mental health consultation

mWeek 2 – Assignment

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Mental Health Consultation

Prior to beginning work on this assignment, it is recommended that you read Chapter 1 in Turning Points in Dynamic Psychotherapy: Initial Assessment, Boundaries, Money, Disruptions and Suicidal Crises and Chapters 1, 2, and 4 in The Psychiatric Interview: Evaluation and Diagnosis.

Respond to at least one of your colleagues in the discussion forum before creating your assignment submission.

For this assignment, you will take on the role of a mental health professional providing a consultation to a colleague. Your colleague in this case happens to be a licensed clinical psychologist. Carefully review the

PSY645 Fictional Mental Health Consultation Scenario (Links to an external site.)

which provides information on your colleague’s patient and specific questions your colleague has posed to you as a consultant. Once you have reviewed the scenario, research a minimum of two peer-reviewed articles in the Ashford University Library related to the situation(s) presented in the scenario and how these have been approached and treated in previous cases.

Write an evaluation of the patient’s symptoms and presenting problems within the context of one theoretical orientation (e.g., psychoanalytic, cognitive, behavioral, humanistic, etc.). Summarize views of these symptoms and presenting problems within the context of at least one historical perspective and two theoretical orientations different from the one used in your evaluation (e.g.:, cognitive, humanistic, psychodynamic, integrative) in order to provide alternative viewpoints. To conclude, justify the use of diagnostic manuals and handbooks besides the DSM-5 that might be used to assess this prospective patient.

The Mental Health Consultation:

Must be two to three double-spaced pages in length (not including title and references pages) and must be formatted according to APA style as outlined in the Ashford Writing Center (Links to an external site.).
Must include a separate title page with the following:
Title of paper
Student’s name
Course name and number
Instructor’s name
Date submitted
Must use at least two peer-reviewed sources in addition to the course text.
Must document all sources in APA style as outlined in the Ashford Writing Center.
Must include a separate references page that is formatted according to APA style as outlined in the Ashford Writing Center.

Grading rubrics

Evaluates of the Patient’s Symptoms and Presenting Problems Within the Context of One Theoretical Orientation

Total: 2.00

Distinguished – Comprehensively evaluates of the patient’s symptoms and presenting problems within the context of one theoretical orientation.

Summarizes Views of the Patient’s Symptoms and Presenting Problems Within the Context of at Least One Historical Perspective and Two Theoretical Orientations Different From the One Used in the Evaluation

Total: 3.00

Distinguished – Thoroughly summarizes views of the patient’s symptoms and presenting problems within the context of at least one historical perspective and two theoretical orientations different from the one used in the evaluation.

Justifies the Use of Diagnostic Manuals and Handbooks Besides the DSM-5 That Might Be Used to Assess the Prospective Patient

Total: 1.50

Distinguished – Fully and clearly justifies the use of diagnostic manuals and handbooks besides the dsm-5 that might be used to assess the prospective patient.

Critical Thinking: Explanation of Issues

Total: 1.00

Distinguished – Clearly and comprehensively explains the issue to be considered, delivering all relevant information necessary for a full understanding.

Written Communication: Control of Syntax and Mechanics

Total: 1.00

Distinguished – Displays meticulous comprehension and organization of syntax and mechanics, such as spelling and grammar. Written work contains no errors and is very easy to understand.

Written Communication: APA Formatting

Total: 0.50

Distinguished – Accurately uses APA formatting consistently throughout the paper, title page, and reference page.

Written Communication: Page Requirement

Total: 0.50

Distinguished – The length of the paper is equivalent to the required number of correctly formatted pages.

Written Communication: Resource Requirement

Total: 0.50

Distinguished – Uses more than the required number of scholarly sources, providing compelling evidence to support ideas. All sources on the reference page are used and cited correctly within the body of the assignment.

Running Head: MENTAL HEALTH CONSULTATION 1

MENTAL HEALTH CONSULTATION 2

Mental Health Consultation

PSY645: Psychopathology

Introduction

According to Tasman, Kay & Ursine, (2013) interview is a principal mean of assessing a patient to develop an initial treatment plan or even make a diagnosis. In general, medical assessment, psychiatric interviews and critical in history and physical examination. The fictional mental health consultation scenario does not allow the effective interview, and thus a diagnosis cannot be made. In the review of this scenario, the symptoms and presenting problems by the patient will be evaluated basis it on a theoretical orientation as well as from a historical perspective.

Evaluation of The Patient’s Symptoms

Bob who is 38 years appears untidy and poorly groomed which are behavioral responses possibly from his thoughts. Other behavioral responses include pressured speech, elevated body temperature, and agitated speech. The dysfunctional behaviors and emotions presented by Bob can be explained by cognitive behavioral therapy. Bob shows heightened anxiety such that he makes unintentional and purposeless movements which physically expresses anxiety and mental tension which can be used in cognitive therapy. Anxiety causes irritability and inability to relax which is similar to psychomotor agitation (Ravindran & Stein, 2010). He appears mentally disturbed with the thoughts that the police are after him which he repeats several times. This presents unwanted and intrusive thoughts of being followed by the police triggering feelings that are intensely distressing. Since he repeats this several times, it can be narrowed down to an anxiety disorder known as obsessive-compulsive disorder. His thinking and feeling can be determined to impact on how the behaves and therefore changing on his thoughts patterns will enhance a positive behavioral response — the anxieties that Bob presents results in a psychosomatic condition which is manifest through high body temperature. Also, pressured speech is a symptom that is prevalent in several disorders such as bipolar condition and anxiety when coupled with maniac episodes. There is a wide range of issues that can be explained by cognitive theory and therefore through the presented symptoms, the specific disorder can be identified thus making a diagnosis for admittance. Through cognitive theory, the painful and upsetting thoughts can be identified to determine if they are realistic and if unrealistic, changing the thought patterns can be applied.

Summary of Symptoms and Presenting Problems from One Historical Perspective and Two Theoretical Orientations.

The cognitive perspective emerged in the 1960s and also known as cognitive psychology influenced by core psychologists such as Jean Piaget and Albert Bandura (Stam, 2010). It is an approach that focuses on mental processes such as thinking, memory. The cognitive, historical perspective can be used to analyze the internal mental processes in Bob to analyze his perception that police are following his, his pressured speech among other symptoms that he shows. Information- processing model is enhanced to conceptualize how the information is acquired, processed, stored and utilized. As a result, the behavioral response as in the symptoms presented such as the thoughts that the police are after Bob can be evaluated and explained (Akhtar, 2009).

There is a relationship between the thoughts of being followed by police and the other symptoms which have been reviewed among them pressures and circumstantial speech as well as psychomotor agitation. A holistic orientation will focus on the relationship between the spirit, mind, and body to attempt to understand and address the way issues of one aspect such as the mind can lead to concern in other areas such as the body (Stam, 2010). The consciousness of an individual is housed in the integrated mind body and spirit and thus a connection between the emotions, thoughts and physical experiences. Through the holistic orientation, the symptoms in Bob cannot be eliminated, but they can be used to evaluate his consciousness and bring to attention his self-awareness, acceptance, and esteem. Through psychoanalytic, Bob can be better made to understand the unconscious forces that play critical roles in his current behaviors, thoughts, and emotions. Their unconscious meanings and motivation evidenced in the symptoms can be evaluated. As a result, the patient will learn about himself and the symptoms can be unraveled

Conclusion

In conclusion, diagnostic manuals aids therapists to ensure consistency in diagnosis. Apart from DSM-5, DSM-IV (1994) and DSM-IV-TR can be used for treating and diagnosing this patient. Critical personality disorders can be diagnosed as per the patient symptoms. The review of the symptoms can enhance the right diagnosis using these two DSMs. DSM-IV (2000) can analyze the form of mental disorder through its five-part axial system. The therapist’s guide to brief cognitive behavioral therapy handbook can be used to assessing the patient’s symptoms.

