Empathy begins with "engaged curiosity about another's particular emotional perspective."1 Empathetic listening builds on the concept of empathy and allows one to be fully present for another person's experiences. When empathetic listening is used in health care, patients and families are often more satisfied and more open to hearing their physician's advice. Listening with empathy can save time and effectively defuse difficult situations. It can forge deeper connections with patients, which leads to greater professional satisfaction and joy in work.
Eight STEPS to listening with empathy
- Decide to connect with empathy
- Use subtle cues to convey that you are listening intently and honor the first "golden moments"
- Listen for underlying feelings
- Listen for underlying needs or values
- Remain present when you are listening to the speaker
- Consider responding verbally
- Look for cues that the speaker has finished expressing him/herself
- Reflect on your experience and rejuvenate yourself for the next time you offer empathy
Decide to connect with empathy
Highly charged situations in which you aren't certain what to do are ideal times to use empathetic listening. You might try it with a patient who is experiencing grief related to an illness or with a co-worker who is having a work-related conflict.
I am caring in all my interactions. How will this help me?
Learning to listen with empathy reinforces that you care and that you want to improve your listening skills. Empathy is not a character trait; rather, it is a decision to connect with another person in the moment. For example, if you are able to elicit the patient's agenda at the beginning of a clinic visit and couple it with your goals for the patient's visit, you can be present to what the patient may be experiencing. Practicing empathy can help this come more easily. When a patient recognizes both clinical competence and caring demonstrated by empathy, trust develops (see Figure 1).
What are some benefits to connecting with empathy?
Tangible and intangible benefits to listening with and demonstrating empathy include:1
- Greater therapeutic efficacy
- More trust, which leads to improved patient adherence to treatment
- More effective communication between patient and provider that results in decreasing patient anxiety and improving patients' ability to cope emotionally
- Enhanced patient disclosure of problems and concerns
Use subtle cues to convey that you are listening intently and honor the first "golden moments"
Use body language to show that you are listening. Start by sitting nearby and facing the speaker. Lean toward them and make eye contact. Make sure your arms are not crossed as this can signal to the speaker that you are closed off and not really listening. Periodically echo or summarize to further demonstrate that you heard what the patient had to say.
Practice scenario: A patient presents with persistent neck pain. During the interview, she states, "My neck was fine until the car accident, but it's been getting worse ever since. Now I can't sleep, I can't do chores around the house, and my boss is really getting upset about all the days I've missed at work." It may be tempting to jump in with additional questions, such as, "How would you rate the pain on a scale of 1 to 10?" However, a response like this does not effectively show the patient that you are listening to what she is saying. A better response would be to echo her words (e.g., "I understand. You've missed a lot of days at work because of the pain"), to summarize what she's said (e.g., "So to summarize, you didn't have any neck pain until the car accident, but it's been getting progressively worse since and it is having a major impact on your life") or invite her to share more in an open-ended way (e.g., “Tell me more about your neck pain”).
In a clinical situation, the first few minutes of the encounter are precious. There are many tasks that need to get done during the visit—questions to ask, problems to analyze and solve—and you may feel pressured to dive right in. However, if you leap into these tasks without listening first, you may miss key information. Honor the first “golden moments” of the visit by setting aside distractions such as charts, computers, phones, alarms and pagers. Give your full attention to the person speaking. Deciding to be fully attentive at the very beginning of the visit prevents important issues from coming to light at the end when you need to be moving on to the next patient on the schedule. Empathetic listening can save you time later because you are more likely to understand the patient's concerns or symptoms earlier in the visit.
While the first few minutes of a visit are important, some data suggests that most patients do not reveal their underlying, most serious concerns in the first few minutes of an interaction. Thus, it is equally important to be fully attentive throughout the interaction to ensure that the patient's concerns are heard later on if revealed later in the interaction.
Practice scenario: A patient is seen for a preventive health visit. The office recently developed an electronic note template designed to help physicians navigate preventive health guidelines and recommendations. Dr. Erickson starts the visit facing the computer and asks how the patient is doing. The patient responds with a brief “Fine, thank you.” However, when Dr. Erickson recognizes that she has not given the patient her full attention and turns away from the computer to ask “How are you doing today?” the patient's response is more complete. Seeing that Dr. Erickson is fully attentive, the patient feels free to express the anxiety he has been experiencing related to a conflict with his work supervisor. It also comes to light that he hasn't been sleeping well lately. Together they decide that sleeplessness will also be on their visit agenda today.
