By the end of this unit, participants will be able to:

• Describe how the PSS's attitudes, feelings, and values impact communication with clients.
• Identify at least three forms of verbal and non-verbal behavior.
• Describe the value of praise and encouragement when working with clients.
• Demonstrate the use of positive feedback during role play exercises.
• Paraphrase and summarize another person's feelings and concerns.
• Describe the difference between open-ended and close-ended questions.
• Describe the importance of good listening skills.
• Explain the importance of confidentiality, and identify occasions when confidentiality cannot be kept.
• Translate medical and technical terminology into simple language.
• Write instructions, information, etc. for a low literate population.
• Define transference and counter-transference and give examples of how it can impact on the client-visitor relationship.
• Demonstrate polite interactions with families.

2-1/2 days

A. Introduction
B. Perception and Values Clarification
C. Verbal and Non-Verbal Communication
D. Low Literacy
E. Interviewing and Listening Skills
F. Summary and Review

• Resource Mothers. (1993). Handbook. Sterling, VA: INMED.
• Survey of Attitudes and Beliefs (Training Aid #1).
• Seeing the Woman (Overhead Transparencies) (Training Aid #2).
• Importance of Feedback/Geometric Pattern (Training Aid #3).
• Female Reproductive Organs (Training Aid #4).
• Using Simple Words (Training Aid #5/Handout #3).
• Sample role plays for practicing skill areas covered in this unit (Training Aid #6).
• Five Steps to Behavior Change (Handout#1).
• Values Clarification Sheet (Handout #2).
• Using Simple Words (Handout #3).
• Making Sure Information is Clear (Handout #4).
• Tips on working with Low Literate Families (Handout #4a).
• Writing for People Who are Low Literate (Handout #5).
• Communication (Handout #6).
• Types of Questions (Handout #7).
• Listening Skills Self-Assessment Form (Handout #8).
• Inappropriate Responses (Handout #9).
• Careful Listening and Learning: Some Guidelines for PSS (Handout #10).
• Overhead projector/transparencies.
• Role Play Feedback (Overhead #1).
• Post-Unit Evaluation.
• Post-Unit Test.
• Newsprint, markers, and tape or blackboard and chalk.
• Video Equipment: video camera, tripod, tape, VCR, and television.

• Become thoroughly familiar with the Resource Mothers Handbook, Chapter 2, "Building Rapport and Trust."
• Assign this chapter to trainees as background reading.
• Be prepared to model appropriate behavior and communication skills.
• Prepare any additional handouts, as needed.
• Test the overhead projector to make sure it is working properly. See if you need an extension cord, depending upon location of electrical outlets in training room. Have an extra light bulb on hand.
• Try out video equipment. Set up camera to videotape role plays.
• Create appropriate role plays, etc. to use in practice session.
• Choose a definition of transference and counter-transference.

1. Mini-lecture and discussion. Because this is a long and demanding skill-building session, start this unit on a positive note. A shared poem or a few words of inspiration can go a long way in encouraging the trainees as they prepare for this session. (Handout #1 is one example). Allow a few minutes for reflection.

2. Before you work with participants on all the exercises in this unit, you need to "set the stage" and provide a framework for the session.

Give the participants an overview of what to expect. The first sections (A-C) deal with perception and clarifying their own values. Sections (D-G) deal with verbal and nonverbal communication. And the final sections (H-O) focus on interviewing and listening skills and techniques. Then there will be time to put all these exercises together when practicing mock home visiting scenarios.

3. This unit should be worth the time participants devote to it. Let trainees know that, as they work together to improve communication and relationship-building skills, they will be working on techniques that will go far toward expanding their abilities to be empathetic and effective Parenting Support Specialists

1. Tape papers labeled "Agree" and "Disagree" to opposite ends of a wall of the room. Hand out "Survey of Beliefs and Attitudes" and have people complete them. Do not write name on form. Ask participants to be honest with themselves and mark the response that best represents their feeling or belief. Tell them there should be no talking among themselves or asking questions.

2. When completed, hand them in. Pass them back out to people so that people do not have their own paper. Then read a statement and have people move to where the respondent of their paper answered.

3. Read another statement and again ask participants to stand under the sign that best reflects the answer on the paper they have. Continue in this manner, having participants move around.

4. Process this exercise by asking questions such as:

• Did any of your responses surprise you? Which ones?
• How did people respond to different statements?
• How did you feel about other people's responses? Why?

Try to engage everyone in the discussion.

5. If participants are from the same background (race, age, religion, etc.) and if there are varying responses to the statements, encourage the group to discuss why this is so. How does ethnicity or culture affect attitudes and beliefs? How does acculturation — or the degree to which people from a minority culture become "mainstreamed" in the majority culture -- affect cultural beliefs?

6. Discuss how personal values or experiences might interfere with teaching. For example, if a PSS was abused as a child, how might that affect the way she teaches a client about discipline?

