The Primary Tools: Words, Analogies, Metaphors, Similes and Symbols
To listen and understand requires that the language used between the speaker and the hearer be shared – that the mean-ings of words and phrases are commonly held. Common language is the predominant factor in the social organization of humanity (Chomsky, 1972) and is probably the single most im-portant key to the establishment of an active listener/engaged sto-ryteller dyad which the helping alliance represents. Indeed, the Sapir–Whorf hypothesis suggests that what we are able to think is limited/determined by the language with which we are working (Carroll and Whorf, 1956; Sapir, 2000). Patients are storytellers who have the hope of being heard and understood (Edelson, 1993). Their hearers are physicians who expect to listen actively and to be with the patient in a new level of understanding. Because all human beings listen to so many different people every day, we tend to think of listening as an automatic ongoing process, yet this sort of active listening remains one of the central skills in clinical psychiatry. It underpins all other skills in diagnosis, alli-ance building and communication. In all medical examinations, the patient is telling a story only she or he has experienced. The physician must glean the salient information and then use it in appropriate ways. Inevitably, even when language is common, there are subtle differences in meanings, based upon differences in gender, age, culture, religion, socioeconomic class, race, re-gion of upbringing, nationality and original language, as well as the idiosyncrasies of individual history. These differences are particularly important to keep in mind in the use of analogies, similes and metaphors. Figures of speech, in which one thing is held representational of another by comparison, are very impor-tant windows to the inner world of the patient. Differences in meanings attached to these figures of speech can complicate their use. In psychodynamic assessment and psychotherapeutic treat-ment, the need to regard these subtleties of language becomes the self-conscious focus of the psychiatrist, yet failure to hear and heed such idiosyncratic distinctions can affect simple medical diagnosis as well.
In psychotherapy, the special meanings of words become the central focus of the treatment.