How do I give a patient my full attention when I have a responsibility to keep the electronic health record updated?
With an electronic health record (EHR), there is a temptation to multitask during the encounter by typing while listening to the patient. A more effective strategy is to alternate between working on the computer and communicating with the patient. In moments where empathy is called for, remove your hands from the computer completely and turn to face the patient. If you do need to enter something into the EHR, you can "announce" your transition to the EHR by letting the patient know that you need to put some information into the computer; make sure to turn the screen towards the patient so that you can view it together.
Listen for underlying feelings
Sometimes feelings may be right on the surface; other times they are hidden. Patients might bring up an emotional situation briefly and wait for a clinician's cue that it is okay to continue. Watch for feelings hidden in body language, facial expressions or other non-verbal cues and allow the speaker to elaborate. Take your own emotional temperature and note whether you sense any feelings in yourself (anxiety, sadness, frustration) that might be in response to the patient. This can also be the opportunity for you to switch from medical questioning to an empathetic listening mode. A brief pause, softening of your tone of voice and a question indicating interest in the patient's feelings invites the patient to express her concerns, opens the door to further empathy, and makes it easier to address the patient's unique needs.
Practice scenario: Dr. Nolen tells a patient with cyclic vomiting syndrome that she needs to stop using marijuana. As he says this, he notices a sudden grimace on her face. This expression could mean many things. It could reflect anger because she thinks she's being judged about drug use, it could indicate worry if marijuana was the only thing that has alleviated her symptoms, or she could be confused if a previous physician told her marijuana use was unrelated to her vomiting. She might be embarrassed to talk about her marijuana use in front of others, even confidentially with her physician. In a situation like this, Dr. Nolen should try to ascertain what the grimace means. He might tentatively say, "You seem to be concerned," and pause to allow the patient to elaborate.
How can I be sure I'm correctly identifying someone's feelings?
There will be situations where you might name one feeling while the speaker is actually feeling something else. The important thing is that the speaker hears your interest. Expressing interest invites more expansive conversation and increases the probability that the speaker will reveal the true underlying feeling.
Listen for underlying needs or values
Deep empathetic listening means being attuned to the underlying value or need that the emotion is pointing to. Everyone has a common set of needs or values that include:
Subsistence Health, sustenance, soothing, comfort Safety Security, fairness, protection, consideration Work Competence, contribution, productivity Honesty Authenticity, integrity, clarity Autonomy Choice, freedom, control, independence, power, space Challenge Adventure, play, learning Transcendence Meaning, purpose, beauty, creativity Rest Sleep, relaxation, humor, leisure, ease Empathy Respect, acceptance, support Community Acknowledgement, belonging, cooperation
Adapted with permission from: Brown J. Wheel of universal human needs. Open lines of communication: making your voice heard. Center for Nonviolent Communication. Published June 17, 2011. Accessed April 25, 2015.
Practice scenario: In the example in Step 3, the patient was given an opportunity to say more and states that she is worried she might not be able to find anything other than marijuana to alleviate her nausea. Now that there is clarity about what the underlying feeling is (i.e., worry), Dr. Nolen expresses curiosity to learn more about the underlying need or value. “So it sounds like it's important that you can make sure you're comfortable.” The patient may respond with, “Yes! And I want to have the freedom to help myself be comfortable.” When Dr. Nolen suggested that the patient stop using marijuana, the patient perceived this as a threat to her comfort and autonomy. By inviting the patient to share more about her feelings and needs, Dr. Nolen is able to find common ground with the patient. The focus of the visit can now be turned to suggesting other ways for the patient to alleviate her symptoms.
Alternate Practice scenario: Dr. Rice is running late in clinic, enters a patient room and promptly apologizes for the delay. In spite of the apology, the patient mutters a half-hearted greeting and avoids eye contact. Noting this response, Dr. Rice asks, “I sense that you're angry with me.”
The patient replies, "Yes, I am angry but also embarrassed."
Dr. Rice: "Before we talk about the reason for your visit, can you help me understand why you're feeling that way?"