7. Summarize by saying something like: "Some of you are from similar backgrounds, yet have had some very different responses. People's different experiences lead them to different conclusions. We must first be aware of our own attitudes and beliefs, and then make sure we do not try to impose them on our clients. We must learn to respect others' values and beliefs. This is especially true if we hope to advise and support them." After the group exercise, it may be helpful to tally all responses. If some are overwhelmingly agree or disagree, or if individuals are extreme on certain responses, this may indicate a need to tailor the training in a different way.

1. Begin by asking trainees what the word "perception" means to them. Let participants discuss this word, as well as the verb form, "to perceive."

2. A possible response:

• Perception is how we understand what others show or say to us.

3. Show transparency of woman (Training Aid #2). Have trainees examine it carefully.

4. Then ask for volunteers to describe what they see. Possible responses might be:

• a young woman; an old lady

5. Probe for more information. For example, ask how old they think she is. Elicit information about the person's features, whether she's attractive, and what she's wearing.

6. Ask for a volunteer to explain how the illustration can be both a young and an old woman. Point out that people see and hear things in different ways. Explain that understanding differences in perception is the foundation of understanding communication and relationships. How we perceive others affects the way we communicate with them and relate to them.

7. Introduce the exercises that follow. These were designed to help participants clarify their own values. The exercises should help trainees understand how their perceptions and personal belief systems influence their behavior, which can in turn influence their clients. By first recognizing and understanding their own values, PSS may be able to avoid personal bias when helping, advising, and supporting their clients

1. Ask the group what is meant by "values". Responses may include:

• Values are those things we consider priorities, such as family, happiness, good health, etc. They are things we feel are important.

2. Distribute Handout #2, a Values Clarification Sheet, to each participant. Read the instructions with them. Then ask trainees to take five minutes to list their top six priorities. Ask them to not discuss their answers while completing the task because conversation might bias their response. Assure them that there will be ample time to discuss answers later.

3. After trainees have selected their most important values, go through the values, asking who chose the first one as their number one priority, who chose the second one, and so on. Ask a few people to explain why they chose value "x" or value "y" as their first priority.

Alternate: In lieu of the above procedure, ask for volunteers to read their lists of values important to them and then ask why they chose their first priority.

4. Be sure to process the exercise by reflecting on responses. If many trainees have similar first priorities, discuss possible reasons. Similarly, if you find that priorities are not shared, discuss why this might be so -- e.g., differences in upbringing, education, life experience, etc.

5. Ask what values the clients might have. Would some of these values be different from the trainees? So different that it might be hard to relate or to communicate with the client?

6. Summarize what has been learned together while doing these exercises on perception and values. Some points to make include the following:

• Everyone has different values.
• Sometimes values are so ingrained that we are not aware of them until we are confronted with a situation that challenges our values.
• By understanding our own perceptions and values, we are better able to appreciate and respect the various experiences that shape the perceptions and values of clients.
• When working with and/or counseling clients, it is important to keep people's differences in mind.
• It is important that clients make decisions based on their own values and situations

1. Begin these series of exercises on verbal and nonverbal communication by asking participants to give examples of different ways people communicate with each other. Have someone record this list on the board or on newsprint. Possible responses might include:

• touch
• voice
• body movements
• words
• facial expressions
• signing
• eye contact

2. Another aspect of nonverbal communication involves voice characteristics. It concerns how something is said, not what is said. An effective PSS needs to be very sensitive to the signals that clients may be giving her through their voices. At the same time she must be aware of how her voice can either add or detract from the interpersonal communication she has with clients.

• Mention the different characteristics or aspects of a person's voice:
• Pitch -- highness or lowness of vocal tones;
• Volume -- loudness or softness of the voice;
• Rate -- speed of the speech; and
• Quality -- sound of the voice.

3. What are some of the nonverbal things that people do when talking face-to-face with another person that show negative emotions or feelings? When discussing this question, suggest to trainees that they look to their own experience--perhaps how they were treated when waiting to see a doctor or when going to a Social Security or IRS office for help. Possible responses might include:

• Shuffling papers
• Refusing to make eye contact
• Looking at watch
• Moving about while other person's talking
• Looking bored, distracted

4. Have trainees discuss how these nonverbal behaviors made them feel. When working to build rapport and establish trust with their clients, let trainees talk about what they'd do differently.

1. Let each participant pick at least one folded piece of paper on which you have written an emotion or feeling. [Note: These emotions/feelings could include -- but should not be limited to -- the following: Anger, Sadness, Pain, Defensiveness, Pride, Fear, Happiness, Impatience, Approval, Disapproval.]

2. Give trainees a few minutes to think about the word(s) they picked. Advise them they will then take turns acting out the emotion or feeling. Then the others must guess what they are trying to convey. They may use facial expressions and body language, but no words or vocal expressions.