References

Akhtar, S. (2009). Turning Points in Dynamic Psychotherapy: Initial Assessment, Boundaries, Money, Disruptions and Suicidal Crises.

Ravindran, L. N., & Stein, M. B. (2010). The pharmacologic treatment of anxiety disorders: a review of progress. The Journal of clinical psychiatry, 71(7), 839-854.

Stam, H. J. (2010). Theoretical Communities and Theory & Psychology: A Decade Review.

Tasman, A., Kay, J., & Ursano, R. J. (2013). The Psychiatric Interview: Evaluation and Diagnosis. John Wiley & Sons, Incorporated.

The Psychiatric Interview: Evaluation and Diagnosis, First Edition

Allan Tasman, Jerald Kay and Robert J. Ursano.
© 2013 John Wiley & Sons, Ltd. Published 2013 by John Wiley & Sons, Ltd.
This chapter is based on Chapter 1 (Paul C. Mohl) of Psychiatry, 3rd Edition.

Listening to the Patient1

Listening: The Key Skill in Psychiatr

It was Freud who raised the psychiatric technique of examination – listening – to a level
of expertise unexplored in earlier eras. As Binswanger (1963) has said of the period prior
to Freudian influence: psychiatric “auscultation” and “percussion” of the patient was
performed as if through the patient’s shirt with so much of his essence remaining covered
or muffled that layers of meaning remained unpeeled away or unexamined.

This metaphor and parallel to the cardiac examination is one worth considering as
we first ask if listening will remain as central a part of psychiatric examination as in the
past. The explosion of biomedical knowledge has radically altered our evolving view and
practice of the doctor–patient relationship. Physicians of an earlier generation were taught
that the diagnosis is made at the bedside – that is, the history and physical examination
are paramount. Laboratory and imaging (radiological, in those days) examinations were
seen as confirmatory exercises. However, as our technologies have blossomed, the bedside
and/or consultation room examinations have evolved into the method whereby the physi-
cian determines what tests to run, and the tests are often viewed as making the diagnosis.
So can one imagine a time in the not-too-distant future when the psychiatrist’s task will
be to identify that the patient is psychotic and then order some benign brain imaging study
which will identify the patient’s exact disorder?

Perhaps so, but will that obviate the need for the psychiatrist’s special kind of listening?
Indeed, there are those who claim that psychiatrists should no longer be considered experts
in the doctor–patient relationship, where expertise is derived from their unique training in
listening skills, but experts in the brain. As we come truly to understand the relationship
between brain states and subtle cognitive, emotional, and interpersonal states, one could also
ask if this is a distinction that really makes a difference. On the other hand, the psychiatrist
will always be charged with finding a way to relate effectively to those who cannot effec-
tively relate to themselves or to others. There is something in the treatment of individuals
whose illnesses express themselves through disturbances of thinking, feeling, perceiving,
and behaving that will always demand special expertise in establishing a therapeutic
relationship – and that is dependent on special expertise in listening (Clinical Vignette 1).

All psychiatrists, regardless of theoretical stance, must learn this skill and struggle
with how it is to be defined and taught. The biological or phenomenological psychiatrist

CHAPTER

Tasman, Allan, et al. The Psychiatric Interview : Evaluation and Diagnosis, John Wiley & Sons, Incorporated, 2013. ProQuest Ebook Central,
http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=1187749.
Created from ashford-ebooks on 2020-01-07 21:27:09.

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2 The Psychiatric Interview

listens for subtle expressions of symptomatology; the cognitive–behavioral psychiatrist
listens for hidden distortions, irrational assumptions, or global inferences; the psycho-
dynamic psychiatrist listens for hints at unconscious conflicts; the behaviorist listens
for covert patterns of anxiety and stimulus associations; the family systems psychiatrist
listens for hidden family myths and structures.

This requires sensitivity to the storyteller, which integrates a patient orientation
complementing a disease orientation. The listener’s intent is to uncover what is wrong
and to put a label on it. At the same time, the listener is on a journey to discover who
the patient is, employing tools of asking, looking, testing, and clarifying. The patient
is invited to collaborate as an active informer. Listening work takes time, concentration,
imagination, a sense of humor, and an attitude that places the patient as the hero of
his or her own life story. Key listening skills are listed in Table 1.1.

Table 1.1 Key Listening Skills

Hearing Connotative meanings of words
Idiosyncratic uses of language
Figures of speech that tell a deeper story
Voice tones and modulation (e.g., hard edge, voice cracking)
Stream of associations

Seeing Posture
Gestures
Facial expressions (e.g., eyes watering, jaw clenched)
Other outward expressions of emotion

Comparing Noting what is omitted
dissonances between modes of expression
Intuiting

Reflecting Attending to one’s own internal reactions
Thinking it all through outside the immediate pressure to

respond during the interview

Clinical Vignette 1

A 28-year-old white married man suffering from paranoid schizophrenia and
obsessive–compulsive disorder did extremely well in the hospital, where his
medication had been changed to clozapine with good effects. But he rapidly
deteriorated on his return home. It was clear that the ward milieu had been a
crucial part of his improvement, so partial hospitalization was recommended.
The patient demurred, saying he didn’t want to be a “burden”. The psychiatrist
explored this with the patient and his wife. Beyond the obvious “burdens” of
cost and travel arrangements, the psychiatrist detected the patient’s striving to
be autonomously responsible for handling his illness. By conveying a deep respect
for that wish, and then educating the already insightful patient about the realities
of “bearing schizophrenia”, the psychiatrist was able to help the patient accept the
needed level of care.

Chapter 1 • Listening to the Patient 3

The enduring art of psychiatry involves guiding the depressed patient, for example,
to tell his or her story of loss in addition to having him or her name, describe, and quantify
symptoms of depression. The listener, in hearing the story, experiences the world and the
patient from the patient’s point of view and helps carry the burden of loss, lightening and
transforming the load. In hearing the sufferer, the depression itself is lifted and relieved.
The listening is healing as well as diagnostic. If done well, the listener becomes a better
disease diagnostician. The best listeners hear both the patient and the disease clearly, and
regard every encounter as potentially therapeutic.

