THE ART OF LISTENING

LISTENING WITH THE THIRD EAR

W. L. Tonge, M.D., D.P.M. (Sheffield)Psychiatric patients tend to be unpopular, and I think there are

two reasons for this. In the first place a psychiatric patient oftenmakes complaints which are not very sensible. Take for example aneurotic patient who complains of physical symptoms; usually thepatient's friends and family are fairly well aware that these com-plaints have no organic basis, although occasionally a psychiatricpatient may have not only functional complaints but also complaintsarising out of physical disease. I have currently a patient whocomplains of a functional dyspepsia and also of vertigo of organicorigin. Surprisingly enough, he does not worry about his vertigo,which he accepts as any other patient would, but creates a greatsong and dance about his functional dyspepsia. One gets the feelingthat there is something phoney about these people. Why do theymake such a fuss about their symptoms when other people withmuch worse symptoms don't make so much fuss or realize that theyare not very serious?Another reason why psychiatric patients tend to be unpopular is

that they do not readily take advice. It may well be that all ourpatients tend to forget to take their tablets but the worst offendersfrom this point of view surely are psychiatric patients; they taketheir tablets for three days, and then because they have a headachethey blame it on the tablets; they stop the tablets and then come backsaying they feel worse, not having had any treatment for a fortnight.They complain bitterly about their symptoms; you arrange for themto go to an outpatient department and then they fail to keep theappointment. Are you to be blamed if you find yourself short ofpatience with them? Looking at this sort of situation, it seems tome that some sort of misunderstanding must have arisen between thepatient and his medical adviser, and it is my contention that thismisunderstanding arises out of the way that we listen to people.Normally we listen to the consciously-intended meaning of thespeaker; this is the way in which you are listening to me this after-noon; this is the way in which we listen to our friends and colleagues;this is the way in which we usually listen to our patients. This isthe way we read, and indeed if a word is missed out or is misspelt,or a speaker makes a mistake, we supply the correction in our own

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minds; we know what he meant to say.The art of psychiatric listening is not to listen only to the con-

sciously intended meaning, but to everything that the patient says-and for that matter to pay attention to everything he does aswell. Let me give you an example: recently, I was asked to see agirl of 24 years of age who had a history of neurotic complaintsfor about five or six years. At first she had a fear that she had acerebral tumour, in spite of the reassurances of her own doctor anda specialist. More recently, she had fears of mental illness; shefeared that she was going mad. She communicated these fears toher general practitioner, because in his letter he said to me: 'Iwonder if she is developing schizophrenia'. As I listened to thisgirl I wondered what it was she was seeking. Was she asking forspecialist reassurance; was she asking me, the specialist in psychiatry,to reassure her that she was not going mad, as a neurologist hadpreviously reassured her that she had not got a cerebral tumour; orwas she asking for something more, because it was fairly obviousthat she was not insane?As I pondered on this, I thought of three facts which were arising

out of the interview: in the first place I was wondering what shemeant by 'mad'; one ofthe difficulties of medical consultations is thatwords mean different things to our patients than they do to us, so Ibegan to explore this. Did it mean, for example, that she was goingto lose control of herself and go beserk and break windows and killpeople? No, it was not that. I wondered if madness meant beinglocked up: to many people the stigma of madness is that you areremoved from the community of ordinary people, you are put awayin a mental hospital, and you will not be let out and probably won'tbe visited. That, indeed, was her fear, that I would stigmatize heras being mentally abnormal and summon up a plain van with twomen who would cart her off to the mental hospital; and that wouldbe the last that anybody would see of her.The second fact that I noted in the history-she did not stress this

but it came out almost as an aside-was that her symptoms wereworse when she left home. She was not too bad in the morning,she got very bad whilst waiting for the bus to get to work, and thenshe settled down once she got ensconced in her working environment.Whenever she left home her symptoms always became worse forthat half hour as she journeyed away from home. The third factthat I noticed was that her symptoms had become worse since herfather died three years ago, since she and her widowed motherlived together. As I pondered over this, it struck me that perhapsthe real problem was that she had difficulty and perhaps a sickrelationship with her mother, or perhaps she felt she ought to get

THE ART OF LISTENING14

away from home but was frightened to leave. I said this to her, andI was pleased that she agreed that this was so. To confirm mysuspicion, she added that perhaps it was not irrelevant that whenshe was two years old she was put into hospital for 16 weeks.

I tell you this story because I do not think that psychiatric listeningconsists of being a good spongelike listener. I want to knock on thehead once and for all what has been known as 'grunt therapy': thecounsellor sits there completely silent while the client talks, onlyemitting grunts from time to time just to show that he has not fallenasleep. Isn't this very often the image that we have of psycho-therapy, of the listening of the psychiatrist? I am sure this is wrongand I want to present this sort of listening to you as an active per-ceiving function, a function of becoming aware of the emotionalproblems of the patient who is here and now in front of you.Professor Stengel once remarked to me that our patients come to ushoping not to tell us certain things, and I am sure this is a validobservation. It is also true to say that they hope when they come tous that we will understand what it is they have to talk about butdare not talk about; indeed, if we do not do this I think we let themdown. Emotional problems are always painful, and because theyare painful people prefer to leave them hidden.

