In an earlier post this summer I wrote that the words ‘question’ and ‘quest’ derive from the Latin word ‘quarere,’ meaning to seek, search for, hunt, or ask. I argued for framing our job as clinicians as engaging with the patient on a mutual quest that leads to a better life for the patient, and we do this to a large degree through asking questions.

Through our questions, we can help our patients contemplate what they truly want from life, what actions will likely be needed for them to reach their goals, what kind of plan will most likely lead to success, and what challenges and obstacles will likely arise on their quest toward these goals and how these obstacles can be overcome. The obstacles that arise will undoubtedly include external factors, such as lack of emotional, practical, and financial support; and internal factors, such as lack of skills, maladaptive coping strategies, and emotional dysregulation.

With that as background, today I wish to explore the other half of communication, and that is listening. This is likely a three-part series. I begin by considering whether listening is an encompassing enough concept on its own or should be thought of as part of something larger.

It is natural to think about listening as a process of hearing and taking the effort to try to understand what the speaker meant through their utterances. This is true but incomplete. It is helpful to place “listening” into the broader concept of “perceiving” that is part of the activity of communication that occurs between two or more people. There are two points I wish to make today.

One, when speaking, the information our dialogue partner, in this case our patient, communicates to us contains a diverse array of elements that we can experience across our senses. The speech act contains a string of words that have meanings that inhere directly in the words. We strive to understand these meanings in the way we would if the words were texted to us or transcribed. But speech utterances are more than strings of words; they include interruptions, short pauses, long silences, inflections, tones, emotional coloring, levels of loudness and energy, signs of indecision as the person struggles to find the right words, and perhaps paraphasias as the person misuses a word or a series of words. So, listening itself is much more complex than just hearing the naked words.

And, of course, when a person speaks, they do more than talk. They express and they move. We can look for their facial expressions, their posture, the level of fidgetiness, and their gestures and gesticulations that can intensify or, conversely, counteract the message conveyed by their spoken word. Also, people dress and groom in certain ways and their style communicates much like, for example, which subculture they identify with (sometimes communicating down to which rocker or rapper they’re fans of), how well they’re able to hold it together, and the pragmatics of how appropriate their dress and grooming is to the situation and weather.

And, further, our remaining senses also come into play. We can smell the patient and glean much from that. We are unlikely to touch the patient and even less so to taste them. But we also have as a resource what is sometimes called the sixth sense, a sense base on interoceptive or bodily sensations. So, when we say ‘trust your gut,’ it literally means that our gut generates certain sensations we can become aware of. If, for example, you feel unsafe with a patient, it may be because a certain visceral feeling arises. If this feeling comes upon you, it is wise to be cautious, to have a route of egress, and to make use of safety features in your office, like an alarm button under the desk that you have previously installed.  Other examples of this sixth sense include the gut feelings of disbelief or disgust; the heart feelings of a certain lightness or heaviness that expresses happiness, sadness, grief, awe, love, pride, gratitude, and probably other emotions; and other more generalized sensations that include feelings of sexual attraction or arousal, or its opposite, a feeling of creepiness and wariness.

And further still, not only are we able to perceive what is communicated through our senses, we are able to consider the perceptions as a whole and in comparison to each other. For example, it may be particularly telling when a speaker states their great desire for (or fear about) a certain future event, yet their emotions appear flat, and their energy and engagement remains low. This discrepancy may be the most informative aspect of the entire communication. Initially, you the receiver may not know the source or reason for this discrepancy but should be mindful of its potential importance. As the listener, you can and should develop some hypotheses regarding the meaning of such discrepancies. You can hold these hypotheses lightly and remain attuned to perceiving further information from ongoing communications that can confirm or disconfirm your initial hypothesis and adjust as the dialogue unfolds.

This brings me to the second point about listening. Not only is what is communicated rich and complex, but so is making sense of what is received. Even with an ability to maintain broad perception across sensory modalities, a gap remains between what is communicated and what meanings it can have. The reason for this is not easy to dismiss and is due to the difference in lived experience between two individuals. You experience the world through your eyes, your history, and your future hopes and fears. So does the patient and each aspect of that lived experience, that can and often does differ from your own.

The challenge – a beautiful one, I think – is in listening deeply enough to approach experiencing the speaker’s experience, one that differs from your own, as understandable to you, as approximating one of your own. Listening ‘deeply enough’ entails continuously holding at bay the assumption that you understand what the patient means. Assume your point of view differs from theirs and that you don’t know how it differs. From this comes the realization of the ongoing need to listen and look for clues on the structure of the patient’s ‘frames of meaning.’ Don’t assume you know what the patient wants, what they fear, what they are afraid to lose, what failure looks like, what their preferred ways of moving through the world look like. I can go on, but this gives a taste of what I have in mind. In a future post, I’ll discuss formally the concept of hermeneutics and how it relates to trying to achieve understanding across the gap in two people’s lived experiences. On the other hand, I don’t want to make the meeting of this challenge of understanding seem too dire. I do believe a great deal of understanding can be achieved by two people engaged in genuine dialogue.

Write me if there is anything about listening, questioning, or patient interviewing in general you’d like me to write about, or you’d like to share with us.

Until next time,

Dr. Jack

LanguageBrief

“Love all, trust a few, do wrong to none.” ― William Shakespeare

“Our bodies have five senses: touch, smell, taste, sight, hearing. But not to be overlooked are the senses of our souls: intuition, peace, foresight, trust, empathy. The differences between people lie in their use of these senses.” ― C. JoyBell C.

“Nothing in life is to be feared, it is only to be understood. Now is the time to understand more, so that we may fear less.” ― Marie Curie Sklodowska 

“The best way to find out if you can trust somebody is to trust them.” ― Ernest Hemingway