Patient: "I can't drive anymore so my daughter brings me to my appointments. She's out in the waiting room now. She has a job and kids and I have become such a burden on her. This only makes things worse—the wait, that is."
Dr. Rice: "It sounds like you really value respect—both for your time and for your daughter's time. Did I get that right?"
Patient: "Yes...and independence. I just wish I could be more independent."
We all have common needs but different ways of acting in response to these needs. For example, two clinicians need to make changes in their morning schedule so that they can get their children to daycare. One may choose to approach her boss with a request to start later, making up the productivity by double-booking and going into the lunch hour. Another may send an angry email to her boss lamenting the lack of family-friendly work policies. Both clinicians are expressing how much they want autonomy and balance; however, they have very different strategies.
When we focus on needs and values, we focus on how we are the same. In contrast, when we focus on how a speaker tries to meet those needs, we highlight our differences. During empathetic listening, keep focused on the underlying need, rather than the speaker's communication style or behavior. You may not know what the need is at first; just be open to hearing the need.
What does listening for underlying needs look like in practice?
Dr. Jimenez receives a prescription refill request for a patient, Roger, who has not been seen in the clinic for three years. He decides to prescribe a limited supply and asks his medical assistant (MA), Pattie, to schedule an appointment. When Pattie calls Roger, he becomes angry that Dr. Jimenez won't refill the entire prescription. He says he's going to get a different doctor and hangs up on Pattie.
Pattie tells Dr. Jimenez about the conversation; both are dismayed about his lack of respect. Dr. Jimenez calls Roger back.
If Dr. Jimenez focused on Roger's actions, he might say, “My MA is very upset about the way you treated her on the phone. I would like you to apologize to her.” This would likely result in Roger becoming defensive.
Instead, Dr. Jimenez focuses on Roger's needs and says, “My staff told me you were very upset on the phone. To be honest, I was surprised, as I wasn't expecting that response.” He pauses to give Roger a chance to talk. Roger explains that he has been travelling a great deal, taking care of his ill mother who is hospitalized in another city. He had a long day at work and was very frustrated by having to deal with his own health care. This time, Roger apologizes for having treated Pattie the way he did. Through this exchange, Dr. Jimenez comes to understand that Roger just wants it to be easier to get his medications. He can relate to this need for ease. His openness to understanding why Roger hung up on Pattie paves the way for a civil—rather than contentious—conversation. This conversation still has room for Dr. Jimenez's need for respect to be met. Roger apologizes without prompting and Dr. Jimenez conveys the apology to Pattie. By approaching Roger empathetically, there is accountability for Roger's actions and an opportunity for Roger's, Pattie's and Dr. Jimenez's needs to be met.
What if my speculations about the speaker's feelings/needs are wrong?
You are still listening with empathy. The speaker recognizes your openness to learning more and will likely correct you. For example, a rheumatologist tells a patient that she has lupus and the patient sighs. The doctor says, “I'm wondering if you're overwhelmed with this news?” The patient responds, “No! I'm just so relieved that I finally know what's been causing all my symptoms!” While the word “overwhelmed” was not accurate—at least at this moment—the patient heard the message behind the words: “It matters to me how this news affects you.”
You and your team can practice identifying underlying feelings and needs using the downloadable tools for this module.
Remain present when you are listening to the speaker
Become comfortable with silence. Show you are listening by using non-verbal body language:
- Adopt an open, comfortable stance, making sure your arms aren't crossed
- Make eye contact
- Lean in
- Match the speaker's emotional intensity with your expressions
- Murmur simple responses, such as “Uh huh,” “Mmmm” or “Oh”
- Nod your head
Give the speaker an opportunity to express his or her feelings to completion. Their feelings and values will surface if they are given ample time to express themselves in a welcoming environment. Focus on those moments when the speaker seems to display the most energy around a topic (e.g., more rapid speech, change in facial expressions, more pronounced gestures, etc.) as these signs can provide clues to what the speaker values most.