Patients have three common ways of hiding their problems. Thefirst way of hiding them is to leave them until the end of the interview.How often have we noticed that a patient lets drop really importantremarks just as he is about to leave your room. This, of course, hasa bearing on our interview technique, for as the Balints say, 'If weask questions we will only get answers': we need a good deal morethan that from our patients if we are to understand them. If we letthe patient tell his story, then perhaps we will give him time finallyto get round to the point; this is always assuming that we are workingunder circumstances which will allow us to give time to people. Thesecond way in which people hide their problems is by stressing thesafe points in their story. They talk about the depression or the painor the headaches. Symptoms are always safe. Really importantkey observations, such as the fact that under certain circumstancestheir symptoms get worse, escape their attention because this leadsto the important dynamic factors. These are often never admittedby the patient, or at the most mentioned casually for the sake ofcompleteness. This girl didn't comment at all on the fact that shewas worse on going out; it was just a point of minor interest. Thethird way in which patients both express and hide their fears is bybringing them out indirectly, perhaps in a symbolic form. In thecase I quoted, the girl's fear of separation from her mother wasexpressed as a fear of insanity.

isTHE ART OF LISTENING

Psychiatric listening, therefore, is fundamentally a perceiving ofwhat has not yet been said: this is what I call 'listening with the thirdear'. I have two ears for listening to what people say to me, and Ihave a third ear for listening to what they missed out, what they hintat without quite making explicit, or what they skirt around. Theaim of the psychiatric interview is to make explicit the fears andproblems which lie behind the superficial texture of the interview.You may well feel that the type of understanding I am talking aboutis possible only if one has extensive knowledge of psychopathology,but this is not so. It occurred to me this morning that even a know-ledge of psychology may be an obstacle to understanding otherpeople if we do not listen to them. The girl I mentioned recentlyhad no boy friends, so presumably she had a sexual problem, andindeed many other problems as well. But what she came to see meabout were her difficulties in relationship with her mother, which sheexpressed by her fear of insanity. This was her current problem andthis was the problem to which she wanted me to listen and to makeexplicit.So this sort of listening is an uncovering of anxiety, an experience

which is painful for the patient but also reassuring. It is really likea physical examination: nobody likes to have their naked bodypoked at by a doctor; it is painful yet at the same time it is infinitelyreassuring to have our disability probed and examined, a diagnosismade and treatment instituted. If this is true of a gynaecologic4lexamination, it is even more true of the psychiatric examination.The patient must be sure that we are not going to laugh or to scoldhim when he reveals his disability, whether it be psychological orphysical.What I have been trying to describe to you this afternoon is not a

technical procedure but a relationship. Of course, there are skillsin this; such as to know when to talk, and more important, when tokeep silent, or to know how to choose the word which would deli-cately hint at what has not yet been talked about. These are skillswhich are important in the special type of relationship known aspsychotherapy. 'Relationship' is a jargon word today, a wordwhich is quickly getting devalued, so let me explain what I mean byit. I mean a situation in which a person will dare to reveal somethingintimate and upsetting about themselves to another person, and getfrom that other person an appropriate response which means thatthe speaker is understood. When this sort of dialogue occurs-andwe all know it does not happen very often-be it in the consultingroom or in one's own family, we can say that a relationship is takingplace; an attitude of general benevolence or well-wishing is no substi-tute. You will not get that sort of relationship with your patientunless you understand what the patient is trying to say and has not

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THE ART OF LISTENING 17got around to saying. If I understand I respond appropriately. IfI don't respond appropriately, the patient says 'You don't under-stand', and storms off in a rage. This is what psychiatric listeningis really about: it is the outward and visible signs of quite a specialand important way of getting on with people, an attitude in whichpeople can talk about what is hurtful and be sure that they are goingto be understood.

Finally, a word of warning. I have said that listening is an activeand perceiving process. How can you make sure that you perceivecorrectly, that you haven't misunderstood? The answer to that isquite simple: if your response has been appropriate you get a furtheranswer from the patient; there is a lessening of tension-eventemporarily, a slight clearing of a fog, a volunteering of information,or even an angry repudiation; yet you get something. The time whenyou must be really worried is when a well-trained patient assentspolitely to everything you have to say and nothing else happens;that is when your third ear needs syringing.

LISTENING FROM THE THEOLOGICALPOINT OF VIEW

Rt Rev E. R. Wickham (Lord Bishop of Middleton)I wish to speak about listening from a theological point of view

and I would think that this is not the easiest of tasks, simply becauseour professions in this conference are very different. Listening, oras it is more often put in the Bible, hearing, like the word seeing is adeeply loaded biblical and religious word: these words are used inthe Bible with such a depth of metaphor that to see is to speak aboutseeing things, and to hear is to talk about seeing things, in a markedlydifferent kind of way than when we use the words in a casual way.I think this deeply metaphorical understanding of listening is onethat is relevant to all human beings and all professions, and particu-larly to my own profession. To listen, to hear, is simply not a matterof mere aural capacity, a merely physiological matter: that has beenimplicitly recognized by all the speakers in this symposium. In thebiblical understanding of God (and a great debate is taking placeon this subject in the contemporary Church, so important that it has