3. After several participants have done this, process the exercise by asking them if it was difficult to convey a feeling without words. Why or why not? For those who were guessing, ask if it was difficult to interpret emotions without a verbal explanation. Why or why not? Discuss various characteristics that make it easier or harder to convey or interpret emotions.

4. Have participants discuss what may happen if their clients don't feel comfortable with their PSS. Possible results could include:

• She may not be willing to open up
• She may not keep the next appointment
• She may be unwilling to enroll in the program or, if already in it, may drop out

5. Ask participants to share some of their ideas as to things the PSS can do to make sure that her interest and concern is made evident to the client. How will the PSS make the client feel comfortable? Ask for a volunteer to put these on newsprint, as you may want to come back to them during the training. Possible responses might include:

• Introduce yourself
• Shake hands
• Speak the client's language
• Don't interrupt
• Establish eye contact (if culturally appropriate)
• Say "Mmmm," "yes," or in some way show you are listening

Help the group define additional behaviors that are culturally appropriate for the clients with whom they will be working. Ask for any cultural differences or taboos that may make any of these behaviors inappropriate.

6. Emphasize some key points before moving on:

• Sometimes people feel uncomfortable expressing their emotions in words.
• It is important to look for (and hence recognize) nonverbal clues to clients' feelings. It is equally important to be aware of the feelings and emotions we may nonverbally communicate to our clients.
• Remind participants to keep these techniques in mind when making home visits. (They will also have an opportunity to practice them in role plays later on during the training.

GAME: 1. Explain that a person's tone of voice also communicates different emotions or feelings. Using the same list prepared for the previous exercise, assign trainees different emotions, or let them choose their own.

2. Then ask them each to say the same sentence, for example, "I will be with you in a few minutes," using the emotion/feeling. [Note: Any short sentence you like can be used for this exercise. Other examples: "So, you have a new boyfriend," "Please pass the salt."]

3. Let the others guess which emotion is being displayed and discuss how the feeling is shown. Ask which tone(s) of voice they would prefer to hear when they go somewhere for help and why. Whatever they agree upon, let them know that their clients are likely to react the same way, and for similar reasons.

4. Summarize results of game. Mention that, throughout the training, participants will be doing exercises to strengthen these verbal behaviors.

A few more key points to emphasize:

• Interpersonal or face-to-face communication takes many forms. PSS' need to be attuned to their clients' nonverbal as well as verbal cues.
• PSS' will use both verbal and nonverbal language to demonstrate caring and to build rapport and trust

1. Ask participants to brainstorm the meaning of encouragement. Have someone write responses on newsprint or chalkboard. Work their responses into a definition that goes something like this:

• Encouragement means the act of giving courage, confidence, and purpose; the action of inspiring with spirit or hope.

2. Discuss what this word means, more specifically, when working with a client. For example, to provide encouragement means letting the client know that the PSS believes the client can overcome her problems.

3. Discuss some ways the PSS can provide encouragement to her clients. Possible responses might be:

• Point out hopeful possibilities
• Tell client she is already helping herself by participating in the program
• Help client find ways to accomplish her goals.

4. Have participants brainstorm the meaning of praise. Again, have someone write down trainees' responses. Work these into a definition that goes something like this:

• Praise means to extol, commend, or applaud. Praise is positive feedback building on the client's strengths and accomplishments.

5. Again, as above, discuss what the word means in the context of making home visits. For example, to give praise means to build on good or positive behavior, and to comment on the good things a client has done. Encourage trainees to suggest ways they might do this. Possible responses might include:

• Compliment the client
• Look for something to admire rather than to criticize.

6. Discuss situations where there does not appear to be anything positive to acknowledge. If a client is doing something that is harmful to herself or her baby, this needs to be brought to her attention. Constructive criticism can be helpful.

7. Make up a few statements that a mother with a young baby might say early on to a PSS. Then ask participants to give an encouraging response. For example:

• "I'm too tired to stay in school."

Possible PSS response: "I know you must be tired, young babies can be a lot of work. You should be proud of yourself for going to school all these weeks."

• "Last time I had a baby, the first 3 months were terrible."

Possible PSS response: "That sounds tough. Let's work together on things that can make these months easier for you and your baby."

• "Getting well baby care is a waste of time."

Possible PSS response: "Tell me why you think well baby care is a waste of time." After the client has described what she means, the PSS can discuss with her pros and cons of well baby care.

8. Discuss what happened in step #7, when trainees responded to your "client" statements with encouragement and/or praise. Did they find it difficult to find something nice to say? How do they think it made the client feel? How do they think that particular home visit would proceed? Why?

9. Another way to praise is to comment on what a person is doing ie."I can see that you've been preparing your baby's formula."or "You have put away so many of the baby's things." This can give the person a chance to praise herself ie. "Yes I have" or you can say "You must be really proud of yourself" and give the person a chance to respond.