Practice scenario: An MA notices that the physician she works with is not smiling and seems distracted. The MA asks the doctor, “Everything OK?” and he responds, “Oh, my three-year-old is home with my mom and she won't stop vomiting. Every 15 minutes.” The MA shows concern through her face, murmurs, “Mmmm,” and lets the doctor continue. “I'm also thinking about that little girl who came in yesterday with leg pain. Her labs are back, and it looks like she has leukemia.” The doctor ducks into another exam room while the MA reflects on her own surprise and dismay about the patient's diagnosis. She realizes that the doctor could be experiencing anxiety, weariness, or a feeling of being overwhelmed. She wonders if the doctor might need balance, or perhaps just a chance to be sad about not being with his daughter while she's ill. Later that morning, the doctor shares that his mom called and his daughter has been feeling a little bit better. Instead of looking relieved, the doctor still looks concerned. Picking up on facial expressions, the MA says, “You're still worried?” The physician replies, “Oh, I know she'll get better from this. I am a little worried that my mom will get this bug. But I'll tell you what. I just keep thinking about how that little girl's dad doesn't know if his daughter will get better.” By this time the doctor is speaking with a little more speed and energy. The MA listens while he expresses his need for safety for his child. By the time the doctor and MA need to move on to their next patients, they both can feel a bit better, each one knowing that someone at work cares about what they are going through.
I have a habit of keeping a professional distance and this seems to threaten that distance.
Communicating with empathy involves emotionally engaging with the speaker but does not mean losing your professional boundaries. Empathetic listening does not demand that you become responsible for resolving all feelings or needs expressed by a patient or co-worker, but just that you listen to them with focused attention. You may find yourself becoming more comfortable listening to the needs and feelings of others as you discover that empathy facilitates more effective relationships with patients and colleagues.
I'm already busy managing my patients' medical conditions. I don't know that I can also start worrying about their personal needs.
Strengthening the doctor-patient relationship will lead to more effective clinical care. For example, a woman comes for a check-up and, knowing that her husband is very ill, the doctor asks, “Would you like to talk about your husband?” She responds, “Yes! Yes, it has been so difficult.” She speaks of her responsibilities caring for him and how she doesn't want him to see her cry. She is worried about how her heart is holding up under all this stress. The physician listens and encourages her to talk about these feelings; while he doesn't have the capacity to change the situation with her husband, he has demonstrated caring and understanding, from which she will benefit. He can then re-focus on her medical conditions; a careful check of her blood pressure and heart rate gives her reassurance.
Consider responding verbally
There are opportune moments for verbal responses to what the speaker is sharing. For example, verbal reflection may be helpful when:
- You need more description or explanation from the speaker
- You sense the speaker would like confirmation that you are listening and understanding
When you respond, keep this question in the back of your mind: “Is the patient feeling ____________ because they value/want ______________?”
When you respond, you should speak naturally; be yourself. At this point in the dialogue, the focus is still on listening and it is not the time to share your experiences or opinions. Listening with empathy has a reflective quality, allowing a speaker to reach clearer self-understanding. When you choose to speak about your own feelings and values, you have moved past empathetic listening and into expressing yourself.
There are also some potential mnemonics to keep in mind when responding to patients' emotions. These devices are helpful in remembering important empathy skills and concepts and how to make the speaker feel understood.
How can I make it feel more natural when reflecting feelings back to the other person?
It can be helpful to adopt a tone of curiosity and openness to having missed the mark. Consider starting your response with:5
“I imagine you might feel...”
“I am wondering if you are feeling…”
“Is it important to you that…?”
“Let's see if I have this right...”
Patients perceive a lack of empathy when you:
- Interrupt or finish their thoughts
- Challenge their feelings
- Reassure them in a way that sounds patronizing
- Tell them what they ought to think or feel
- Turn the topic to yourself and away from them
- Do not acknowledge their emotions but simply proceed with medical questions
This is a lot to remember. I'm not sure I can keep track of all these “to-dos” at the same time.
The most important thing is to have the intention to connect with empathy. The techniques are secondary and only useful if they indeed help you to stay true to that intention.
Consider this example: A doctor named Emily found herself as a patient, requiring a dilation and curettage (D&C) procedure after a miscarriage. She awoke in recovery before her husband arrived, feeling sad, defeated and disappointed. Her OB/GYN came to see her, stood next to her and intuited that Emily wasn't ready to talk about the procedure or how she was feeling. Instead, the doctor allowed her to speak of unrelated subjects—her college experience, her husband—and connected to Emily physically by holding her hand. In this instance, the doctor didn't follow a specific sequence of steps or a protocol for demonstrating empathy. A few days later, Emily described her experience to a colleague: "My doctor was with me, and really this is what I needed. There was no person on Earth who was going to have the right words to say to make me feel better in that moment. I didn't need to feel better. I needed to be sad."
