Verbal immediacy refers to the degree of separation created between the speaker and the object of the speaker’s communication as a result of the particular words used by the speaker. Inferences can be drawn about speakers’ feelings concerning the things they are communicating about, their communication, or the listeners.

WHY DO WE USE NONIMMEDIATE LANGUAGE?

Wiener and Mehrabian use the term nonimmediacy to refer to “any indication of separation, nonidentity, attenuation of directness, or change in intensity of interaction” among the communicator, the listener, the object of communication, or the communication itself. Nonimmediacy represents a speaker’s attempt to separate himself or herself from the object of the communication, from the listener, or from the communication. This separation can be construed to represent avoidance behavior motivated by a negative emotional state toward the object, listener, or communication. In other words, nonimmediacy represents an individual’s attempt to avoid identifying with unpleasant objects, persons, or topics. Nonimmediacy is a technique for distancing yourself from objects, events, persons, or topics that you’d rather avoid.

Often, feelings and emotions cannot be easily expressed in words. In fact, in most cultures restraints are imposed on communication regarding emotion, evaluation, or preference in general.² This is true particularly concerning the expression of negative feelings and emotions, evaluation, or preference.

NONIMMEDIACY AND THE HEALTH CARE PROVIDER

Von Friederichs-Fitzwater³ studied the use of verbally immediate language in conversations between health care providers and terminally ill patients. Von Friederichs-Fitzwater’s review of the literature revealed that health care providers are uncomfortable when communicating with dying patients.³ Furthermore, health care providers are uncomfortable discussing the topics of death and dying. That analysis showed that health care providers used far more nonimmediate language than the dying patients they cared for. This is evidence that communicating with dying patients represents an essential but difficult task for health care professionals. The study showed that dying patients did use some nonimmediate language in their communications with health care providers. Like health care providers, patients use nonimmediate language as a means of dealing with uncomfortable feelings. The researcher suggested that patients’ use of nonimmediate language may be connected to their fears of abandonment, pain, loss of independence, or fear of the unknown. This further suggests that patients and health care providers may choose to use more nonimmediate language in an effort to protect feelings of vulnerability, guilt, or resentment.

In that study, the differences between the verbal immediacy scores of physicians, nurses, and hospice workers were not significant. This suggests that hospice workers and nurses are as uncomfortable as physicians in communicating with dying patients. Perhaps all the health care providers included in the study used nonimmediacy or distancing behavior as a means of coping with such an emotionally taxing situation as death and dying.

IMPLICATIONS FOR PHARMACISTS

Sometimes, health care providers’ communication with patients is marked by a climate of distance and aloofness. Like other health care professionals, pharmacists may be using nonimmediate language when communicating with particular patients or when discussing difficult or unpleasant topics, issues, or events. The use of nonimmediate language may hamper the establishment of healthy, trusting therapeutic relationships with patients. In addition, the use of nonimmediate language may prove detrimental when trying to build rapport with patients.

Pharmacists should consider adopting a more immediate style of communication. They should use more immediate language to help build therapeutic relationships with patients. Pharmacists are in a unique position to be the health care providers who create environments where patients feel comfortable enough to communicate openly and honestly about their health-related concerns and issues. This niche is currently unfilled by other health care providers.

STEPS TO MORE IMMEDIATE LANGUAGE

Step 1a: Identify topics and issues that make you uncomfortable. Make a list of topics, issues, objects, and events that you find difficult to discuss or that make you uncomfortable. Here are some examples: death and dying, cancer, AIDS, sexual dysfunction. You should be more specific in your list.

Step 1b: Identify groups and persons with whom you feel uncomfortable. Make a list of groups and individuals who make you feel uncomfortable and with whom you find it difficult to communicate. Again, be more specific than the following examples: minority groups, mentally challenged people, physically challenged people, people suffering from specific diseases.

Step 2: Identify nonimmediate language when it is spoken. Wiener and Mehrabian devised six categories for identifying nonimmediate language. This chapter outlines three very basic categories for identifying nonimmediate language (symbol used, us versus them, and temporal). Remember that nonimmediate language works to separate the speaker from the listener or from the object or subject spoken about. Nonimmediacy serves as a means of exclusion rather than inclusion. Therefore, nonimmediate language hinders rapport building, because it excludes either the pharmacist or the patient. Exclusive communication reveals negative feelings and emotions and alludes to treatment that is not personal.