The Primary Tools: Words, Analogies, Metaphors, Similes,
and Symbols

To listen and understand requires that the language used between the speaker and the
hearer be shared – that the meanings of words and phrases are commonly held. Patients
are storytellers who have the hope of being heard and understood. Their hearers are
physicians who expect to listen actively and to be with the patient in a new level of under-
standing. Because all human beings listen to so many different people every day, we tend
to think of listening as an automatic ongoing process, yet this sort of active listening
remains one of the central skills in clinical psychiatry. It underpins all other skills in
diagnosis, alliance building, and communication. In all medical examinations, the patient
is telling a story only she or he has experienced. The physician must glean the salient
information and then use it in appropriate ways. Inevitably, even when language is
common, there are subtle differences in meanings, based upon differences in gender, age,
culture, religion, socioeconomic class, race, region of upbringing, nationality and original
language, as well as the idiosyncrasies of individual history. These differences are partic-
ularly important to keep in mind in the use of analogies, similes, and metaphors. Figures
of speech, in which one thing is held representational of another by comparison, are very
important windows to the inner world of the patient. differences in meanings attached to
these figures of speech can complicate their use. In psychodynamic assessment and
psychotherapeutic treatment, the need to regard these subtleties of language becomes the
self-conscious focus of the psychiatrist, yet failure to hear and heed such idiosyncratic
distinctions can affect simple medical diagnosis as well (Clinical Vignettes 2 and 3).

Clinical Vig nette 2

A psychiatric consultant was asked to see a 48-year-old man on a coronary care
unit for chest pain deemed “functional” by the cardiologist who had asked the
patient if his chest pain was “crushing”. The patient said no. A variety of other
routine tests were also negative. The psychiatrist asked the patient to describe his
pain. He said, “It’s like a truck sitting on my chest, squeezing it down”. The
psychiatrist promptly recommended additional tests, which confirmed the
diagnosis of myocardial infarction. The cardiologist may have been tempted to
label the patient a “bad historian”, but the most likely culprit of this potentially
fatal misunderstanding lies in the connotative meanings, each ascribed to the word
“crushing” or to other variances in metaphorical communication.

4 The Psychiatric Interview

In psychotherapy, the special meanings of words become the central focus of
the treatment.

How Does One Hear Words in This Way?

The preceding clinical vignettes, once described, sound straightforward and easy. Yet, to
listen in this way, the clinician must acquire specific yet difficult-to-learn skills and atti-
tudes. It is extremely difficult to put into words the listening processes embodied in these
examples and those to follow, yet that is what this chapter attempts to do.

Students, when observing experienced psychiatrists interviewing patients, often
express a sense of wonder such as: “How did she know to ask that?” “Why did the patient
open up with him but not with me?” “What made the diagnosis so clear in that interview
and not in all the others?” The student may respond with a sense of awe, a feeling of inep-
titude and doubt at ever achieving such facility, or even a reaction of disparagement that the
process seems so indefinable and inexact. The key is the clinician’s ability to listen. Without
a refined capacity to hear deeply, the chapters on other aspects of interviewing in this text-
book are of little use. But it is neither mystical nor magical nor indefinable (though it is
very difficult to articulate); such skills are the product of hard work, much thought, intense
supervision, and extensive in-depth exposure to many different kinds of patients.

Psychiatrists, more than any other physicians, must simultaneously listen symptom-
atically and narratively/experientially. They must also have access to a variety of
theoretical perspectives that effectively inform their listening. These include behavioral,
interpersonal, cognitive, sociocultural, and systems theories. Symptomatic listening is
what we think of as traditional medical history taking, in which the focus is on the
presence or absence of a particular symptom, the most overt content level of an interview.
Narrative–experiential listening is based on the idea that all humans are constantly
interpreting their experiences, attributing meaning to them, and weaving a story of their

Clinical Vignette 3

A psychiatrist had been treating a 35-year-old man with a narcissistic personality and
dysthymic disorder for 2 years. Given the brutality and deprivation of the patient’s
childhood, the clinician was persistently puzzled by the patient’s remarkable
psychological strengths. He possessed capacities for empathy, self-observation, and
modulation of intense rage that were unusual, given his background. during a
session, the patient, in telling a childhood story, began, “When I was a little fella…”.
It struck the psychiatrist that the patient always said “little fella” when referring to
himself as a boy, and that this was fairly distinctive phraseology. Almost all other
patients will say, “When I was young/a kid/a girl (boy)/in school”, designate an age,
etc. On inquiry about this, the patient immediately identified “The Andy Griffith
Show” as the source. This revealed a secret identification with the characters of the
TV show, and a model that said to a young boy, “There are other ways to be a man
than what you see around you”. Making this long-standing covert identification fully
conscious was transformative for the patient.

Chapter 1 • Listening to the Patient 5

lives with themselves as the central character. This process goes on continuously, both
consciously and unconsciously, as a running conversation within each of us. The
conversation is between parts of ourselves and between ourselves and what Freud called
“internalized objects”, important people in our lives whose images, sayings, and attitudes
become permanently laid down in our memories. This conversation and commentary on
our lives includes personal history, repetitive behaviors, learned assumptions about the
world, and interpersonal roles. These are, in turn, the products of individual background,
cultural norms and values, national identifications, spiritual meanings, and family system
forces (Clinical Vignette 4).

It seems that three factors were present that enabled the psychiatrist in Clinical
Vignette 4 to listen well and identify an unusual diagnosis that had been missed by at least
three other excellent clinicians who had all been using detailed structured interviews that
were extremely inclusive in their symptom reviews. First, the psychiatrist had to have
readily available in mind all sorts of symptoms and syndromes. Second, he had to be in a
curious mode. In fact, this clinician had a gnawing sense that something was missing in
his understanding of the patient. There is a saying in American medicine designed to
focus students on the need to consider common illnesses first, while not totally ignoring
rarer diseases: when you hear hoofbeats in the road, don’t look first for zebras. We would
say that this psychiatrist’s mind was open to seeing a “zebra” despite the ongoing assump-
tion that the weekly “hoofbeats” he had been hearing represented the everyday “horse” of
clinical depression. Finally, he had to hear the patient’s story in multiple, flexible ways,
including the possibility that a symptom may be embedded in it, so that a match could be
noticed between a detail of the story and a symptom. eureka! The zebra could then be
seen although it had been standing there every week for months.

Looking back at Clinical Vignette 3, we see the same phenomenon of a detail leaping
out as a significant piece of missing information that dramatically influences the treatment
process. To accomplish this requires a cognitive template (symptoms and syndromes;
developmental, systemic, and personality theories; awareness of cultural perspectives),

Clinical Vignette 4

A 46-year-old man was referred to a psychiatrist from a drug study. The patient
had both major depression and dysthymic disorder since a business failure 2 years
earlier. His primary symptoms were increased sleep and decreased mood, libido,
energy, and interests. After no improvement during the “blind” portion of the
study, he had continued to show little response once the code was broken, and he
was treated with two different active antidepressant medications. He was referred
for psychotherapy and further antidepressant trials. The therapy progressed slowly
with only episodic improvement. One day, the patient reported that his wife had
been teasing him about how, during his afternoon nap, his snoring could be heard
over the noise of a vacuum cleaner. The psychiatrist immediately asked additional
questions, eventually obtained sleep polysomnography, and, after appropriate
treatment for sleep apnea, the patient’s depression improved dramatically.

6 The Psychiatric Interview

a searching curious stance, and flexible processing of the data presented. If one is able to
internalize the skills listed in Table 1.1, the listener begins automatically to hear the mean-
ings in the words.

