Listening in Psychiatry
Listening in Psychiatry
Sound is the way to express life.
Most of us listen in one way or another. But listening can be taken for granted, even in psychiatry. Not long ago, my “way of” listening got my attention.
For one thing, despite wearing hearing aids, the hearing in my right ear was deteriorating. Fortunately, I found out it was due to accumulated wax blocking the sound. Then, in a trip to New York City, we went to the Rubin Museum of Art to see, and hear, the “The World in Sound” exhibit. It was devoted to examples and discussion of sound, especially from a Buddhist perspective. Among other reactions, it was said to be a sought after zone for “stressed out New Yorkers.”1
The Fourth of July, as always, has special fireworks, and among the most special are Macy’s, which were accompanied by inspirational music. When there are booming bangs instead, I cringe. They sound more like guns to me, or at least the environmental and hearing hazard of noise pollution, let alone the insult to hearing that caused my hearing loss in the first place. In everyday life, or in psychiatric practice, harsh words can also hurt, though we learn not to take them personally from patients.
Listening with the third ear
What is the role of listening in psychiatry? Is psychotherapy mainly a potential “talking cure,” a listening cure, or both? One of my most memorable lessons from residency training over 40 years ago was to listen with my “third ear.” At the time, psychodynamic psychotherapy was still dominant, and this thereby meant to listen for the underlying meaning of the words, not only the surface content.2 That could include transference implications and symbolic representations. In traditional psychoanalysis, the analyst would say few words, but listened intently. With the newly more popular cognitive-behavioral psychotherapy, surface words are what is paid more attention to, unless there is some block in the progress of treatment.
I learned to apply this method to psychopharmacology. Besides the physiological effects of a medication, what did the patient convey of its psychological meaning? Did the medication stir up dependency issues? Was there a positive placebo hope being conveyed?
No wonder, perhaps, that Peter Kramer named his groundbreaking and bestselling book, Listening to Prozac.3 He wrote this several years after Prozac became the first of the new wave of SSRIs. Though touted to relieve depression with fewer adverse effects than earlier antidepressants, Dr. Kramer listened more deeply to what patients were saying at the time they were prescribed Prozac, concluding that it helped alter, for the better, certain undesirable personality traits, such as irritability.
The same principle and parallel process can be applied to the relationship of clinicians to administrators. Just as patients need to be heard by their clinicians, and then responded to appropriately, clinicians need to be listened to by their administrators. Without listening to and empowering clinicians to do their desired healing, the stage is set for developing burnout, which will then feed back into not hearing their patients as well, with poorer clinical outcomes.
When listening is not practiced, there can be mutual silence for some period. Here, we should hear what the silence may mean: thoughtfulness, fear, irritability, or something else. This silence can be golden, or fool’s gold. It depends on the interpretative skill of the clinician to ascertain which it is.
Another complication of true listening is when patients come from different cultures with language limitations. Interpreters may be needed, most obviously with the hearing impaired when one does not know sign language.
In a crisis, listening for subtler messages is nearly impossible. That may need to come after the crisis is over.
I don’t know about you, but over time I came to pay quite a bit of attention to the tonality of the initial words spoken in any given session. That conveyed a patient’s mood that day and helped me tune in empathically right away.
Such tonality is part of non-verbal communication during sessions. Often, more information is contained in this kind of communication than in the actual words. The tone of closing words can even convey how well a session went.
It is essentially this variation in tonality that is missing from written online communication. That limitation should evoke caution about doing any substantial treatment online. Telepsychiatry, though, allows an approximation of face-to-face verbal tonality.
Can listening be therapeutic? Physician Rachel Naomi Reven thinks so. She calls it “generous listening,” which she feels she can teach young physicians.4 This kind of listening contains such components as curiosity and vulnerability, which can yield better questions that invite honesty, dignity, and revelation.
Generous listening is almost the opposite of the rapid-fire questioning encouraged by those who want us to spen less time with patients. Consequently, physicians are tempted to find out as quickly as possible about the patient’s symptoms and any adverse effects of medications.