Psychiatry: The Key Skill of Listening

Listening: The Key Skill in Psychiatry

• Freud promoted listening to an expert level in psychiatric examination.
• Past psychiatric practices were superficial, leaving layers of meaning unexplored.
• Listening is key in psychiatric examination, even with growing biomedical knowledge
• Early physicians emphasized bedside diagnosis, laboratory and imaging tests were secondary.
• Increased technology has changed how physicians diagnose illnesses and conditions.
• Electronic medical records have altered the doctor-patient dynamic, sometimes creating a disconnect.
• Despite potential future reliance on imaging, psychiatry still necessitates skilled listening.
• Psychiatry should not replace listening with focus only on the brain.
• Psychiatrists need to relate to those who can't connect with anyone, necessitating listening expertise.
• Psychiatric training programs emphasize teaching listening skills.
• The need for listening has led to the creation of resources that offer listening training.
• Psychiatric interviewing and listening continue to be the subject of published books.
• This kind of listening has been called "listening with the third ear".
• Terms like interpretive stance, interpersonal sensitivity, and narrative perspective have been used to describe it.
• Psychiatrists learn and struggle with how to define and teach it.
• Biological psychiatrists listen for subtle symptomatic expressions.
• Cognitive-behavioral psychiatrists listen for distortions or irrational assumptions

Clinical Vignette 1

• A 28-year-old man with schizophrenia and OCD improved in the hospital due to medication changes.
• His condition worsened upon returning home.
• Partial hospitalization was recommended, but the patient hesitated due to feeling like a burden.
• The psychiatrist sensed the patient's desire to maintain autonomy when dealing with his illness.
• Respecting the need and educating him on bearing schizophrenia helped the patient accept care.

Integrating Sensitivity & Therapeutic Listening

• Therapeutic listening involves sensitivity to the storyteller and combining the focus of illness and patient
• The listener uncovers what is wrong then diagnosis it to provide a label.
• The listener discovers who the patient is through inquiry and collaboration.
• Therapeutic listening necessitates time, focus, and imagination along with an attitude that sees patients as the hero of their life story.
• Addressing depression involves guiding patients to discuss their story of loss, beyond symptom description.
• Hearing the story helps psychiatrists experience from the patient's perspective, easing the burden of pain and providing both healing and diagnosis.
• The best listeners hear both the patient and condition, viewing each meeting as therapeutic

Primary Tools for Listening

• Understanding requires a shared language between speaker and listener.
• Common language is the predominant factor in organizing humans.
• It allows active listening and engaged story-telling.
• The Sapir-Whorf hypothesis suggests that language limits what we can think.
• Evolutionary thinking sees language as key in maintaining social organization.
• Normal everyday speech is tied to relationships.

Clinical Vignette 2

• A man with "functional" chest pain was referred to a psychiatric consultant.
• Routine tests were negative, despite his description of crushing chest pain.
• The psychiatrist recommended tests that confirmed myocardial infarction.
• The misunderstanding stemmed from connotative differences in how "crushing" was understood.

Clinical Vignette 3

• A psychiatrist had been treating a 35-year-old man with a narcissistic personality and dysthymic disorder for 2 years.
• The brutality and deprivation of the patient's childhood made his remarkable psychological strength puzzling
• The patient would describe himself as "little fella" as a boy, an interesting choice of words.
• Others might designate an age or "When I was young"
• This revealed the secret identification with TV show characters who offered a model of positive masculinity.
• Making his identification fully conscious was transformative.

Patients as Storytellers

• Patients are storytellers, they share their important relationships.
• People hope to be heard and understood.
• Active listening is a key skill, underpinning diagnosis, alliance-building, and communication.
• Even with shared language, meanings differ via gender, age, culture, religion, class (SES), race and nationality.
• Differences are important in analogies, similes, and metaphors.
• Figures of speech reveal the inner world, but complicate usage.
• Subtleties of language is key in psychodynamic assessment, failure to hear distinctions can affect simple medical diagnosis
• Special meanings of words become central in psychotherapy.

How to Hear Words in This Way

• Clinicians need particular but challenging skills and attitudes.
• Students are often in awe of seasoned psychiatrists.
• Listening is key, which requires hard work, thought, supervision, and exposure to patients.
• Psychiatrists must listen symptomatically and narratively.
• Symptomatic listening involves traditional medical history-taking.
• Narrative listening understands lived experiences.
• Internalized views are factored, which reflect individual background, culture, national identity, and family system.
• It is not always clear when the complex meanings of words is important, except in psychiatry

Clinical Vignette 4

• A psychiatrist saw a 46-year-old man referred from a drug study.
• He had major depression and dysthymic disorder since a business failure 2 years before.
• Primary symptoms included increased sleep, decreased mood, libido, energy, and interests.
• Despite antidepressant treatment, the patient showed little sign of improvement.
• During therapy, the patient's wife reported his snoring over the vacuum cleaner.
• The psychiatrist then asked questions and polysomnography to identify the underlying sleep apnea which improved the depression after therapy