Listening as More Than Hearing

Listening and hearing are often equated in many people’s minds. However, listening
involves not only hearing and understanding the speaker’s words, but attending to
inflection, metaphor, imagery, sequence of associations, and interesting linguistic selec-
tions. It also involves seeing – movement, gestures, facial expressions, subtle changes in
these – and constantly comparing what is said with what is seen, looking for dissonances,
and comparing what is being said and seen with what was previously communicated and
observed. Further, it is essential to be aware of what might have been said but was not, or
how things might have been expressed but were not. This is where clues to idiosyncratic
meanings and associations are often discovered. Sometimes, the most important mean-
ings are embedded in what is conspicuous by its absence.

There appears to be a biogrammar of primary emotions that all humans share and
express in predictable, fixed action patterns. The meaning of a smile or nod of the head is
universal across disparate cultures. The amygdala and the inferior temporal lobe gyrus
have been identified as the neurobiological substrate for recognition of and empathy for
others and their emotional states. Further research has identified that these parts of the
brain are, on the one hand, prededicated to recognizing certain gestures, facial expres-
sions, and so on, but require effective maternal–infant interaction in order to do so
(Schore, 2001). All of this is synthesized in the listener as a “sense” or intuition as to what
the speaker is saying at multiple levels. The availability of useful cognitive templates and
theories enables the listener to articulate what is heard (Clinical Vignette 5).

Clinical Vignette 5

A 38-year-old Hispanic construction worker presented himself to a small-town
emergency department in the Southwest, complaining of pain on walking, actually
described in Spanish-accented english as “a little pain”. His voice was tight, his
face was drawn, and his physical demeanor was burdened and hesitant. His
response to the invitation to walk was met by a labored attempt to walk without
favor to his painful limb. A physician could have discharged him from the
emergency department with a small prescription of ibuprofen. The careful
physician in the emergency department responded to the powerful visual message
that he was in pain, was beaten down by it, and had suffered long before coming
in. This recognition came first to the physician as an intuition that this man was
somehow more sick than he made himself sound. A radiograph of the femur
revealed a lytic lesion that later proved to be metastatic renal cell carcinoma. To
hear the unspoken, one had to be keenly aware of the patient’s tone and how he
looked, and to keep in mind, too, the cultural taboos forbidding him to give in to
pain or to appear to need help.

Chapter 1 • Listening to the Patient 7

As has been implied, not only must one affirmatively “hear” all that a patient is
communicating, one must overcome a variety of potential blocks to effective listening.

Common Blocks to Effective Listening

Many factors influence the ability to listen. Psychiatrists come to the patient as the product
of their own life experiences. does the listener tune in to what he or she hears in a more
attentive way if the listener and the patient share characteristics? What blocks to listening
(Table 1.2) are posed by differences in sex, age, religion, socioeconomic class, race,
culture, or nationality? What blind spots may be induced by superficial similarities in
different personal meanings attributed to the same cultural symbol? Separate and apart
from the differences in the development of empathy when the dyad holds in common
certain features, the act of listening is inevitably influenced by similarities and differences
between the psychiatrist and the patient.

Would a woman have reported the snoring in Clinical Vignette 4 or would she have been
too embarrassed? Would she have reported it more readily to a woman psychiatrist? What
about the image in Clinical Vignette 2 of a truck sitting on someone’s chest? How gender and
culture bound is it? Would “The Andy Griffith Show”, important in Clinical Vignette 3, have
had the same impact on a young African-American boy that it did on a Caucasian one? In
how many countries is “The Andy Griffith Show” even available, and in which cultures
would that model of a family structure seem relevant? Suppose the psychiatrist in that
vignette was not a television viewer or had come from another country to the USA long after
the show had come and gone? Consider these additional examples (Clinical Vignette 6).

Table 1.2 Blocks to Effective Listening

Patient–psychiatrist dissimilarities Race
Sex
Culture
Religion
Regional dialect
Individual differences
Socioeconomic class

Superficial similarities May lead to incorrect assumptions of shared
meanings

Countertransference Psychiatrist fails to hear or reacts
inappropriately to content reminiscent of
own unresolved conflicts

external forces Managed care setting
emergency department
Control-oriented inpatient unit

Attitudes Need for control
Psychiatrist having a bad day

8 The Psychiatric Interview

It is likely that different life experiences based on gender fostered this misun-
derstanding. How many women easily identify with the stereotyped role of the
barnyard rooster? How many men readily identify with the role of a prostitute?
These are but two examples of the myriad different meanings our specific gender
may incline us toward. Although metaphor is a powerful tool in listening to the
patient, cross-cultural barriers pose potential blocks to understanding (Clinical
Vignettes 7 and 8).

Clinical Vignette 7

A 36-year-old black woman complained to her therapist (of the same language,
race, and socioeconomic class) that her husband was a snake, meaning that he was
no good, treacherous, a hidden danger. The therapist, understanding this
commonly held definition of a snake, reflected back to the patient pertinent,
supportive feedback concerning the care and caution the patient was exercising in
divorce dealings with the husband.

In contrast, a 36-year-old Chinese woman, fluent in english, living in her
adopted country for 15 years and assimilated to Western culture, represented her
husband to her Caucasian, native-born psychiatrist as being like a dragon. The
therapist, without checking on the meaning of the word “dragon” with her patient,
assumed it connoted danger, one of malicious intent and oppression. The patient,
however, was using “dragon” as a metaphor for her husband – the fierce, watchful
guardian of the family – in keeping with the ancient Chinese folklore in which the
dragon is stationed at the gates of the lord’s castle to guard and protect it from evil
and danger.

Clinical Vignette 6

A female patient came to see her male psychiatrist for their biweekly session.
Having just been given new duties on her job, she came in excitedly and began
sharing with her therapist how happy she was to have been chosen by her male
supervisor to help him with a very important project at their office. The session
continued with the theme of the patient’s pride in having been recognized for her
attributes, talents, and hard work. At the next session, she said that she had
become embarrassed after the previous session at the thought that she had been
“strutting her stuff”. The therapist reflected back to her the thought that she
sounded like a rooster strutting his stuff, connecting her embarrassment at having
revealed that she strove for the recognition and power of men in her company, and
that she, in fact, envied the position of her supervisor. The patient objected to the
comparison of a rooster, and likened it more to feeling like a woman of the streets
strutting her stuff. She stated that she felt like a prostitute being used by her
supervisor. The psychiatrist was off the mark by missing the opportunity to point
out in the analogous way that the patient’s source of embarrassment was in being
used, not so much in being envious of the male position.

Chapter 1 • Listening to the Patient 9

even more subtle regional variations may produce similar problems in listening and
understanding.

Psychiatrists discern meaning in that which they hear through filters of their own –
cultural backgrounds, life experiences, feelings, the day’s events, their own physical sense
of themselves, nationality, sex roles, religious meaning systems, and intrapsychic conflicts.
The filters can serve as blocks or as magnifiers if certain elements of what is being said res-
onate with something within the psychiatrist. When the filters block, we call it countertrans-
ference or insensitivity. When they magnify, we call it empathy or sensitivity. One may
observe a theme for a long time repeated with a different tone, embellishment, inflection, or
context before the idea of what is meant comes to mind. The “little fella” example in Clinical
Vignette 3 illustrates a message that had been communicated in many ways and times in
exactly the same language before the psychiatrist “got it”. On discovering a significant
meaning that had been signaled previously in many ways, the psychiatrist often has the
experience: “How could I have been so stupid? It’s been staring me in the face for months!”