Symbol used. The “symbol used” category of nonimmediacy examines the symbols that take the place of the referent or word and the adjectives used to describe words. The more ambiguous or nonspecific the symbols used, the more nonimmediate the language.

Notice the words you use as symbols for people, places, objects, events, and so on. For example, when referring to Mrs. Henderson, you may select the symbol “my patient,” “a patient,” or “the person”—in decreasing degrees of immediacy. The final symbol, “the person,” represents the greatest degree of separation of the pharmacist from the patient. It expresses the most negative degree of emotion and feeling about Mrs. Henderson.

The symbols for people, objects, and events being communicated are often pronouns. The less specific the symbol, the more nonimmediate the communication. For example, if the pharmacist asks why the patient smokes, the patient might give the following responses:

I smoke because I enjoy it. (most immediate)
We smoke because we enjoy it.
One smokes because one enjoys it.
You (you meaning I) smoke because you enjoy it. (least immediate)

The patient’s increasing nonimmediacy is a means of separating himself from the subject of the communication. The symbols become less and less specific.

In another example, a pharmacist might respond, regarding a pharmacy convention that he or she attended:

I discussed the new legislation. (most immediate)
We discussed the new legislation.
Pharmacists discussed the new legislation.
There was a discussion of the new legislation. (least immediate)

Or, a pharmacist might say to a patient:

Remember, we said that you should come in for a checkup. (most immediate)
Remember, you said that you would come in for a checkup.
Remember, it was said that you should come in for a checkup. (least immediate)

When you substitute words such as “everyone” for “I,” you indicate nonimmediacy and nonidentity with the object of the communication. In such instances, the speaker works to exclude himself or herself from the object or subject of the communication. For example, a pharmacist says, “Mrs. Jones, I noticed that you’re 5 days late on your blood pressure medicine.” The patient replies:

I forget to take my medication sometimes. (most immediate) Everyone forgets to take their medications sometimes. (least immediate)

To assess the immediacy of your use of symbols in communication with patients, answer the question, Do I include or exclude myself when I communicate with patients? For example:

Am I more likely to refer to a patient as “my patient” or “the patient”?

When talking about a patient’s problem(s), am I more likely to refer to the patient’s problem as “my problem,” “our problem,” “your problem,” or “their problem”?

The terms “my” and “our” are considered more immediate than “your” or “their.” Use of the terms “my” and “our” includes, rather than excludes, the pharmacist. By using “my” or “our” in discussing a patient’s problem, the pharmacist takes responsibility and participates in the process with the patient. This can be a very effective in building rapport. The use of these terms indicates to the patient that he or she does not have to deal with the problem alone. Rather, the patient can infer that he or she has a partner.

On the other hand, use of the terms “your” and “their” excludes the pharmacist from the problem. Using “your problem” or “their problem” separates the pharmacist from the problem. Patients can infer that they must deal with the problem alone.

When discussing a patient’s options, are you more likely to say, “You and I should discuss your options” or “We should discuss your options”? “You and I” represents more nonimmediate language than “we.” “We” represents more inclusive communication than “you and I.” Using “you and I” signifies the pharmacist’s attempt to separate himself or herself from the patient.

Us versus them. The “us versus them” category of nonimmediacy describes the relationship between the communicator and the object of the communication in terms of space and time (here and now versus far away and long ago). Words denoting time and space clearly identify the degree of separation between the communicator and the object.

To assess your use of these indicators of nonimmediacy, ask yourself, Do I try to include my patients or exclude them in my communication endeavors? The first step in identifying nonimmediate language in this category is to notice when you use the term “that” as opposed to “this,” or “those” as opposed to “these.”

For example, the pharmacist says, “I don’t understand those people” or “when those people are in the same room.” “Those” is considered nonimmediate because it signifies separation between the speaker and the object of the communication. The use of the word “those” as opposed to “these” may be interpreted as signifying the speaker’s negative emotions, evaluations, or lack of personal feelings about “those” people.

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