10. Be sure to remind trainees to refer to Chapter 2 of the Resource Mothers Handbook where they can read more about the importance and usefulness of giving praise and encouragement. Also emphasize some key points before moving on:

• Praise and encouragement are more effective in helping a client acknowledge and solve her problems than are scolding and condemning.
• To praise does not mean to patronize. It is easy to sound condescending, not only in the words chosen but in the tone of voice used. If you are aware of this possibility, you can guard against it. Ask for examples.
• Remember that clients need praise and encouragement but, above all, they need respect. Giving unmerited praise does not show respect. (Discuss this idea more fully, if warranted.)
• You will empower your clients by treating them like responsible adults, remembering that even responsible adults need praise and encouragement. (Let participants know that they will also discuss empowerment in the next unit. Here's a good opportunity to emphasize that so many of the tools, techniques, and skills they will be talking about and practicing during training are interrelated. Topic areas don't neatly divide themselves into discrete units.)
• Praise and encouragement are also important for building and reinforcing positive self-esteem.
• Modeling how to give praise and encouragement can help clients learn how to praise and encourage their children

1. Advise trainees that the exercise they are about to observe (and/or participate in) illustrates the importance of feedback in the communication process.

2. Ask for two pairs of volunteers from among the participants. [Note: If you are only working with a small number of PSS trainees, you can adapt this exercise so that staff or other "outsiders" are recruited to help you.]

3. Take the two pairs to another room away from the other participants. Tell both pairs that they will be given the same drawing. One person in the pair will be the "describer," the other one will be the "illustrator." The describer must not show the drawing to her partner.

Instructions for Pair A: One partner describes the drawing while the other one illustrates it, in front of the other trainees, on newsprint or the blackboard. The rules however, include:

• "Describer" is not allowed to repeat her instructions or give any nonverbal messages.
• "Illustrator" is not allowed to ask questions or use any kind of nonverbal communication.

Instructions for Pair B: Again one describes while the other one illustrates, but this time the rules are:

• "Describer" is allowed to repeat instructions in any way she wants. She can also use nonverbal communication techniques.
• "Illustrator" is encouraged to ask questions and may use nonverbal language.

4. Before bringing Pair A into the training room, show the other trainees a copy of the drawing, found in Training Aid #3. (Or, if your group is large, make and use a transparency to project the image for all to see).

5. Put the drawing out of sight and bring in Pair A. Give illustrator a marker and a clean piece of newsprint. Give the describer a copy of the drawing. Before describer starts giving instructions, tell the participants the rules that Pair A will follow. Give Pair A five minutes to complete their part of the exercise, and then tell them to stop.

6. Cover up the drawing completed by Pair A. Bring in Pair B. Repeat the same process as above, but this time the rules are different. Explain the new rules to the other trainees.

7. Compare the two drawings with the original. Extract observations from the trainees. Which drawing is closer to the original? (Pair B's should be). Why? Some possible reasons you will hear include:

• The describer in Pair B could repeat the instructions.
• The describer could use hand gestures and other nonverbal communication techniques.

8. Process this exercise by discussing the fact that effective communication needs constant feedback -- either verbal or nonverbal -- and repetition. PSS' will probably need to repeat important instructions and encourage clients to ask questions.

1. Ask for one volunteer to "play" your client. Pretend you are a PSS and explain some phenomena to your client using medical terminology. Take a few lines from a medical textbook or say something like the following: "About the time of ovulation, the fimbriae of the oviduct cover the site of ovulation. The cumulus cells appear to be important in the pick up and transport of the egg by the oviduct. Tubal cilia and peristalsis contribute to the transport of the egg down the fallopian tube." The client can look confused or intimidated.

Now, repeat your performance but, this time, use lay language and a picture (Training Aid #4). If you went with the example provided above, this time you might say: "The finger-like ends of the woman's fallopian tube help to take the egg down to the womb." This time the "client" should demonstrate understanding.

2. Show overhead of Training Aid #5 and give out Handouts #3, "Using Simple Words", showing some examples of how to use simple words instead of technical or "proper" terminology. Ask participants to try practicing using these words in the exercise.

For the exercise "Using Simple Words", have people take out a piece of paper. Read the "jargon-filled" statements and ask them to restate the phrase. Ask for volunteers to give their restatements.

3. Discuss other examples or any questions the participants have. Discuss the pros and cons of using slang or other "street language." When educating clients about family planning and infant care, how does one decide how graphic to get and what terminology to use? Elicit trainees' reactions and comments. Sometimes this can be quite controversial. Some lay home visitors speak to their clients using slang. Others say they would never use such language, and they feel they should act as a role model and not use slang or crude terms. Often, with very little instruction, terms that are not offensive but are "proper" can be used with clients without the need for medical jargon.