Managed care and the manner in which national health systems are administered can
alter our attitudes toward the patient and our abilities to be transforming listeners. The
requirement for authorization for minimal visits, time on the phone with utilization review
nurses attempting to justify continuing therapy, and forms tediously filled out can be
blocks to listening to the patient. Limitations on the kinds and length of treatment can lull
the psychiatrist into not listening in the same way or as intently. With these time limits and
other “third-party payer” considerations (i.e., need for a billable diagnostic code), the psy-
chiatrist, as careful listener, must heed the external pressures influencing the approach to
the patient. Many health benefit packages will provide coverage in any therapeutic setting
only for relief of symptoms, restoration of minimal function, acute problem solving, and
shoring up of defenses. In various countries, health-care systems have come up with a
variety of constraints in their efforts to deal with the costs of care. Unless these pressures
are attended to, listening will be accomplished with a different purpose in mind, more
closely approximating the crisis intervention model of the emergency room or the medical
model for either inpatient or outpatient care. In these settings, the thoughtful psychiatrist
will arm himself or herself with checklists, inventories, and scales for objectifying the
severity of illness and response to treatment: the ear is tuned only to measurable and
observable signs of responses to therapy and biologic intervention (Clinical Vignette 9).

Clinical Vignette 8

In a family session, a psychiatrist from the South referred to the mother of her
patient as “your mama”, intending a meaning of warmth and respect. The patient
instantly became enraged at the use of such an offensive term toward her mother.
Although being treated in Texas, the patient and her family had recently moved
from a large city in New Jersey. The use of the term “mama” among working-class
Italians in that area was looked upon with derision among people of Irish descent,
the group to which the patient was ethnically connected. The patient had used the
term “mother” to refer to her mother, a term the psychiatrist had heard with a
degree of coolness attached. What she knew of her patient’s relationship with her
mother did not fit in with a word like mother; hence, almost out of awareness, she
switched terms, leading to a response of indignation and outrage from the patient.

10 The Psychiatric Interview

With emphasis on learning here and now symptoms that can bombard the dyad with
foreground static and noise, will the patient be lost in the encounter? The same approach
to listening occurs in the setting of the emergency department for crisis intervention.
emphasis is on symptom relief, assurance of capacities to keep oneself safe, restoration of
minimal function, acute problem solving, and shoring up of defenses. Special attention is
paid to identifying particular stressors. What can be done quickly to change stressors that
throw the patient’s world into a state of disequilibrium? The difference in the emergency
room is that the careful listener may have 3–6 hours, as opposed to three to six sessions for
the patient with a health maintenance organization or preferred provider contract, or other
limitations on benefits. If one is fortunate and good at being an active listener–bargainer,
the seeds of change can be planted in the hope of allowing them time to grow between
visits to the emergency department. If one could hope for another change, it would be for
a decrease in the chaos in the patient’s inner world and outer world.

Crucial Attitudes That Enable Effective Listening

The first step in developing good listening skills involves coming to grips with the impor-
tance of inner experience in psychiatric treatment and diagnosis. The advent of modern
diagnostic classifications has been responsible for enormous advances in reliability and
accuracy of diagnosis, but their emphasis on seemingly observable phenomena has

Clinical Vignette 9

An army private was brought to the emergency room in Germany by his friends,
having threatened to commit suicide while holding a gun to his head. He was
desperate, disorganized, impulsive, enraged, pacing, and talking almost
incoherently. Gradually, primarily through his friends, the story emerged that his
first sergeant had recently made a decision for the entire unit that had a
particularly adverse effect on the patient. He was a fairly primitive character who
relied on his wife for a sense of stability and coherence in his life. The sergeant’s
decision was to send the entire unit into the field for over a month just at the time
the patient’s wife was about to arrive, after a long delay, from the USA. After
piecing together this story, the psychiatrist said to the patient, “It’s not yourself
you want to kill, it’s your first sergeant!” The patient at first giggled a little, then
gradually broke out into a belly laugh that echoed throughout the emergency
room. It was clear that, having recognized the true object of his anger, a coherence
was restored that enabled him to feel his rage without the impulse to act on it. The
psychiatrist then enlisted the friends in a plan to support the patient through the
month and to arrange regular phone contact with the wife as she set up their new
home in Germany. No medication was necessary. Hospitalization was averted, and
a request for humanitarian dispensation, which would have compromised the
patient in the eyes of both his peers and superiors, was avoided as well. And, with
luck, the young man had an opportunity to grow emotionally as well.

Chapter 1 • Listening to the Patient 11

allowed the willing user to forget the importance of inner experience even in such basic
diagnoses as major depressive disorder. Consider the symptom “depressed mood most of
the day” or “markedly diminished interest or pleasure” or even “decrease or increase in
appetite”. These are entirely subjective symptoms. Simply reporting depression is usually
not sufficient to convince a psychiatrist that a diagnosis of depression is warranted. In
fact, the vast majority of psychiatric patients are so demoralized by their illnesses that
they often announce depression as their first complaint. Further, there are a significant
number of patients who do not acknowledge depression yet are so diagnosed. The clinician
might well comment: “Sitting with him makes me feel very sad”.

The psychiatrist must listen to much more than the patient’s overt behavior. There
are qualities in the communication, including the inner experiences induced in the lis-
tener, that should be attended to. The experienced clinician listens to the words, watches
the behavior, engages in and notices the ongoing interaction, allows himself or herself to
experience his or her own inner reactions to the process, and never forgets that depression
and almost all other psychiatric symptoms are exclusively private experiences. The
behavior and interactions are useful insofar as they assist the psychiatrist in inferring the
patient’s inner experience.

Therefore, to convince a clinician that a patient is depressed, not only must the patient say
she or he is depressed, but the observable behavior must convey it (sad-looking face, sighing,
unexpressive intonations, etc.); the interaction with the interviewer must convey depressive
qualities (sense of neediness, sadness induced in the interviewer, beseeching qualities
expressed, etc.). In the absence of both of these, other diagnoses should be considered, but
in the presence of such qualities, depression needs to remain in the differential diagnosis.

even when we make statements about brain function with regard to a particular
patient, we use this kind of listening, generally, by making at least two inferences. We
first listen to and observe the patient and then infer some aspect of the patient’s private
experience. Then, if we possess sufficient scientific knowledge, we make a second
inference to a disturbance in neurochemistry, neurophysiology, or neuroanatomy. When
psychiatrists prescribe antidepressant medication, they have inferred from words, moved
into inner experiences, and come to a conclusion that there is likely a dysregulation of
serotonin or norepinephrine in the patient’s brain.

As one moves toward treatment from diagnosis, the content of inner experience
inferred may change to more varied states of feelings, needs, and conflicts, but the
fundamental process of listening remains the same. The psychiatrist listens for the
meaning of all behavior, to the ongoing interpersonal relationship the patient attempts to
establish, and to inner experiences as well.

despite all of the technological advances in medicine in general and their growing
presence in psychiatry, securing or eliciting a history remains the first and central skill
for all physicians. even in the most basic of medical situations, the patient is trying to
communicate a set of private experiences (how does one describe the qualities of pain
or discomfort?) that the physician may infer and sort into possible syndromes and
diagnoses. In psychiatry, this process is multiplied, as indicated in Figure 1.1.

