built up over a series of micro interactions. You know, two people can go and have a conversation with the same person with the same goal and they're never going to have an identical interaction because there's so much going on that's a very, very dynamic, very dynamic process. As you wrap up interactions and wrap up conversations, you want to be sure that you're creating what's called a win win scenario where you're both on track to meet whatever your goals are. And again, you should be really explicit about what those goals are talking to your patient about what they expect from a consultation and make sure that at the end of the consultation that actually got what they were expected or at least close to and you've done the same thing. So thinking about what everyone's trying to achieve is always going to be super helpful for ensuring good communication. It's always helpful to use as I alluded to earlier emotions to your advantage, you should reward people when they're giving you the information you want, tell them that they're actually doing well. But when people are being unnecessary aggressive or they're crossing your boundaries, you shouldn't hesitate to tell them that they're doing so. So reward people positively when they're giving you what you want, um negatively reinforce what they're saying, use boundaries when they're not giving you what you want and be sure if you want someone to take a piece of information, seriously, deploy it with some kind of emotional impact, you know, and use all your nonverbal cues and signals in order to do that. There's a few general discussion points that I think are, are important to, to bring up, as I mentioned, earlier, everyone is wired differently. So this is from Ray Dalio's book Principles. Ray Dalio is a, he's an investor and he's one of the richest men in the world. He founded a company called Bridge House or Bridge Bridge Water. And he wrote a book Principles which talks about many different things but communication and how everyone is wired differently. Everyone has different personalities and a personality, you know, a personality trait isn't just the behavior, but it really is a way of seeing the world hard working people. For example, for example, people have uh industrious personality, see the world as a place to work hard. Uh extroverts see the world as a social landscape. People who are high in the trait called openness, see the world as full of ideas and, and new aesthetics to be explored. Um because people see the world differently, people who are in the exact same situation as you are going to see the exact same situation very differently. And you really want to keep that in mind when you're communicating with people because they're gonna have different motivations to you. They're going to, they're going to at a perceptual level, see things very differently. They're going to want different outcomes than you. And the more you understand that the more you're going to be able to communicate um effectively with, with people. And I'm going to, at the end, I'll link you to a podcast that I made all about personality and personality differences. The next thing I want to mention is that people have defenses. So this is from psychoanalytic theory, we all have an ego and there's lots of ways you can define an ego. But one of the things an ego is, it's kind of a story or a narrative that you tell yourself about yourself. And like any story, there's gonna be truth in it. But there's also gonna be some fiction when people, when people's egos are threatened, that tends to be a barrier to good communication. So you want to be mindful that people have defenses. Sometimes people are very open straight away. Sometimes people have defenses which need to be gradually lowered over a period of time. Sometimes people are open and then one particular thing comes up or one misstep happens and then people's defenses go right up. So you want to be aware that people have defenses and you want to get really good at recognizing when people are open, ready to communicate, ready to receive information, ready to receive communication or when they're actually quite when the barriers are. And that can take the form of denial when they want to pretend the problem doesn't exist rationalization, which is basically using uh kind of rational kind of logical argument again to pretend uh something doesn't exist projection when they disowned the problem and puts on uh something else, someone else, all sorts of other defense mechanisms that are really interesting to read about actually, um those are all barriers to good communication. People are try ballistic. Um This is kind of a hangover of our evolutionary past. People need very few reasons to fall into an US and them mentality. And that because that might be because you side of the different football team, a different political party, it might because you grew up on a different side of the street, different part of the city or a different country. I come from a very small island. I come from Malta, which only has 500,000 people and which can cross in 15 minutes of driving and people in the north are prejudiced, prejudiced against people in the south and vice versa. People need very, very little reason to fall into that us and them trap and that is going to be a really big barrier to communication. So be mindful that that comes up between doctors. It comes up all the time. This is shocking to me, comes up between the surgeons and the medics, between the general surgeons and the orthopedic surgeons. Um It even comes up in psychotherapy. I mean, people who are really into cycle analysis, people are more into cognitive behavior therapy. It's kind of maddening how pervasive try ballistic thinking is. So be aware of that. People, as I mentioned earlier, love to be listened to. Most people don't because most people are not good listeners, most people are not listened to and so people will really want you around if you, if you learn the skills of active listening that I, that I mentioned earlier. Uh And the last thing I want to mention that kind of ties in stuff we've discussed is that people existing hierarchies. Again, this is kind of a feature of our evolutionary past were social primates and like most animals, but especially social primates, we exist in status hierarchies. This is kind of explicit in the medical world. You know, you've got consultant, register junior doctor, etcetera, uh nursing staff have their own hierarchies, admin managers all have their own hierarchies. And I point this out just to be aware that, you know, where you're at on a hierarchy can affect your communication and that can most of the time, that's probably a good thing like you are going to communicate differently to a superior than to an inferior or other junior. Uh You will communicate differently with, with appear and most of the time that's appropriate at the same time, it's important to be aware when hierarchy is maybe an exert exerting an undue effect on your communication when you're being, for example, to differential to a superior, or maybe you're acting in a condescending way to your junior. You know, it's important to point this out and not have people take advantage of you or not to take advantage of other people and just be mindful of the way these status hierarchies will subtly influence how confident you might come across even though you might not be that confident in the information or worse when you're extremely confident in the information. But because you're talking to a superior, you unconsciously feel that you can't communicate that in a confident way, you know, that's not true. You should be able to communicate in a confident way. Um You should still probably show some element of deference to someone who's in a superior position. Um But don't let it have that undo effect and that's something I see really commonly in, in junior staff members. Okay. So I'll just wrap up quickly, but there are a few specific scenarios that I want to point out conflict. The escalation is a big one. I