I joined a group co-teaching a resident seminar in psychotherapy a few weeks ago. It is an interesting exercise blending didactics and experience. The format is an hour of psychodynamic focused didactics followed by an hour-long discussion of a transcript by everyone in attendance including residents and 4 faculty. That is an interesting discussion of the technical aspects of therapy as well as individual differences in interpretation and intervention.
Today’s session was about listening and how listening in
therapy may be different from what people consider to be typically focused or
unfocused listening. There was some
discussion of how you listen to friends as opposed to strangers. There was a secondary discussion of the depth
of listening with a focus on unconscious determinants. It led me to reflect on a couple of things
during the session.
The first was focus.
Very early in my discussion with patients I was focused on what they
were saying. My focus was the same focus
I would have with friends or family even though none of my patients would ever
enter that sphere. People knew that I was serious and took them seriously. As I thought about the way I interacted with
people over the years – it was apparent that even though patients are
technically not friends within a very short period, I would know more about
them than I knew about most of my friends.
In some cases, I was more worried about them and spent more time
worrying about them than I ever worried about most of my friends. The
difference was in the relationship. With
friends there is a mutual affiliation and expectation of support. In the case of patients – the relationship is
for the benefit of the patient. Apart from payment, the gratification of doing good work, and the occasional thank you
- the therapist should expect nothing
back from the patient.
The focus in both diagnostic interviews and psychotherapy
was meditative to me. I felt extremely
comfortable in that setting. I looked
forward to seeing people. It was the
place in life where I felt the most comfortable. I was not particularly
interested in one problem compared with another – just hearing every unique
story. When you get to a certain point
in your career you are full of confidence.
You no longer have to worry about running into an issue that you don’t
know how to address. You know that most people will leave your office feeling
better than when they entered – even if it is an initial evaluation.
Focus in a psychiatric interview is multifaceted. It involves hearing both the content of what
is being said and whether it makes any sense.
Do all the elements hang together in a cohesive picture or not? If not, the job is to immediately clarify
what is happening. That always leads me
back to think of an Otto Kernberg seminar that I attended 30 years ago. Kernberg described the process of
confrontation as exactly that – an indirect inquiry that would facilitate
bringing these seemingly disparate elements together. An extreme example that I frequently use is
from acute care settings. In those
settings, my first task of the day was to interview people who had been
admitted on involuntary holds. They were
often very angry to be hospitalized and demanded to be released. Their
first words were typically: “I want you to discharge me. You have no right to hold me in this hospital
and I want to be discharged.” The
reality is that I had never seen the patient before. I had nothing to do with how they came into
the hospital or the fact that they were on an involuntary hold. Restating those
facts to the patient was the type of confrontation Kernberg discussed and it
most frequently led to a more productive reality-based conversation.
The focus for me always has the elements of attention, testing what is being said against my internal knowledge of reality and doing the same with any emotional content, and thinking about underlying theories for what I am seeing. At times I will explicitly ask the patient for their theories about what is happening to them to see if they have any and if they do whether they are plausible. It is generally important to try to figure out the meaning of certain patterns of thought and behavior including dreams fantasies, and other potential unconscious content.
There is also a focus of kindness toward the patient. The relationship is one of beneficence. It always reminds me of Jerry Wiener’s
comments about the essence of psychotherapy “Be kind and say something useful
to the patient.” When I bring that up – many therapists bristle at the apparent
oversimplification. Kindness does get
directly to the point that the therapeutic relationship is different from the
patient’s perspective in that they should experience the therapist as unique
relative to the common experiences in their life. Some therapists I have
encountered over the years have talked about “reality therapy” to mean that the
therapist should be reacting to what the patient does just like everybody
else. This misses one of the main
advantages of psychotherapy as an opportunity to examine what is really going
on in those other relationships and correct it if necessary.
I addition to attending to the primary problem in sessions
the therapist must also have a focus on the relationship and empathic responses
to communicate to the patient that he had an adequate understanding of the
mental problem that the patient is describing and what all the elements may
be. The relationship aspect may include
the stimulus value of the therapist and how that varies with age, sex, physical
appearance, and communication style. To
cite age as an example – it is common for early career psychiatrists just out
of residency to be greeted with: “You are too young to be a psychiatrist. I have never seen a psychiatrist as young as
you are”. Those statements come with varying degrees of enthusiasm and carry several
implications that can be explored. On
the other end of the spectrum I have not had anyone comment on my advanced age
directly – but have heard comments that some doctors are so old “they did not
know I was in the room.”