I communicate with my patients frequently through a secure web portal. Is it possible to show empathy in my typed responses?
Empathy is different in a written conversation than in a live conversation, since non-verbal cues of facial expression and body language, as well as intonations, are absent. Acknowledging the patient's emotional experience in writing can still provide a benefit. It is possible to demonstrate caring by responding in a way that shows you recognize the underlying feelings and values the patient is trying to communicate in their message.
Consider the difference between the following two email responses to a patient:
Look for cues that the speaker has finished expressing him/herself
Cues might be a decrease in emotional intensity, a deep sigh or a shift in the focus of the conversation. At this point, it is natural to move to another stage of the communication process—either expressing yourself, attempting to solve a problem together or attending to the medical care needed.
I understand that empathetic listening may save me time, but I'm not sure I have the energy to listen like this to all of my patients.
No one has the expectation that you should listen empathetically to all of your patients or coworkers all of the time. If you are new to the practice of listening with empathy, make it a goal to apply it with one person today.
Reflect on your experience and rejuvenate yourself for the next time you offer empathy
As you reflect on a conversation in which you listened with empathy, begin to think about how you are feeling. Is there anything you are grateful for in your life or this specific interaction? Anything you would like to do differently next time? Offer yourself a chance to be heard and understood for your own experiences.
You can listen to yourself with empathy using the same steps outlined here. For emotionally charged situations, writing narratives about your experience can be helpful. Consider asking a supportive person to listen to you, and if you want, request that they listen without offering advice or solutions to problems. Often, it can be helpful to seek trusted colleagues and mentors with whom you can share some of the emotional impact of patient care. There are venues in which you can safely share these emotions as well:
Empathy prepares another person to receive what you have to say more effectively; it may also encourage them to cooperate with you more fully.
Feelings are signals that point to what's important to the speaker.
During empathetic listening, keep focused on the individual's personal values or needs, rather than the specific strategy used to meet that need. This helps you refrain from becoming judgmental or getting pulled into a conflict.
Listening to others with empathy is a learnable skill that can foster trust in the physician-patient relationship, increase collaboration among co-workers and enhance personal well-being. Focusing on a speaker's underlying feelings and needs demonstrates that you are committed to understanding their experience, and your choice of language and other non-verbal responses is key to drawing out their feelings and values. In a clinical setting, patients are more likely to hear you and be open to your counsel if they first have sensed your empathy.
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- Street RL, Makoul G, Neeraj A, Epstein RM. How does communication heal? Pathways linking clinician-patient communication to health outcomes. Patient Educ Counsel. 2009; 74(3):295-301.
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- A Framework for Practicing and Teaching Compassionate, Relationship-Centered Care. http://medicine.tufts.edu/~/media/TUSM/MD/PDFs/Education/OEA/Faculty%20Development/Clinical%20TeachingFramework%20for%20Practicing%20%20Teaching%20Compassionate%20CareLown.pdf. Accessed May 20, 2016.
STEPS in practice
How’s it working in Houston, TX?
Robert Janda* is a 73-year-old man who has chronic congestive heart failure. His wife, Naomi, is a retired nurse who has been helping to manage his care at home. His doctors include Dr. Antonelli, a general internist, and Dr. Salzwedel, a cardiologist. Dr. Salzwedel has been Robert's cardiologist for about two years since he fired his previous cardiologist. During the past couple of years, the patient has had several exacerbations of his disease. His wife has emailed the cardiologist and internist about her dissatisfaction with the medical care her husband has received. Dr. Antonelli received the following email from the patient's wife:
“I want to tell you that I think Robert's medical care off hours is lousy. Unless I reach Dr. Salzwedel, the cardiologists on call don't take the job seriously. Once when I called, I talked to a doctor who didn't even seem like he had graduated from medical school. Is your night call any better? I haven't tried it but I doubt it. I can't take him to the emergency department because it's actually dangerous. If it hadn't been for me, he would have died on two occasions. What can I do about it?”