4. As a summary of these last few sections, distribute Making Sure Information is Clear (Handout #4). Go over it with participants and suggest they keep it for future reference. Be sure to ask for any questions before moving on.

Exercise: 1. Pass around sheets of paper that have one word or phrase at the top. As they are passed around ask each person to write down any expression or word they have ever heard for this. Papers are passed around until no one has anything to add. Words on the top of pages should include: bowel movement, condom, vagina, having sex, oral sex, boyfriend, sexually transmitted disease, Aids, extra marital affair, abortion, miscarriage, anus, anal sex, got pregnant, oral contraception, prostitute, homosexual, penis, husband, wife, rape, live-in partner, masturbation, baby girl genitals, baby boy genitals, navel, umbilical stump.

2. Handout completed pages at random.

3. Ask each person to read aloud the list in front of them. After the list is read, discuss with the group:

a. Which 2 to 3 words are the most commonly used. Put an asterisk next to these words or phrases.

b. Talk about whether there are age differences that make some words more or less appropriate to use with younger moms, older moms, grandmothers; discuss which words they would use with their clients. Repeat this with each page.

Using Handouts 4a and 5:

1. Explain what makes things easy or hard to read.

2. Explain how to print clear instructions without jargon.

3. Do a series of exercises:

• On the overhead, show examples of instructions that are written inappropriately.
• On their own paper, have each person write out how they would leave a note for a mother who is low literate.
• Go around the room and give individual comments as people complete this task.
• As a group, compare what they did; discuss what was difficult and why.
• On the overhead, show how you wrote notes that are appropriate for a low literate population; review how there is more that one right way to do this.

Interpersonal communication skills are key to the success of the PSS. This unit reminds the PSS of the skills they may need to practice to maximize the effectiveness of their communication. It should also get them thinking about how their own qualities, characteristics, and "caring nature" can be used to facilitate good face-to-face communication between themselves and their clients.

The following sections are designed to help trainees to develop interviewing and listening skills. Almost everyone is either a good talker or a good listener. It's much more unusual to find people who are good at both. Just being aware of one's behavior when someone else is talking is a good first step to making changes and working to improve one's communication skills.

1. Mini-lecture and discussion. Begin by summarizing the above rationale so participants don't lose sight of the focus of this unit. Assure them that, although you seem to be rapidly covering many topics, they can review the concepts in the Resource Mothers Handbook, and will have an opportunity to practice all the characteristics and skills that make for good interpersonal communication.

Before doing exercises designed to demonstrate how well they hear and understand what others tell them, explain and discuss three words: respect, genuineness and empathy (Handout #6). These characteristics are of critical importance to any PSS who needs to establish effective helping relationships with others.

2. Ask if anyone wants to comment on, or define, one of these words. They will probably all have something to say about respect and genuineness. You might summarize by writing a few definitions on newsprint:

• Respect is the ability to treat another person with dignity and with a feeling that he or she is worthy of being understood.
• Genuineness is the ability to convey sincerity in both words and actions.

3. Have participants share experiences when they showed either respect or genuineness, or both.

4. Discuss empathy last, as the word may be less familiar to the trainees and require more explanation. Empathy is the ability to put ourselves in "another person's shoes" in order to view an experience from that person's perspective. It is often confused with sympathy, but the two are not synonymous. Sympathy doesn't involve the degree of understanding that empathy does.

Being able to empathize is an important skill, and one that may not come naturally. Empathizing means being focused on the other person instead of being focused on ourselves. When we empathize, another person's experiences become our own, at least temporarily.

5. Discuss with trainees what empathizing entails. Here's a summary of the procedure.

• Listen to what the other person is saying. Concentrate on nonverbal behavior as well as on the words being spoken. Actively care about what has happened to the person.
• Try to recall or imagine how you, the listener, would feel under similar circumstances.
• Take what you know about the person and think about what the other person is feeling. (Be aware that it may be different from what you would feel in similar circumstances.)
• Say something that indicates your sensitivity to the other person's feelings.

6. Ask trainees what skills/attitudes are needed in order to be able to empathize. Possible responses may include:

• open-mindedness
• imagination
• a genuine desire to understand the other person

7. Summarize by giving trainees time to voice their thoughts and opinions about these skills/attitudes. Ask if anyone has experiences to share of times they were empathetic. How does it feel to be empathetic? In terms of helping clients, how would being empathetic vs. sympathetic affect the helping relationship?

1. Mini-lecture. Explain that one way to initiate a dialogue that may help a client deal with some problematic situation and make an appropriate decision is by accurately reflecting the client's feelings and concerns.

2. Model how this process of reflecting works. Two trainers (or you and an assistant) can demonstrate this reflection process by role playing. One reflection scenario might go like this:

"You feel angry because you waited in the prenatal clinic all morning to be seen and now you never want to go back."

"You feel upset and also angry because you asked your boyfriend to do something and he didn't do it, and now you want to make him understand the seriousness of his neglect."

