Listening: The Key Skill in Psychiatry
It was Freud who raised the psychiatric technique of examination – listening – to a level of expertise unexplored in earlier eras. As Binswanger (1963) has said of the period prior to Freudian influ-ence: psychiatric “auscultation” and “percussion” of the patient was performed as if through the patient’s shirt with so much of his essence remaining covered or muffled that layers of meaning remained unpeeled away or unexamined.
This metaphor and parallel to the cardiac examination is one worth considering as we first ask if listening will remain as central a part of psychiatric examination as in the past. The explosion of biomedical knowledge has radically altered our evolving view and practice of the doctor–patient relationship. Physicians of an earlier generation were taught that the diagnosis is made at the bedside – that is, the history and physical exami-nation are paramount. Laboratory and imaging (radiological, in those days) examinations were seen as confirmatory exercises. However, as our technologies have blossomed, the bedside and/or consultation room examinations have evolved into the method whereby the physician determines what tests to run, and the tests are often viewed as making the diagnosis. A cardiologist colleague expresses the opinion that, given the growing availability of non-invasive tests – echocardiograms, for example – he is not sure this is a bad thing (Hillis, 2001, personal communication).
So can one imagine a time in the not-too-distant future when the psychiatrist’s task will be to identify that the patient is psychotic and then order some benign brain imaging study which will identify the patient’s exact disorder?
Perhaps so, but will that obviate the need for the psychiatrist’s special kind of listening? Indeed, there are those who claim that psychiatrists should no longer be considered experts in the doctor– patient relationship (where expertise is derived from their unique training in listening skills) but experts in the brain (Nestler, 1999, personal communication). As we come truly to understand the relationship between brain states and subtle cognitive, emotional, and interpersonal states, one could also ask if this is a distinction that really makes a difference. On the other hand, the psychiatrist will always be charged with finding a way to relate effectively to those who cannot effectively relate to themselves or to oth-ers. There is something in the treatment of individuals whose illnesses express themselves through disturbances of thinking, feeling, perceiving and behaving that will always demand special expertise in establishing a therapeutic relationship – and that is dependent on special expertise in listening.
Traditionally, this kind of listening has been called “listening with the third ear” (Reik, 1954). Other efforts to label this difficult-to-describe process have developed other terms: the interpretive stance, interpersonal sensitivity, the narrative perspective (McHugh and Slavney, 1986). All psychiatrists, regardless of theoretical stance, must learn this skill and struggle with how it is to be defined and taught. The biological or phenomenological psychiatrist listens for subtle expressions of symptomatology; the cognitive–behav-ioral psychiatrist listens for hidden distortions, irrational assump-tions, or global inferences; the psychodynamic psychiatrist listens for hints at unconscious conflicts; the behaviorist listens for covert patterns of anxiety and stimulus associations; the family systems psychiatrist listens for hidden family myths and structures.
This requires sensitivity to the storyteller, which integrates a patient orientation complementing a disease orientation. The listener’s intent is to uncover what is wrong and to put a label on it. At the same time, the listener is on a journey to discover who the patient is, employing tools of asking, looking, testing and clar-ifying. The patient is invited to collaborate as an active informer. Listening work takes time, concentration, imagination, a sense of humor, and an attitude that places the patient as the hero of his or her own life story. Key listening skills are listed in Table 1.1.
The enduring art of psychiatry involves guiding the de-pressed patient, for example, to tell his or her story of loss in addi-tion to having him or her name, describe, and quantify symptoms
of depression. The listener, in hearing the story, experiences the world and the patient from the patient’s point of view and helps carry the burden of loss, lightening and transforming the load. In hearing the sufferer, the depression itself is lifted and relieved. The listening is healing as well as diagnostic. If done well, the listener becomes a better disease diagnostician. The best listen-ers hear both the patient and the disease clearly, and regard every encounter as potentially therapeutic.