would say most conflicts, most aggression in a clinical setting can be um deescalated verbally, you can do that using the skills that we've already discussed. What I really want to point out is that most aggression in a clinical setting is defensive aggression by which it's aggression resulting from a perception by the person that they're not getting something important that they want, that they're not getting their needs met. In psychiatry, we see it a lot of people are paranoid often in a pathological way and it responds really well to clear communication which shows a willingness to meet or at least attempt to meet whatever it is that they need or want a very small minority of the time aggression is by people who want to be aggressive for its own sake. And in those instances, it's probably more important to get a lot of people on board to get things like security on board. But those are really are a minority of situations. Most of the aggression you see is a more defensive aggression as a result of unmet needs breaking bad news obviously is a situation which comes up a lot. I think you've probably all had some kind of training on breaking bad news at this point. But if you have specific questions, you can ask me the basics are calm, appropriate environment, phones and destructions off really as much time as it takes um fire do it very gradually giving someone a warning shot, letting them know it's gonna be a serious conversation as you know, with your nonverbal cues that it's not going to be an easy conversation or present conversation and then just very, very slowly introducing whatever information you have to introduce, given them time to understand clarifying, slowly being empathic, making sure that they have enough time to process, you know, what, what they're being told. Um Really, I guess gent gentleness is the key with breaking bad news. And the last thing I'd like to discuss is persuasion, as I said before, you know, as, as health professionals were often in the position where we need to persuade people and aside from the information and putting the appropriate amount of emphasis on the information that you think is important, emotional leverages, really important. There's really two dimensions to emotions, positive and negative. If you want to persuade someone of something, you need to use both of them. So if you're trying to persuade someone to stop smoking, use a lot of positive leverage, get them to imagine just how good their life could be, how much longer they could live, how much better their quality of life would be uh if they stopped smoking. But also get them to imagine how negative the negative consequences of not stopping smoking. Get them to imagine how difficult things would be. If they didn't stop all the different complications, they could potentially develop the negative impact on the quality of life. So that way you're using both dimensions of emotion, you have the negative emotion propelling them forward and the positive emotion, putting them forward. And that's the best way to persuade people to do things and obviously getting, they're getting it centered really around their own interests rather than your interests of being a good doctor and being good at persuading. What are their interests in their situation? How does this information apply to them and to their lives? That's really different, that's really being empathic essentially. So just to conclude, and then we'll do some questions, what I'd like to you guys to take home is really to, to accept that, to understand and execute good, good communication. You have to understand certain aspects of human psychology. It doesn't mean you have to be a psychologist but not an understanding of a few principles can be very helpful. Communication is a set of skills which can be learned and which you can get better at. It's one of the most valuable skills that you can develop, particularly in light of current technological advantages. Advances, as I mentioned, it's a core skill in healthcare. Every healthcare professionals should have excellent communication skills, I believe. And it's immensely helpful in your personal life as well. Communication is taking place constantly on multiple levels simultaneously. And I would ignore the different levels at your peril. If you choose to focus purely on the informational level of communication, you're gonna be missing a lot, particularly missing a lot from other people, but other people are going to be missing a lot from you as well. Most people are terrible at listening because they're so self conscious. So please put your self consciousness side, learn to listen people want you around and you're gonna learn so much doing it. Um There are a number of obstacles to good communication which are kind of hardwired into our psychology, like tribalism, as I mentioned before, like our defense mechanism. So just be mindful of that, how they come up with you, how they come up with other people and that will make you a much better communicator. I'll just briefly sign post you guys to my podcast before questions. So it's called the Thinking Mind podcast is all about psychiatry, psychotherapy, self development and right topics. We interview experts. We do all the oh essays as well. The two which I thought would be really pertinent to this discussion is our 15th of us a which we, which we made all about personality, why we have personalities and how personalities differ and therefore how people view things in very different ways and how discuss all sorts of conflict, including personal conflicts, where conflicts, political conflict, etcetera. And we also made one all about conflict, how to engage in conflict. Why to engage in conflict, the difference between healthier and unhealthy forms of conflict and how to think about all of that. Obviously, conflict is a very important aspects of the communication, but we didn't really have time to go into it today. I'll put links to those in the chat shortly. Um But in the meantime, if you guys have any questions, feel free to put them in the chat and I hope that you guys found it helpful. Mhm. So, uh I'm not sure there are any questions yet, but like I said, just put them in the, uh I'll let you know when you come up. Uh, just one from earlier was do you think, uh what do you think about the difference in people's tones based on their cultural background? I thought that was quite an interesting question. Have you noticed anything in your practice? I, I haven't noticed a huge amount, but I think it's actually really worth thinking about cultural differences and being mindful of them. I think there's a book by Malcolm Gladwell. I don't want to get it wrong. Let me just look it up. There's a book by Malcolm Gladwell about, I call talking to strangers, which actually is all about how different ways that communication can go wrong. And one of the things he does talk about is cultural differences. I haven't noticed huge differences in the basics by which I mean, kind of the different patterns of vocal tone that I talked about uh and things along those lines. But I think in that book, Macken Gradual does even say that in certain cultures, even facial expressions can mean different things. Um and other nonverbal cues can be different things. So, you know, if you're talking to someone of a different cultural background to you and things seem a bit unusual in terms of how they're communicating nonverbally, I would be mindful of that, you know, as a possibility. And I don't think there's any other questions. Actually, I think you stand up and into silence. I hope not. Uh if you could prove fill out the feedback in the chat as well before you head out, just uh things that I mentioned in the chat as well, so you guys can look them up if you're interested. Okay. Okay. That Alex. Thank you so much for your time. Thank you. Um, I hope all of you found that really useful. I know that I, I learned a lot actually. So, uh, I'll give, I'll have a listen to those episodes, for sure. Great. Thanks to us. Good evening much.