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COMMENTARY.

Listening Deeply in Clinical Practice

Fam Syst & Health 16:213-216, 1998

THE respectful response to something inspirational is, "I believe, Amen!" This brief commentary is in that spirit. "Just Listening: Narrative and Deep Illness," by Arthur Frank (1998), is life-affirming, not only affirming of the place of narrative in clinical practice. In the depersonalizing face of "bottom line" thinking, it is about being real, present to another human being, not just clinically, and about what happens when that attentiveness takes place. "Just Listening" is about what is at the heart of therapeutic "countertransference" (Balint, 1972; Bion, 1959; Boyer, 1993; Ogden, 1997; Stein, 1985; Stein & Apprey, 1990), that part of emotional intersubjectivity that takes place in and from the caregiver.

It is about the professional being a "Thou," not a machine-like "It," to a fellow-suffering "I," as Martin Buber spoke of it (1925/1958). It is about what we in English speak of as "turning toward another with our whole selves," what in German is called Umkehr, and in Hebrew is called Tseshuvah. "Just Listening" is never mere listening; it is a listening that, to borrow from the Judeo-Christian tradition, takes place "with all your heart, all your soul, and all your might." While much of biomedical training and practice derive from "just doing" with no, or minimal, listening, it turns out that "just listening" consists of a form of doing and a foundation for other, more conventional, forms of clinical "doing" (clinical activism in the service of mastery). From what we learn as we listen (to the other person, and to ourselves as their voice resonates in us), we learn what next to say or do (see Ogden 1997).

The author shows how narratives make not only good stories but also good medicine. What makes this essay so persuasive is its absence of polemics: it is a montage of stories about clinical stories; it crosses and transcends disciplines, including mine. It is refreshingly inclusive. It is empirical, methodological, theoretical, taxonomic, and deeply clinical, all while being elegantly written (or should I say "told"?) by an author who is at once patient, clinician, narrator, story-teller, interpreter, and wounded healer. The essay not only places narrative at the center of clinical work--all sickness and suffering, I would add, not only deep illness. It also places deep listening at the center of clinical narrative. All illness, deep or "shallow" (if that is the proper contrast), threatens identity, even if it does not irrevocably alter it. Patients and their illnesses, too, remind physicians of the tentativeness of all certain identity every time physicians enter an exam room.

Donald W. Winnicott (1965) said over four decades ago that there is no such thing as a baby without a mother; the author here says that there is no story without a listener--or maybe it is the triad of doctor, patient, and story. A story is a relationship, "child" of a relationship; it is not a thing. Patients do not bring stories; they tell them, with the caring help of their caregivers. Many, if not most clinical relationships prohibit and intrude upon such intimacies as deeply (and not so deeply) ill persons have to tell. They presume what (and how long) the story should be about, how it should be structured, and how it should be told. The author, by contrast, provides a safe, protected space for the patient, a place less for a prepackaged story to be "told" than as one in which a story may be shaped and reshaped.

I wish to situate the subject of listening, story-telling, and clinical narrative in cultural time. The accelerating time pressure of the managed care era, successor to the DRG era, would seem to render obsolete if not absurd any deep listening and story-telling. Given the short-term, financial horizon of managed care and other corporations, deep listening would appear to be highly cost-ineffective. In reality, close attention to people's lived lives and to the therapeutic value of telling their stories has never had high status in biomedicine. The culprit--our values and the defenses against fears of intimacy and vulnerability on which they are founded--long antedates managed care.

We in healthcare would rather do anything than "just listen," because such listening confronts us with the suffering of others and of our own to which we have not attended. To listen deeply requires that we can bear the anxiety in patients and in ourselves that wells up when issues of death, annihilation, separation, fragmentation, abandonment, shame, guilt, dependency, impotence, arise. Bio-medicine (if I may reify in order to make the point) is founded on values of control and mastery. It requires the relinquishing of such cherished values, expectations, and illusions, in order to listen and truly follow a patient's lead. Even the supposedly golden age of fee-for-service, physicians fled from relationships with patients in which they might hear too much.

Yet ... the need for therapeutic narrative remains, which makes the essay timely and timeless. If story-telling is good enough for "deep illness," its attitude toward the experienced life behind the disease is good enough for the clinic full of sore throats and runny noses during winter "flu season." What appears extraordinary and radical also deserves to be made ordinary (remember Ignaz Semmelweis and asepsis?).(*) We "just" need to tolerate our own anxiety in the face of sickness so as to allow ourselves to stand or sit still for a moment and to feel. We often cannot bear to hear (listen to) another person in order to protect ourselves from feeling. The clinical relationship can be a powerful defense for the physician. Yet, maybe the story behind the 15th sore throat of a clinic session will assist in diagnosis, or treatment, or in the very least, in reassurance that the patient's worst fear is not true. Dare I suggest a formula (that draws upon an electrical metaphor)?: Short-circuited narrative, short-circuited treatment. Or: Simon and Garfunkel's haunting song, "The Sounds of Silence."