It was widely assumed that development, and problems related to development,
effect the inner experiences of various affects. does, for example, a person with border-
line personality disorder experience “anxiety” in the same qualitative and quantitative
manner in which a neurotic person does? What is the relationship between sadness and

12 The Psychiatric Interview

guilt and the empty experiences of depression? This perspective underlies the principle
articulated in text after text on interviewing that emphasizes the importance of establish-
ing rapport in the process of history taking. It is incredibly easy for the psychiatrist to
attribute to the patient what she or he would have meant and what most people might have
meant in using a particular word or phrase. The sense in the narrator that the listener is
truly present, connected, and with the patient enormously enhances the accuracy of the
story reported.

Words that have been used to describe this process of constant attention to and infer-
ence of inner experience by the listener include interest, empathy, attentiveness, and
noncontingent positive regard. However, these are words that may say less than they seem
to. It is the constant curious awareness on the listener’s part, that she or he is trying to
grasp the private inner experience of the patient, and the storyteller’s sense of this stance
by the psychiatrist that impel the ever more revealing process of history taking. This
quality of listening produces what we call rapport, without which psychiatric histories
become spotty, superficial, and even suspect. There are no bad historians, only patients
who have not yet found the right listener.

It is well established that two powerful predictors of outcome in any form of psychotherapy
are empathy and the therapeutic alliance. This has been shown again and again in study
after study for dynamic therapy, cognitive therapy, behavior therapy, and even medication
management. The truth of this can be seen in the remarkable therapeutic success of the

My
stor

Mys
elf

My p
ain

Words

My symptomsMy feelings

All personal history, past and present

Cultural norms and values
Institutional social systems

Institutional roles and expectations
Interpersonal roles and expectations

Intrapsychic drives and conflicts
Subjective experience of biological phenomena

Gender-specific experiences
Experience of the interview

Family systems

Cognitive sets

Figure 1.1 Finding the patient (Kay and Tasman, 2006).

Chapter 1 • Listening to the Patient 13

“clinical management” cell of the National Institutes of Mental Health Collaborative Study on
the Treatment of Major depression. Although the Clinical Management Cell was not as effec-
tive as the cells that included specific drugs or specific psychotherapeutic interventions, 35%
of patients with moderate to severe major depressive disorder improved significantly with
carefully structured supportive clinical management alone (elkin et al., 1989).

Helpful psychiatric listening requires a complicated attitude toward control and
power in the interview (see Table 1.3). The psychiatrist invites the patient/storyteller to
collaborate as an active informer. He or she is invited, too, to question and observe him-
self or herself. This method of history taking remains the principal tool of general clinical
medicine. However, as Freud pointed out, these methods of active uncovering are more
complex in the psychic realm. The use of the patient as a voluntary reporter requires that
the investigator keep in mind the unconscious and its power over the patient and listener.
Can the patient be a reliable objective witness of himself or herself or his or her symp-
toms? Can the listener hold in mind his or her own set of filters, meanings, and distortions
as he or she hears? The listener translates for himself or herself and his or her patient the
patient’s articulation of his or her experience of himself or herself and his or her inner
world into our definition of symptoms, syndromes, and differential diagnoses, which
make up the concept of the medical model.

Objective–descriptive examiners are like detectives closing in on disease. The psy-
chiatric detective enters the inquiry with an attitude of unknowing and suspends prior
opinion. The techniques of listening invoke a wondering and a wandering with the patient.
Periods of head scratching and exclamations of “I’m confused”, or “I don’t understand”,
or “That’s awful!”, or “Tell me more”, allow the listener to follow or to point the way for
the dyad. Finally, clear and precise descriptions are held up for scrutiny, with the hope
that a diagnostic label or new information about the patient’s suffering and emotional pain
be revealed.

It is embarking on the history taking journey together – free of judgments, opinions,
criticism, or preconceived notions – that underpins rapport. Good listening requires a
complex understanding of what objective truth is and how it may be found. The effective
psychiatrist must eschew the traditional medical role in interviewing and tolerate a collab-
orative, at times meandering, direction in which control is at best shared and sometimes

Table 1.3 Attitudes Important to Listening

The centrality of inner experience
There are no bad historians
The answer is always inside the patient
Control and power are shared in the interview
It is OK to feel confused and uncertain
Objective truth is never as simple as it seems
Listen to yourself, too
everything you hear is modified by the patient’s filters
everything you hear is modified by your own filters
There will always be another opportunity to hear more clearly

14 The Psychiatric Interview

wholly with the patient. The psychiatrist constantly asks: What is being said? Why is it
being said at this moment? What is the meaning of what is being said? In what context is
all this emerging? What does that tell me about the meaning of and what does it reflect
about the doctor–patient relationship?

Theoretical Perspectives on Listening

Listening is the effort or work of placing the therapist where the patient is (“lives”). The
ear of the empathic listener is the organ of receptivity – gratifying and, at times, indulging
the patient. every human being has a preferred interpersonal stance, a set of relationships
and transactions with which she or he is most comfortable and feels most gratified. The
problem is that for most psychiatric patients, they do not work well, but the psychiatrist,
through listening and observing, must understand the patient. Beyond attitudes that enable
or prevent listening, there is a role for specific knowledge. It is important to achieve the
cognitive structure or theoretical framework and use it with rigor and discipline in the
service of patients so that psychiatrists can employ more than global “feelings” or
“hunches”. In striving to grasp the inner experience of any other human being, one must
know what it is to be human; one must have an idea of what is inside any person. This
provides a framework for understanding what the patient – who would not be a patient if
he fully understood what was inside of him – is struggling to communicate. Personality
theory is absolutely crucial to this process.

Whether we acknowledge it or not, every one of us has a theory of human person-
ality (in this day and age of porous boundaries between psychology and biology, we
should really speak of a psychobiological theory of human experience), which we apply
in various situations, social or clinical. These theories become part of the template alluded
to earlier, which allows certain words, stories, actions, and cues from the patient to jump
out with profound meaning to the psychiatrist. There is no substitute for a thorough
knowledge of many theories of human functioning and a well-disciplined synthesis and
internal set of rules to decide which theories to use in which situations.

different theoretical positions offer slightly different and often complementary
perspectives on listening (Table 1.4). each of the great schools of psychotherapy places
the psychiatrist in a somewhat different relationship to the patient. This may even be
reflected in the physical placement of the therapist in relation to the patient. In a classical
psychoanalytic stance, the therapist, traditionally unseen behind the patient, assumes an
active, hovering attention. existential analysts seek to experience the patient’s position
and place themselves close to and facing the patient. The interpersonal psychiatrist
stresses a collaborative dialogue with shared control. One can almost imagine the two
side by side as the clinician strives to sense what the storyteller is doing to and with the
listener. Interpersonal theory stresses the need for each participant to act within that
interpersonal social field.

In the object relations stance, the listener keeps in mind the “other people in the
room” with him and the storyteller, that is, the patient’s introjects who are constantly
part of the internal conversation of the patient and thus influence the dialogue within
the therapeutic dyad. In connecting with the patient, the listener is also tuned in to
the fact that parts and fragments of him or her are being internalized by the patient.