Transference and countertransference are obviously relevant
here but I want to stay with the focus in interviews and sessions. In the seminar today, a paleontology metaphor
was described about mining the different layers of the unconscious and how to
get there. That suggests a lot of heavy
lifting to me. I see it as a much more dynamic situation. After all – here I am extremely comfortable
and interested listening to people and editing their comments for plausibility,
cognitive and emotional content, defensive patterns, and their own theories
about what may be happening to them.
Together we are defining what brought them in to see me along with all
the relevant cultural, social, biological, and developmental factors. This is all unfolding in the context of a
specially defined relationship.
Throughout that session I am switching between listening mode and an
interventional mode that involves supportive, clarificatory, and interpretive
remarks. That switching needs to be
dynamic, context based, and is not the same for any two patients. There is also the practical or real
relationship including payment arrangements, appointment times, call
instructions, and emergency contact instructions.
There is a check that must happen during or between
sessions. Every therapist has to ask if they really understand what this
patient is saying and if the patient is being helped. That check can occur as early as the first
interview. In some cases, the therapist
may consider the patient’s problem to be outside of their field of expertise.
This can also happen after prolonged therapy where the benefit to the patient
is uncertain – but they want to continue the therapy.
The title of this blog post refers to a famous book called Listening
with the Third Ear by psychoanalyst Theodor Reik. I purchased the book in
1986 on the recommendation of one of my psychotherapy supervisors. The subtitle of the book says it all: “the
inner experience of the psychoanalyst.” Reik
was one of Freud’s first students. In
the chapter “The Third Ear” he describes attending to various cues of the
unconscious life of the patient as well as what may prevent the analyst from
perceiving them. He illustrates how the subjective reaction of the analyst to
the patient can be one of those clues.
Reflecting on this essay so far – the one dimension that
needs additional commentary is the non-linear nature of listening and the
interview process. It is easy to think of the process as a matrix dependent on
focused attention and a long sequence of questions. That is the format of a structured interview.
In many cases these interviews are algorithmic based on hierarchies and
inclusion and exclusion criteria. In a
clinical and psychotherapy setting the focus is more on all aspects of the
presenting problem. What the patient brings in to the session and the
continuity over multiple sessions is more of a priority. Reik describes a
patient who caused him to feel annoyed, two different patients walking by a
mirror outside his office and how they react to the mirror, and the way a
patient looked at him as well and what that meant for their unconscious
life.
In a subsequent chapter he goes on to describe how the
analyst must avoid selective attention to what they might want to hear and how
they must attend to everything. He
points out that Freud used the term gleichschweben that has the connotation of equal
distribution and revolving or circling (p. 157). He suggests the terms freely floating
and poised attention. He adds
Freud’s rationale for this type of attention as being two-fold. First, it avoids exhaustion since it is
impossible to attend to anything for an hour.
Secondly, it avoids biasing the interview or session toward a particular
aim or goal. The session after all is
directed at what the patient is deciding is relevant.
As I revisited my technique, this captures what I tend to do
in interviews and sessions. Since I read this book nearly 40 years ago – I cannot
claim to have invented it. I can add a
little to what Reik and Freud have to say especially in diagnostic
interviews. It is possible to incorporate
free-floating attention and transition to a more structured interview as
necessary. Most psychiatric practices these days require that psychiatrists
seen anywhere from 2 to 5 new patients per day.
Most of those patients will not be seen in either psychoanalysis or
psychodynamic psychotherapy. But most of those patients will benefit from the
listening techniques and interventions that can be attributed to the early
analysts. It is also possible to add a psychotherapy component to practically every
patient seen by a psychiatrist over time – even in relatively brief appointments.
George Dawson, MD
References:
Reik T. Listening
with the Third Ear. Farrar, Strauss, and Giroux. Toronto. 1948: 144-172.
Supplementary 1: Both
Drs. Otto Kernberg and Jerry Wiener in the above essay are psychoanalysts with
extensive teaching and publication experience. They are both medical
doctors. I left the qualifications out
for the sake of brevity. I heard Dr. Wiener’s remarks at one of the Aspen
Psychotherapy Conferences organized by Jerald Kay, MD.
Supplementary 2: According to Reik, The
metaphor listening with the third ear was borrowed from Nietzsche - Beyond Good and Evil, part VIII, p.246. A partial excerpt follows:
"What a torture are books written in German to a reader who has a THIRD ear! How indignantly he stands beside the slowly turning swamp of sounds without tune and rhythms without dance, which Germans call a "book"! And even the German who READS books! How lazily, how reluctantly, how badly he reads! How many Germans know, and consider it obligatory to know, that there is ART in every good sentence--art which must be divined, if the sentence is to be understood! If there is a misunderstanding about its TEMPO, for instance, the sentence itself is misunderstood!..."