3. Ask trainees for one example of something a client might say and then model for them what you, as a PSS, might say in response.

4. Then ask for volunteers in groups of two to role play the following situations--or others you have substituted. The PSS trainees should try to reflect, or summarize, what the client is feeling. You may want to write out the client statements on notecards ahead of time and have the group pick a card.

Possible Client Statements:

a. My life is going very well. We just had our first child and I want to wait awhile before I get pregnant again.
b. Just give me medicine to stop my baby's cough.
c. My mother-in-law is always nagging me. Nothing I do is right.
d. My husband beats me whenever I do something wrong. I don't like it but he is right to do it.
e. My baby was fine when you convinced me that she needed a vaccination. Now she has a fever and is fussy.

Possible Parenting Support Specialist responses (but trainees may come up with others):

a. You sound content with your situation and are ready to learn about family planning options.
b. You sound worried about your baby's illness.
c. It sounds like you are feeling frustrated and angry with your mother-in-law.
d. I'm hearing that you feel guilty for the things your husband says you do wrong.
e. You sound angry and worried because your baby is feverish.

5. Suggest that trainees think of summarizing and clarifying feelings as "door openers," ways of getting their clients to "open up" and think about options for future action. How else can the PSS encourage the client to talk in ways that will help them establish rapport? Ask participants to identify some other "door openers." Possible responses are:

• "Yes"
• "Uh huh"
• "Tell me more"
• "That sounds interesting"
• Touch, smile, nod, lean toward client
• "I understand what you're saying"

6. Activity. Ask trainees to take 5 minutes to write down a problem they might be having--with a relative, housing, a doctor ,etc..

7. Have them divide into pairs and take 5-minute turns talking about the problem they have written down. The listening partner should attempt to reflect or summarize, but not judge feelings expressed.

8. After completing the exercise, process it by discussing the following questions:

• Why is it important to summarize your client's feelings?
• Were you able to summarize your partner's feelings accurately?
• How does it feel?
• How did it feel to ask the questions?

9. Before moving on, emphasize that accurate reflection and acknowledgement of feelings are necessary and critical to the process of relationship-building. Before a client is ready and willing to trust the PSS enough to "open up" and ask for help and advice with problem situations, she must first believe that the PSS hears and understands her feelings and individual needs and concerns.

1. Go to the first PSS and ask the group how old they think she is. Each member of the group guesses and tells why. The person then tells the group her real age and the group briefly discusses the discrepancies.( The person might bring up how she is always perceived as younger or older and what she does about it ie. how she dresses, slang she uses, makeup, etc.). Do this with each member of the group.
2. Group the people by age including the facilitator/ trainer after everyone has divulged their true age . Age groups could be 20-29 years, 30-40 years, etc.
3. Pick one age group at a time. First, ask them to talk about their concerns about visiting mothers of different ages. Second, ask the other age groups to give more insights or hints on what this particular age group can do, or should not do, to win the confidence of women in their respective age groups.

1. Introduce the concept of transference and countertransference. Define the terms. Briefly touch on the possible consequences for the home visitor as well as the mother.
2. Remind trainees that the goal of their intervention is not psychotherapy. Discuss the limits of their interaction and the general differences between support and education, and psychotherapy.

1. Discussion. Distribute Handout #7, Types of Questions, to participants. Go over the four types of questions and list them on newsprint. Make sure everyone understands the different types of questions. (To simplify this exercise you may wish to use just "open-ended" and "close-ended" questions and adjust the exercise accordingly).
2. Ask participants to identify the types of questions the Parenting Support Specialists used in the previous role plays.
3. Practice using "open-ended" questions. Give participants several "close-ended" questions to change to "open-ended" questions. Have everyone share their attempts. Give participants a simple situation, ie. On the first visit to a new mom, she is visibly upset. How can you sensitively find out what is bothering her?. Have them ask "open-ended" questions to elicit information.
4. Conclude this session by pointing out that tone of voice is very important when asking questions in a non-threatening, non-judgmental way.

1. Activity. Hand each participant a copy of Handout #8, Listening Skills Self-Assessment. Go over the instructions with the group to make sure everyone understands its purpose. Read each statement aloud and allow time for trainees to reflect and mark the column that best describes themselves.
2. Let participants know that this is for their own personal benefit. It should point out to them how they can improve their listening skills. They can keep the sheet for future reference. Responses that include "Almost Always", "Usually" or "Sometimes" indicate poor listening skills.

1. Mini- lecture and discussion. Explain that when asking questions, it is important to listen to the answers. That sounds obvious, but many people don't do it. We're so busy thinking about what we want to say next that, although we hear, we aren't really listening.