Chapter 1 • Listening to the Patient 15

The listener becomes another person in the room of the patient’s life experience,
within and outside the therapeutic hour. Cognitive and behavioral psychiatrists are
kindly experts, listening attentively and subtly for hidden assumptions, distortions,
and connections. The family systems psychiatrist sits midway among the pressures
and forces emanating from each individual, seeking to affect the system so that all
must adapt differently.

Referring again to Clinical Vignette 3, we can see the different theoretical models
of the listening process in the discovery of the meaning of “little fella”. Freud’s model
is one in which the psychiatrist had listened repeatedly to a specific association and
inquired of its meaning. Object relations theorists would note that the clinician had
discovered a previously unidentified, powerful introject within the therapeutic dyad.
The interpersonal psychiatrist would see the shared exploration of this idiosyncratic
manner of describing one’s youth; the patient had been continually trying to take the
therapist to “The Andy Griffith Show”. That is, the patient was attempting to induce
the clinician to share the experience of imagining and fantasizing about having Andy
Griffith as a father.

existentialists would note how the psychiatrist was changed dramatically by the
patient’s repeated use of this phrase and then altered even more profoundly by
the memory of Andy Griffith, “the consummate good father” in the patient’s words.
The therapist could never see the patient in quite the same way again, and the patient
sensed it immediately. And Kohut would note the mirroring quality of the psychia-
trist’s interpretation of the meaning of this important memory. This would be mirroring
at its most powerful, affirming the patient’s important differences from his family,
helping him to consolidate the memories. The behavioral psychiatrist would note the

Table 1.4 Theoretical Perspectives on Listening

Theory Focus of Attention Listening Stance

ego psychology Stream of associations Neutral, hovering attention
Object relations Introjects (internalized images of

others within the patient)
Neutral, hovering attention

Interpersonal What relationship is the patient
attempting to construct?

Participant observer

existential Feelings, affect empathic identification
with the patient

Self-psychology Sense of self from others empathic mirroring and
affirmation

Patient centered Content control by patient Noncontingent positive
regard, empathy

Cognitive Hidden assumptions and distortions Benign expert
Behavioral Behavioral contingencies Benign expert
Family systems Complex forces maneuvering each

member
Neutral intruder who forces

imbalance in the system

16 The Psychiatric Interview

reciprocal inhibition that had gone on, with Andy Griffith soothing the phobic anxieties
in a brutal family.

A cognitive psychiatrist would wonder whether the patient’s depression resulted
from a hidden assumption that anything less than the idyllic images of television was
not good enough. The family systems psychiatrist would help the patient see that he
had manipulated the forces at work on him and actually changed the definition of his
family.

The ways and tools of listening also change, according to the purpose, the nature
of the therapeutic dyad. The ways of listening also change depending upon whether or
not the psychiatrist is preoccupied or inattentive. The medical model psychiatrist lis-
tens for signs and symptoms. The analyst listens for the truth often clothed in fantasy
and metaphor. The existentialist listens for feeling, and the interpersonal theorist lis-
tens for the shared experiences engendered by the interaction. Regardless of the theo-
retical stance and regardless of the mental tension between the medical model’s need
to know symptoms and signs and the humanistic psychiatrist’s listening to know the
sufferer, the essence of therapeutic listening is the suspension of judgment before any
presentation of the story and the storyteller. The listener is asked to clarify and classify
the inner world of the storyteller at the same time he or she is experiencing it – no
small feat!

Using Oneself in Listening

Understanding transference and countertransference is crucial to effective listening.
Tomkins, Ledoux, damasio, and Brothers have given us a basic biological perspective on
this process. However, one defines these terms, whatever one’s theoretical stance about
these issues. To know ourselves is to begin to know our patients more deeply. There are
many ways to achieve this. Personal therapy is one. Ongoing life experience is another.
Supervision that emphasizes one’s emotional reactions to patients is still a third. Once we
have started on the road to achieving this understanding by therapy, supervision, or life
experience, continued listening to our patients, who teach us about ourselves and others,
becomes a lifelong method of growth.

To know oneself is to be aware that there are certain common human needs,
wishes, fears, feelings, and reactions. every person must deal in some way with
attachment, dependence, authority, autonomy, selfhood, values and ideals, remembered
others, work, love, hate, and loss. It is unlikely that the psychiatrist can comprehend the
patient without his or her own self-awareness. Thus, Figure 1.1 should really look
like Figure 1.2. The most psychotic patient in the world is still struggling with these
universal human functions (Clinical Vignette 10).

In this case, the psychiatrist was able to connect with a patient’s inner experience in a
manner that had a fairly dramatic impact on the clinical course. That is the goal of listening.
The art is hearing the patient’s inner experience and then addressing it empathically,
enabling the patient to feel heard and affirmed. There are no rules about this, and at any
given point in a clinical encounter, there are many ways to accomplish it. There are also
many ways to respond that are unhelpful and even retraumatizing. The skilled psychiatrist,
just as she or he never forgets that it is the patient’s inner experience that is to be heard, also
never stops struggling to find just the right words, gestures, expressions, and inflections

Chapter 1 • Listening to the Patient 17

Words

Nonverbal cues

All personal history, past and present

Cultural norms and values
Family systems

Institutional social systems
Institutional roles and expectations

Interpersonal roles and expectations

Intrapsychic drives and conflicts
Subjective experience of biological phenomena

Cognitive sets
Gender-specific experiences
Experience of the interview

All personal history, past and present
Cultural norms and values
Family systems
Institutional social systems
Institutional roles and expectations

Interpersonal roles and expectations
Intrapsychic drives and conflicts

Subjective experience of biological phenomena
Cognitive sets

Gender-specific experiences
Experience of the interview
My
stor
y
Mys
elf

My p
ain

My symptomsMy feelings

Professionaltraining

Persona
l

therapy
Supervision

Consultation

Figure 1.2 The therapeutic dyad (Kay and Tasman, 2006).

Clinical Vignette 10

A young man with paranoid schizophrenia had been admitted in 1979 to the
hospital following a near lethal attack on his father. When asked about this
incident, he became frankly delusional, speaking of the Arab–Israeli conflict,
the preciousness of Jerusalem, how the Israelis must defend it at all costs.
Unspoken was his conviction that he was like the Israelis, with the entire
world attacking and threatening him. He believed his father had threatened
and attacked him when, in fact, his father had done little more than seek to be
closer, more comforting, and advising with the patient. The psychiatrist
understood the patient to be speaking of that core of selfhood that we all
possess, which, when threatened, creates a sense of vulnerability and panic, a
disintegrating anxiety unlike any other. The psychiatrist spoke to the patient of
Anwar Sadat’s visit to Jerusalem and engaged him in a discussion of how that
had gone, what the outcome had been, had the threat been lessened or
increased? The patient, although still delusional, visibly relaxed and began
to speak much more directly about his own sense of vulnerability and
uncertainty over his personal integrity and its ability to withstand any
closeness. He still required neuroleptic medication for his illness; however,
his violent thoughts and behaviors reduced dramatically. He was able to begin
interacting with his father, and his behavior on the ward changed as well.

18 The Psychiatric Interview

that say to a patient, “you have been understood”. The most clever diagnostician or
insightful interpreter who cannot “connect” with the patient in this manner will miss
valuable information. This issue has been addressed by writers who have pointed out how
little understood are the concepts of support and empathy (Peteet, 1982).

