The Step Before: Noticing how we feel before we speak
I’ve started to really focus on the step before
The step before the conversation. Of course it goes without saying that the preparation by gathering clinical information is essential, but I really wanted to talk about that internal step. The point when we realise there is something sad that needs to be said.
And we know that without it there can be no honest planning, only a limbo that doesn’t allow agency, choice while life moves on in its new direction.
But once it has been said we know the door is opened to difficult emotions for all involved.
When things have changed…
Unwelcome news is news that is going to changes your patient’s future. Knowing you will be the one to share it (what has been termed “Breaking Bad News”) can feel like a huge responsibility. The dread is real (and magnified when we feel under-prepared, inexperienced, or believe someone else should already have had this conversation).
It’s these feelings that might lead to hesitancy, might make us rush without pausing for the news to be understood, avoid questions, or hide in jargon, which all give the unspoken message “don’t feel bad” (or maybe, more honestly “don’t let me see you feeling bad”.
Some of our least helpful communication habits may even be our attempt at softening the blow - for them and by extension for us as we deliver the news. And yet we are all going to feel something about this news. Maybe we can make a conscious choice to reflect on our feelings and to make sure we do the best for our patients.
Being intentional about the internal steps we take prior to a difficult conversation can be more supportive to our patients
In “the step before” we can take a moment acknowledge how we feel about these conversations.
“I wish this wasn’t happening for them”
“I’m worried about how they’ll take it”
“I’m not sure what the future holds”
“I’m worried they’ll ask me something I can’t answer”
And we can resolve to do our best with the information, experience and skills that we have.
“I wish we didn’t need to have this conversation, and I’m going to do my best to elicit their concerns and goals in light of this change”
“I’m going to walk them through their options and support them to make the choices that have the best chance of giving them the future they are hoping for, in light of this new information”
But am I making it all about me?
Does a moment of self-reflection take away attention from your most pressing concern your patient?
I have found that taking a moment before we have the conversation to acknowledge how we are sitting with a challenging task, and actively choosing to do the best we can is keeping the patient at the centre. It ensures that our concerns don’t swamp theirs in the moment. And conversely, sometimes, when we don’t take this time, overwhelm might lead us to have a rushed, incomplete conversation which does not centre our patient’s needs. What are your thoughts on this?
Some people fear that acknowledging their own emotions may make them less effective in conversation. Interestingly, research into what is known as “Affect-Labelling” has shown that naming our emotions may diminish their influence on us (functional MRI studies show reduced amygdala activity when emotions are named). This could possibly give more bandwidth to have a measured and supportive response.
Think about “the step before”
Some questions to reflect on
What do you notice in yourself before you have to share difficult or unwelcome news?
Do you allow yourself to notice those feelings?
How do you prepare to be fully present in a challenging conversation?
Who would you talk to about having these conversations?
What resources do you have locally to support you with these important moments?
I now use “the step before” to be ready and fully present for my patients whilst recognising and taking care of my own human emotions.
Affect labelling
Lieberman MD, Eisenberger NI, Crockett MJ, Tom SM, Pfeifer JH, Way BM. Putting feelings into words: affect labeling disrupts amygdala activity in response to affective stimuli. Psychol Sci. 2007 May;18(5):421-8. doi: 10.1111/j.1467-9280.2007.01916.x. PMID: 17576282.
Understanding Empathy
Stevens F, Taber K. The neuroscience of empathy and compassion in pro-social behavior. Neuropsychologia. 2021 Aug 20;159:107925. doi: 10.1016/j.neuropsychologia.2021.107925. Epub 2021 Jun 26. PMID: 34186105.