Listening is foundational, far more so than a mere instrumental means to a clinical end. It is part of the intersubjective act of caring; it is everywhere or nowhere. Moreover, it is not private clinical property. The essay, "Just Listening," is about clinical work with patients, with people who are profoundly ill. But its spirit could just as well be about clinical "training" of students and apprentice health professionals, about an attitude often banished from the adversarial model of medical education. To be listened to is a gift--of grace, not pedagogical gimmickry. Such listening can never be merely a trick or technique. Only one who has been listened to can bear to listen to another. Like empathy, it is taught by being lived.

A few years ago I wrote a book on how one might try working in such an mode to understand organizational culture (specifically biomedical ones) and to consult. I titled the book, Listening Deeply (1994). A year or so later, the CEO of The University Hospitals in Oklahoma City invited me to become an ongoing internal consultant to the downsizing and restructuring process. Over the course of three waves of layoffs, and during the next year and a half, I met with members of the Human Relations, Nursing, and Continuing Education Department, at first weekly for two or so hours, then twice a week, then monthly, then through occasional telephone conversations. We agonized over how they could help with morale and task functioning among the remaining employees; how they might conduct seminars for those who had been fired; and how they might deal with the intense emotions and fantasies that arose from work about which their co-workers did not even wish to hear, let alone acknowledge. As the weeks and months went on, I kept wondering why they kept wanting me to come back. What exactly was I doing? How was I helping in such extreme circumstances?

In April 1997 1 received an answer--one that the author of "Just Listening" portrays, evokes, and confirms. Two members of the transition team, with whom I had met, surprised me by a visit at my office in the Family Medicine Center. I had always visited them on their hospital turf. They presented me with a framed plaque containing the following words in large type: "To feel heard and understood is perhaps the most precious gift in life." Typed in smaller print beneath it was: Listening Deeply. They were returning to me words they had made their own. The moment was overwhelming. I also felt heard and understood. And I began to understand what I do under the clumsy linguistic rubrics of "clinical ethnographer" or even "clinical behavioral science teacher."

Several years earlier I had given them a copy of my book and inquired nothing further about it. Today, they told me they had circulated the book throughout the hospital. Deep listening to continuously changing, harrowing workplace stories, told by emotionally engaged storytellers, turned out to be the foundation for healing. On the cultural surface, the onlooker brings an altogether different image of clinical work to the process of assessment, diagnosis, and treatment (for instance, "intervention"). "Just listening" looks like nothing related to "real work." Throughout my career, in fact, I have long struggled professionally to have such activities officially authorized as actual, real work. Yet, to my hospital colleagues, I had been doing something. As the author of this essay says so many times, "just listening" is never "just listening" if it is real listening. This essay deserves to become an immediate classic, and to be read by every student, apprentice, practitioner, and veteran of all the healing professions.

(*) Ignaz Semmelweis (1818-1865), a Hungarian physician, developed the practice of handwashing in hospitals in order to prevent the spread of childbed fever during delivery. His notions about asepsis were rejected by members of the Viennese medical community. They ostracized him for what they regarded as an unnecessary, unscientific procedure.

REFERENCES

Balint, M. (1972). The doctor, his patient, and the illness (2nd ed.). New York: International Universities Press.

Bion, W.R. (1959). Experiences in groups. New York: Basic Books.

Boyer, L.B. (1993). Countertransference: Brief history and clinical issues (pp. 1-24). In L.B. Boyer & P.L. Giovacchini (eds.), Master clinicians on treating regressed patients (vol. 2). Northvale NJ: Jason Aronson.

Buber, M. (1925/1958). I and Thou (rev. ed.). New York: Scribners.

Frank, A.W. (1998). Just listening: Narrative and deep illness. Families, Systems & Health 16:197-212.

Ogden, T.H. (1997). Reverie and interpretation. Psychoanalytic Quarterly 65: 567-595.

Stein, H.F. (1985). The psychodynamics of medical practice: Unconscious factors in patient care. Berkeley: University of California Press.

--. (1994). Listening deeply. Boulder CO: Westview Press.

--, & Apprey, M. (1990). Clinical stories and their translations. Charlottesville VA: University Press of Virginia.

Winnicott, D.W. (1965). The maturational processes and the facilitating environment. New York: International Universities Press.

HOWARD F. STEIN, Ph.D.([dagger])

([dagger]) Howard F. Stein, Ph.D., a medical and psychoanalytic anthropologist, is a Professor in the Department of Family and Preventive Medicine, University of Oklahoma Health Sciences Center, 900 NE 10, Oklahoma City OK 73104; e-mail: howard-stein@ouhsc.edu.
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Title Annotation:Listening to patients
Author:STEIN, HOWARD F.
Publication:Families, Systems & Health
Geographic Code:1USA
Date:Sep 22, 1998
Words:1848
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