This email was sent through a non-secure email, despite requests to communicate through the electronic patient portal. It is representative of other emails sent by Naomi over the past few years.
Dr. Antonelli asked his staff to call the patient to request that he and his wife come into the clinic to discuss the issue. They agreed. Before the appointment, Dr. Antonelli spent a few minutes thinking about what he would like to say to Naomi. He made a decision to listen with empathy at the beginning of the visit. He stuck a Post-it note to the chart to remind himself of his intentions.
Dr. Antonelli met the patient and his wife in the room and after a friendly greeting, said, “I believe our goal for our visit today is to find out how to provide you with more support. I want to make sure I understand the situation, and what your needs are, so we can figure out how we can best support you.” Then he listened silently.
Robert started, saying, “I think that this is honestly more my wife's concern, rather than mine. But it has been a pretty bad experience, the couple times I've been sick. I was pretty upset about waiting so long in the emergency room.”
Dr. Antonelli nodded, “Mmm, hmmm.” Robert looked at his wife.
Naomi talked for five to six minutes about her husband's care and her dissatisfaction with it. She described several evenings when she needed to talk to a doctor and didn't get the response she wanted. She spoke of the stress and pressure that put on her. She used language that placed the blame for her stress on the doctors and the medical system. She also spoke of a time that she went to the emergency room for her own care and waited for several hours. She said, “The health care system just doesn't support us. We just have to fend for ourselves when it's not business hours.”
During these five to six minutes, Dr. Antonelli didn't speak but did convey that he was listening by using body language that showed his attention and concern. At a lull, he said, “It sounds like in the evenings and on weekends you haven't gotten the care that you've needed. That's put you in the really uncomfortable position of having to be his wife and his medical provider at the same time. Am I understanding that right?”
Naomi nodded her head yes and then continued to speak for a few moments about the dissatisfaction. There was less urgency and emotion in her speech.
Dr. Antonelli decided to speak: “Let me talk to you about access to care. I understand that we let people down all the time; they can't get an answer to a phone call when they want. May I tell you about some of the things that I've done to help my patients get better access to care?” When Naomi and Robert nodded yes, he continued by explaining about his practice's on-call system and the electronic patient portal. He explained the role he could play as primary care physician, as a first contact for any questions they might have. He closed by saying, “I hear you loud and clear. You want to be able to trust that you will be able to reach a doctor when you need one.”
Robert and Naomi expressed some surprise, saying that they hadn't understood they could call their primary care doctor about a cardiac issue. Naomi said that would help a lot.
Dr. Antonelli went on, “I feel like I know what your needs are and it sounds like you understand better how I can help meet those needs. I'd like to tell you what my needs are now.” Robert and Naomi nodded. “It's a hospital policy that we not use email for any patient communication. I'd like for you to avoid using email and instead use the electronic patient portal. I'd like to be able to give you my cell phone number, but I want to make my practice sustainable and I want to be fair to my family. I just can't have patients calling my cell phone directly.”
Both the patient and his wife agreed and Naomi concluded by saying, “I feel better about what you're going to be able to do to help us in the evenings and on weekends.”
After meeting with Naomi and Robert, Dr. Antonelli reflected on the conversation: “The Post-it note was an effective tool to remind me of what I had decided to do, which was listen with empathy. I settled on that approach because I believed it would be good for them and ultimately good for me. After this experience, I feel very good about how I handled it and have a lot less stress as a result.”* Names, locations and other identifying details have been changed.
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Listening with empathy module
Download a printable PDF version of this module.
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Listening with empathy PowerPoint
Use this PowerPoint presentation to review this module with your team.
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This document provides common forms of communication that can hinder empathy.
MS WORD, 49 KBPreview
Identifying underlying needs
This document assists readers in gaining a deeper understanding of the underlying needs we all have but may not openly or knowingly express.
MS WORD, 521 KBPreview
Identifying underlying feelings
This document helps readers gain a deeper understanding of the underlying feelings a speaker may be expressing.
MS WORD, 55 KBPreview
Worksheet for self-reflection
This form assists the listener in setting the stage for listening with empathy and acknowledging his or her own state of mind.
MS WORD, 48 KBPreview
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