The Challenge of Effective and Empathic Listening
Associate Chief of Staff, Mental Health Service Line, Department of Veteran Affairs Medical Center, Washington,
DC; Professor of Psychiatry and Associate Chairman for the Clinical Neurosciences, Georgetown University
School of Medicine
Chief of Psychiatry, Mental Health Service Line, Department
of Veterans Affairs Medical Center, Washington, DC; Professor of Psychiatry, Georgetown University School of Medicine
First published in Psychiatry Weekly, Volume 3, Issue 1, on January 7, 2008
One of the most difficult skills that the psychiatrist in-training must acquire—and the experienced psychiatrist must practice and maintain—is the ability to listen effectively and empathically. Effective listening is especially difficult in the noisy and sometimes chaotic environment of the hospital. Moreover, effective listening requires us to temporarily suspend our own personal concerns, ignore internal distractions and focus attentively on another human being, a task that is far from easy.
The difficulty of listening can be exacerbated if we are anxious, which is not an uncommon occurrence among residents. Residents in-training are anxious about not getting the correct information, uncertain about what to listen for, and confused about the meaning of what they hear. Further, the resident in-training is “listening” in order to become a “clinician-investigator;” he or she is listening in order to learn how to generate diagnostic hypotheses, collect data in order to accept or refute some of these hypotheses, and develop a plan of treatment. The resident is not a novelist or transcriptionist and will never be able to record the content of an interview with the fidelity of a tape recorder; these are not the listening goals. Rather, the resident is listening in order to ascertain evidence of a thinking disturbance (eg, circumstantiality, perseveration, loss of goal-directedness and illogical thinking), obtain early developmental and family history (eg, did the patient repeat a grade or require special class placement for problems with attention, learning or conduct; is there a family history of major psychiatric and substance abuse disorder in closely-related biological relatives?), and assess whether the normal trajectory of social, educational and vocational growth and development was interrupted.
Not infrequently, the patient may have a different agenda during the diagnostic interview or therapeutic session, and may be uncertain about what information is important and necessary to the “clinician-investigator.” The inexperienced trainee may be unable to create an atmosphere that feels unrushed, especially when the reality that only a limited amount of time is allotted for history-taking, the performance of the mental status examination, and completion of necessary documentation. Also, the resident may be uncomfortable with directing an interview in order to obtain necessary information, feeling that to do so may appear as aggressive or uncaring to the patient.
Residents are sometimes confused by the meaning of “empathy” and the importance of maintaining an empathic stance vis-à-vis the patient. Empathy is a technical term not synonymous with liking the patient. Furthermore, an empathic psychiatrist is not necessarily one in whom intense feelings are elicited in response to the history or observable distress of the patient. Empathy implies that we recognize and appreciate the distress of another human being or, when visible distress is not present, the adverse consequences of the illness on the social and vocational functioning of the patient. An empathic stance enables us to be helpful and “want to be helpful,” even when a patient is not likeable. For example, although we may not like them, when we are required to evaluate patients with current and past histories of physical and sexual abuse towards others, our recognition that these behaviors are manifestations of psychiatric disorder that cause serious adverse social and vocational consequences for patients allows us to be helpful and, often, want to be helpful.
There are several practical and concrete suggestions, such as the following, that may improve the ability of trainees to listen effectively and empathically.
1. Minimize physical discomforts that may serve as distractions. Unfortunately, we are often asked to conduct evaluations at the least opportune times and in the worst settings, such as a busy and noisy hospital inpatient service.
2. One of the unfortunate consequences of the “medicalization” of psychiatry is the assumption of a hurried, rushed demeanor during the acquisition of the patient’s psychiatric history. If the interviewer just leans back and assumes the stance of someone ready to hear a patient’s story, even if inchoate and confused, the patient will feel that the interviewer is more “available” to hear empathically and caringly the patient’s story.
3. Very importantly, make a deliberate and conscious decision to suspend, or at least minimize, consideration of personal concerns during the interview.
4. Be vigilant and prepared to make empathic remarks, Thus, if the patient says something that we can infer was shameful, embarrassing or painful, no matter how rushed we may be for time, pause, take a deep breath and formulate a thoughtful, sincere and brief response, such as, “I imagine that this was a difficult thing to share,” or “I appreciate you sharing this with me.” A patient’s feelings of alienation may be ameliorated by the use of empathic “normalizing” comments such as, “patients with depression often feel and think the way you do.” However, it is important to not overly embellish or elaborate and, thereby, confuse your brief empathic interventions or run the risk of only seeming sincere.
5. When we feel that our ability to maintain an empathic stance has been ruptured or is in jeopardy of being ruptured, imagine how we would want a psychiatrist evaluating our loved ones. Imagine for no more than a few seconds that the patient is a loved one. Imitate the behaviors we would want a psychiatrist to display under these imagined circumstances.
6. When treating or evaluating an unlikeable patient, who may be unlikeable because of his or her insincerity, manipulativeness, or sexual or physical abusiveness, we may pause and consciously force ourselves to recognize the “pathetic” state of the patient and his or her situation. Not uncommonly, the authors evaluate patients that are seeking disability benefits and do not truly appreciate the fact that they have an illness, are in need of treatment and the consequences of refusing or not adhering to recommended treatment. At these times, it is helpful to reflect on how “sad” it is that someone would actually be consciously seeking classification as a psychiatrically disabled person or admission into an acute psychiatric inpatient bed section.
7. Finally, trainees should take full advantage of time spent with clinical supervisors to discuss obstacles to effective and empathic listening and concrete strategies for overcoming them.
Drs. Deutsch and Rosse report no affilitations with or financial interests in any organization that may pose a conflict of interest.