Factors Enabling Psychiatrist

• The psychiatrist had to have many symptoms and syndromes available.
• The psychiatrist was curious to seek out missing information.
• The psychiatrist had an open mind, considering zebras instead of only horses.
• The psychiatrist heard the patient's story in flexible ways
• A match could be noticed between the story and a symptom

Phenomenon of a Detail Leaping Out

• A detail powerfully influences the treatment process
• Requires cognitive template (symptoms and syndromes)
• This necessitates looking/questioning and flexible data processing
• Clinicians start to hear multiple meanings automatically with experience

Listening vs. Hearing

• Listening involves attending to tone, metaphor, and imagery, not just understanding the speaker's words.
• Changes in movement is important and what has/hasn't been said
• These patterns can reveal idiosyncratic meanings.
• Darwin observed the biogrammar shared by humans
• Emotions shown through actions can be recognized
• Researchers have identified neurobiological substrates for emotions
• Mirror neurons also help understand neurobiology of listening by firing.

Clinical Vignette 5

• A Hispanic construction worker reported a little pain when walking.
• His tone/demeanor conveyed deeper suffering
• Physical exam revealed a lytic lesion detected by radiograph, ultimately metastatic renal cell carcinoma.
• Tone/appearance important, overcoming cultural barriers.
• Clinicians must overcome barriers for effective listening

Potential Blocks in Listening

• Psychiatrists influence interactions per their own experiences.
• Similarity in characteristics helps listeners tune in.
• Differences with patients lead to blocks in listening with race, sex,SES, or nationality.
• Cultural factors can influence shared meaning assumptions
• The unconscious failing to react is a counter transference issue
• Interference may occur in the emergency room setting
• Patients may need to feel the need to be in or out of control

Clinical Vignette 6

• A 45-year-old attorney's family turmoil included issues with his spouse.
• When asked what he valued about his family, he omitted intimacy and friendship.
• Gender likely fostered this omission
• Understanding cultural barriers in metaphors can be important

Clinical Vignette 7

• Female patient told a male psych she was excited about the project her male supervisor let her work on.
• Said that she had been, strutting her stuff like a rooster.
• Patient expressed that she strives for male recognition/power and envies male supervisor.
• Patient felt like a prostitute who is used by supervisor.
• Point was the patient felt used, not envious of male position.

Clinical Vignette 8

• Black woman told therapist (same race + language) husband a snake or no good, treacherous.
• Therapist gave cautious advice regarding the divorce based on this.
• Chinese woman, assimilated to Western culture, told a West psychiatrist that husband was like a dragon.
• Therapist (no check patient meaning): husband was assumed to have malicious intent, oppression
• Patient: dragon was fierce, watchful protector at gates of castle (Chinese folklore)

Dissimilarities in Patient Listening

• Dissimilarities between patient and psychiatrist may include race, sex, culture, religion or dialect
• This can lead to incorrect shared meanings from superficial Similarities
• It can also create a Counter transference that causes the psychiatrist to inappropriately react to content

Regional Variations

• Subtle regional variants/Attitudes may block listening - need for control or thinking bad day
• Filters may be blocks or magnifiers (elements in patient's story resonates or not)
• Ineffective listening is a form insensitivity
• They can be empathy or sensitivity if assisting understanding
• Long repeated theme can signal underlying meaning to psychiatrist
• Communication may be sent various times before psych realizes/Understands it

Managed Care

• Healthcare administration alters ability to be transforming listeners with visit and time Limitations
• Tedious forms can be a block to patient/therapist connection
• Third-party payers may want/require a Billable diagnosis code
• Emphasis may be placed on symptom relief rather than on solving problem
• A crisis intervention model of the medical model may be needed to treat, but
• Checklists and inventories may be needed

Clinical Vignette 9

• Psychiatrist from South called patient's mother "your mama," meaning respect
• Patient (from Northeast, Irish) angered- "mama" derisive (working class Italian)
• Switched term: "Mother" (coolness) - led to indignation/outrage
• With emphasis on these symptoms, how far can this line of treatment be taken from
• Is can have potential conflicts are seen (external and internal forces)

Attitudes That Enable

• First step being important for listening for the inner self diagnostic
• Advances can help with the diagnosis for this and others have had important for the
• For any of its basic, there are people who may even have interest and with decreased interest/pleasure
• These people come off as non engaging in the same way when with those having their own way with some time,

The Psychiatrist Must

• Psychiatrists must first try to be understanding the inner feeling
• To get to something other than a purely logical view
• To get to there and all other aspects, there needs to
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Clinical Vignette 18

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Clinical Vignette 19

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Clinical Vignette 20

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