2. Ask trainees to break into groups of three. Ask them to select a topic to discuss -- preferably something that would encourage differences of opinion. Pick topics from the exercise on attitudes and beliefs (Training Aid #1) that showed disagreement or use other topics of varying levels of controversy, such as dieting, toilet training and abortion. Note: After the topic of greatest controversy, discuss and reinforce the idea that we all have our own opinions and must be able to be non-judgmental if a client does not share our viewpoint.

3. Explain the rules for this exercise: One person begins the conversation, talks for a minute (or less) and then stops. The second person must summarize what the other said in a non-judgmental fashion before continuing and giving her own viewpoint. Then the first person repeats the process, summarizing what the second person said (again, non-judgmentally) and then adding her thoughts. The third person will serve as observer and make sure the rules are followed. (If you don't have enough trainees, you can bring in other staff or volunteers to participate in this exercise.)

4. Demonstrate how to do this exercise with another trainer or with a staff colleague or volunteer. You can use the following example or, better yet, make up one of your own.

Person A: I think hot pepper is bad because it is harmful to the digestive tract.

Person B: You said that you think hot pepper is harmful to the digestive tract. I find that it helps cleanse the system.

Person A: You think hot pepper helps cleanse the system, but I think it causes diarrhea.

Person B: Etc.

5. Give each group five minutes for their discussion. The observer then gives her comments to the two discussants. Then ask them to change roles so that everyone has a chance to take part in a discussion (as well as observe).

6. Process the exercise by asking trainees what they thought of it. What happened? Was it difficult to follow the rules?

7. Ask trainees for their ideas as to skills and/or behaviors the PSS should exercise in order to be a good "active" listener. Have someone record the suggestions on newsprint. Possible responses might include:

• Concentrate on the client
• Be attentive
• Don't interrupt
• Summarize, reflect
• Give nonverbal feedback (like nodding, smiling, saying "Mmmmm," leaning forward
• Ask for clarification

8. Next discuss with trainees those listening responses that can create problems. Let them know that sometimes even the best communicators respond in ways that are bound to be a "turn off" to the speaker. Ask if anyone can think of examples of inappropriate responses. Use Handout #9, Inappropriate Responses.

a. Irrelevant response. It bears no relationship or relevance to what has been said. Thus, it ignores the "sender" entirely. Example:

Person A: My boyfriend won't let me visit my cousin in San...

Person B: Hey, Chuck starts a new job tomorrow.

b. Changing the subject. This response suggests acknowledgement of what the other person was saying but changes the subject. Example:

Person A: My boyfriend won't let me visit my cousin in San Francisco.

Person B: Well, boyfriends are like that. Hey, Chuck starts a new job tomorrow.

c. Incongruous response. This occurs when a nonverbal message appears to conflict with the verbal message. Example:

Person A: We really accomplished a lot by doing these exercises.

Person B: (Rolling her eyes and looking bored) Yes, I sure learned a lot.

d. Interrupting the speaker. Interruptions means that the listener breaks in before the other person has finished a statement. This can happen because: 1) she believes what she has to say is superior to what the other person is saying; 2) she believes she knows what the other person is going to say and she wants the other person to realize she already knows; 3) she is not paying careful attention; 4) she is excited by what the speaker is saying and wants to hurry the conversation along. Example:

Person A: I'm worried about the way my boyfriend...

Person B: I see... your boyfriend is really temperamental, but I don't think that's a big problem.

After going through these different kinds of inappropriate responses, ask participants to give examples of real conversations they have had where people responded in a similar fashion. How did it make them feel? Why? Similarly, if PSS' ignore a client's statement, what effect may it have on the client?

9. As you summarize this session, emphasize key points:

• Listening is a skill that requires constant practice.
• Summarizing the main points is good discipline for listening, as it helps confirm to the client that she is being understood. Often the PSS is able to point out issues or emotions of which a client may not be aware, particularly when a feeling is communicated nonverbally. This can provide the PSS with additional information which she and the client can then use when working together to assess needs, solve problems, and/or in some other way help the client take control of her own life.

10. Distribute Handout #10, Careful Listening and Learning: Guidelines for the PSS. Ask participants to look over this summary sheet on listening skills. Then ask for one volunteer to share the five main points with the group. Suggest that trainees keep these guidelines for future reference.

1. Discussion. Begin by engaging trainees in a discussion of keeping confidential all information they will hear on the job. Refer trainees to Chapter 2 of the Resource Mothers Handbook where the importance of confidentiality is addressed.

2. Ask trainees to think back to a time when they told someone something in confidence and that person did not maintain confidentiality. What happened as a result? How did they feel?

3. Ask trainees if they can think of times when the Parenting Support Specialist should not maintain confidentiality. What are they? Possible responses might include:

• When the PSS sees or hears something that makes her suspect that the client or her family's safety or well-being is in jeopardy.
• It is mandatory to report certain confidences, like evidence of child abuse.
• Problem situations in which they feel they need the input of their Supervisor, and perhaps, other professionals in order to help the client.

4. This is an appropriate time for you to invite the PSS' Supervisor to discuss with trainees examples of situations where the PSS should share pertinent information with a professional. Other topics the Supervisor might discuss that relate to this topic include:

• Any specific rules your program has established about ways of maintaining the confidentiality of people participating in your program.
• How the PSS should discuss the issue of confidentiality with clients during the first home visit.
• Your organization's position as to what a PSS should say regarding when she may disclose information to the Supervisor.
• Your organization's policy on assigning a friend or family member to a PSS.
• Protecting client records -- perhaps by never leaving them around the house or in an unlocked car.
• The rights of a client to ask to read anything the PSS has written about her. (Let trainees know that later in the training when we discuss documenting and assessing home visits, there will be more discussion of this and the importance of having PSS record only the facts, without judgements and guesses as to what's going on.)

5. Make sure trainees have an opportunity to ask questions so that they fully understand your program's policies regarding confidentiality. [Note: This may be a good time to share reporting requirements for suspected child abuse. Have handy a copy of our project's policy on handling this.]

1. Discussion. Ask trainees what the words "to observe" and "observation" mean to them.

2. Ask for a volunteer to close her eyes and describe any paintings or pictures on the walls of the room, whether or not there is a calendar and, if so, to describe it; the color of the walls; what the light fixtures look like; what the other participants are wearing, etc.

Pick up on one item she could not recall, for example, the content or color of any painting, and have the group discuss why they think this was not mentioned. Do any others admit to not remembering colors, fabrics, etc. in the room? Does everyone now know what the pictures look like? Why?

3. Discuss with trainees possible reasons for feeling that observation is such an important skill. Probe: What are some of the things a PSS can learn, from observation alone, during a home visit? Possible responses might include:

• All about the environment in which the client lives
• Safety and security issues
• Something about her possessions and how she spends her time and money, e.g., does she have furniture for the baby, TV, video, books and magazines?; what's in the refrigerator and on the kitchen shelves?; any children's creative playthings/toys (if she has older children)?; are furniture and appliances in working order?
• Insights into personal habits such as neatness and cleanliness.
• All about how family members interact; what's going on within the family.

4. Observation also gives a PSS insights into the client's lifestyle. Discuss how values and perceptions may influence a PSS observation skills.

1. Make sure trainees are familiar with the Resource Mothers Handbook, Chapter 2, Building Rapport and Trust. First discuss the meanings of the words rapport and trust (definitions are in the chapter) and why it's such an important challenge for all PSS' to build rapport and trust.

2. Discuss what it means to build a relationship with another person. Have trainees share their personal experiences. Is relationship-building easy or difficult or somewhere in between? Why? Is it something that happens quickly or does it take time? Again, encourage participants to draw from their own background and share experiences with the group. What allowed a relationship to grow? Was it trust, honesty, open communication, understanding of values, etc.?

3. Ask trainees what things they will do to build rapport with their clients and promote a working relationship based on trust.

They should respond with examples from previous sessions and from the chapter -- e.g., having a positive attitude, showing empathy, being a good listener, making oneself clearly understood, using praise and encouragement, etc.

What has happened within this group to build rapport and trust? Elicit many examples, write on newsprint, and discuss the process.

4. Modeling a situation is an excellent way to help trainees "see" how relationships can be built. Pick a role play scenario and demonstrate what a PSS might do and say. Have a co-trainer or a program staff person play the role of the client. For the demonstration: The mom is very overwhelmed and breaks down crying. After the demonstration, be sure to discuss how to handle crying, how to gauge the level of distress, how to build rapport and find out what problems exist.

Training Aid #6 provides one case history and many role play situations. [Note: These are only examples; you and/or other program staff are encouraged to make up your own or to use those that colleagues in other programs used and found effective.]

When modeling a home visit, you don't have to do everything perfectly. In fact, a good learning technique is to ask participants for their critique and feedback as to parts of a conversation that went well and parts that failed, followed by a discussion of why. Emphasize that we all learn by making mistakes.

Allow 15 minutes for each role play. Focus on building rapport on the first visit and being observant and non-judgmental.

5. Have each trainee pick a partner. Give each team a different scenario. As they act out the role plays in front of the group, they should trade off and take turns "playing" the PSS and the client.

6. Videotape all role plays and critique as a group. Use overhead #1 as a guide. If there are specific issues related to individual participants, review individually.

7. Repeat all role plays with different trainees as the Parenting Support Specialists but the same PSSs as the mothers.

1. Refer back to the objectives on the first page of this unit and rephrase them so they are questions. Do trainees feel the objectives have been met? Ask for a volunteer to answer each question. Encourage everyone to participate.
2. If your program plans to do a process evaluation at the end of each unit, distribute a copy of this form to each trainee at this time. A sample evaluation form is included in this unit.
3. Distribute Post-Unit Test.