Being human is also to be a creature of habit and pattern in linguistic, interper-
sonal, and emotional realms. The skilled psychiatrist listens with this ever in mind.
What we see in the interview, what we hear in interactions may be presumed to be rep-
etitions of many other events. The content may vary, but the form, motive, process, and
evolution are generally universal for any given individual. This, too, is part of listening.
To know what is fundamentally human, to have a well-synthesized rigorous theory, and
to hear the person’s unique but repetitive ways of experiencing are the essence of
listening. These skills “find” the patient in all his or her humanity, but then the psychi-
atrist must find the right communication that allows the patient to feel “found”.

To Be Found: The Psychological Product of Being Heard

Psychiatric patients may be lonely, isolated, demoralized, and desperate, regardless of
the specific diagnosis. They have lost themselves and their primary relationships, if
they ever had any. Many therapists believe that before anything else can happen, they
must be found, and feel found. They can only be found within the context of their own
specific histories, cultures, religions, genders, social contexts, and so on. There is
nothing more healing than the experience of being found by another. The earliest
expression of this need is in infancy and we refer to it as the need for attachment.
Referring to middle childhood, Harry Stack Sullivan spoke of the importance of the
pal or buddy. Kohut spoke of the lifelong need for self-objects. In lay terms, it is often
subsumed under the need for love, security, and acceptance. Psychiatric patients have
lost or never had this experience. However obnoxious or destructive or desperate their
overt behavior, it is the psychiatrist’s job to seek and find the patient. That is the
purpose of listening.

If we look back to Clinical Vignette 3, wherein the phrase “little fella” bespoke
such deep and important unverbalized meaning, the patient’s reaction to the memory and
recognition by the psychiatrist was dramatic. He had always known he was different in
some indefinable ways from his family. That difference had been both a source of pride
and pain to him at various developmental stages. However, the recognition of the specific
source, its meaning, and its constant presence in his life created a whole new sense of
himself. He had been found by his psychiatrist, who echoed the discovery, and he
had found an entire piece of himself that he had enacted for years, yet which had been
disconnected from any integrated sense of himself.

Sometimes objectifying and defining the disease/disorder enables the person to feel
found. One of the most challenging patients to hear and experience is the acting out,
self-destructive, demanding person with borderline personality disorder. even as the prior
sentence conveys, psychiatrists often experience the diagnosis as who the patient is rather
than what he or she suffers. The following case conveys how one third-year resident was
able to hear such a patient, and in his listening to her introduce the idea that the symptoms
were not her but her disorder (Clinical Vignette 11).

Chapter 1 • Listening to the Patient 19

Gender can play a significant role in the experience of feeling found. Some individuals
feel that it is easier to connect with a person of the same sex; others, with someone of the
opposite sex. Clinical Vignette 6 is an excellent example of this. In these days of significant
change in and sensitivity to sex roles, a misinterpretation such as that early in treatment
could result in a permanent rupture in the alliance. Psychiatrists vary in their sensitivity to

Clinical Vignette 11

The psychiatrist was working the midnight Friday to 11 a.m. Saturday shift in a
Psychiatric emergency Room. The patient was a 26-year-old woman brought in
by ambulance after overdosing on sertraline following an argument with her
boyfriend. She had been partying with him and became enraged at the attention he
was paying to the date of a friend who was accompanying them. After being
cleared medically, the patient was transferred to psychiatry for crisis intervention.
It was about 4 a.m. when she arrived. She was crying and screaming for the
psychiatric staff to release her. In the emergency department, she had grabbed a
suture scissors attached to the uniform of the charge nurse. The report was given
to the psychiatric resident that she had been a “management problem” in the
medicine eR.

The psychiatrist sat wearily and listened to the patient tell her story with tears,
shouts, and expletives sputtered through clenched teeth. She stated that she did not
remember ever being happy, that she frequently had thoughts of suicide, and that
she had overdosed twice before, following a divorce from her first husband at the
age of 19 and then 8 months prior to this episode when she had been fired from a
job for arguing with her supervisor. Her parents had kept her 6-year-old and
7-year-old sons since her divorce. She was currently working as a file clerk and
living with her boyfriend of 2 months. She stated that she felt like there was a cold
ice cube stuck in her chest as she watched her boyfriend flirting with the other
woman. She acknowledged that she felt empty and utterly alone even in the
crowded bar. She created an unpleasant scene and they continued to argue until
they got home. Then he had laughed at her and left, stating that he would come
back when she had cooled down.

The resident sat quietly and listened. He looked dreary. The night had been a
busy one. She looked at him and complained, “don’t let me and my problems
bore you!” He looked at her and said, “Quite the contrary. I’ve been thinking as
you speak that I know what disorder you suffer from”. With that statement, he
pulled out the dSM-IV and read with her the description of the symptoms and
signs of borderline personality disorder. She had been in therapy off and on since
she was 16 years old. No one had ever shared with her the name of the diagnosis
but instead had responded to her as if the disorder was the definition of who she
was. In his listening, he was able to hear her symptoms as a disorder and not the
person. And in his ability to separate the two, he was able to allow her to distance
herself from the symptoms, too, and see herself in a new light with her first
inkling of her own personhood.

20 The Psychiatric Interview

the different sexes. Some may do better with those who have chosen more traditional roles;
others may be more sensitive to those who have adopted more modern roles.

We now know that just as there is a neurobiological basis for empathy and countertrans-
ference, there is a similar biological basis for the power of listening to heal, to lift psychological
burdens, to remoralize, and to provide emotional regulation to patients who feel out of control
in their rage, despair, terror, or other feelings (Table 1.5). Attachment and social support are
psychobiological processes that provide the necessary physiological regulation to human
beings. A neurobiological view supports the notion of the patient’s capacity to perceive
empathy through the powerful nonverbal, universally understood communication of facial
expressions. His research in basic human emotions sets forth the idea of their understanding
across cultures and ages. It further supports the provocative idea that facial expressions of the
listener may generate autonomic and central nervous system changes not only within the
listener but within the one being heard, and vice versa. Indeed, the evidence is growing that
new experiences in clinical interactions create learning and new memories, which are associ-
ated with changes in both brain structure and function. When we listen in this way, we are
intervening not only in a psychological manner to connect, heal, and share burdens but also
in a neurobiological fashion to regulate, modulate, and restore functioning. When patients feel
found, they are responding to this psychobiological process.

Listening to Oneself to Listen Better

To hold in mind what has been said and heard after a session and between sessions is the
most powerful and active tool of listening. It is a crucial step often overlooked by students
and those new at listening. It is necessary to hear our patients in our thoughts during the
in-between times in order to pull together repetitive patterns of thinking, behaving, and
feeling, giving us the closest idea of how patients experience themselves and their world.
In addition, many of our traumatized patients have not had the experience of being held in
mind, of being remembered, and their needs being thought of by significant others. These
key experiences of childhood affirm the young person’s psychological being. It is important
to distinguish this kind of “re-listening” to the patient – an important part of the psychia-
trist’s ongoing processing and reprocessing of what has been heard and experienced – from
what some may leap to call countertransference. One way of identifying this distinction
would be to differentiate listening to oneself as one reviews in one’s mind the

Table 1.5 The Basic Sciences of Listening

Neurobiology of primary affects
Universality of certain affective expressions
Neurobiology of empathy
Biological need for interpersonal regulation
Psychobiology of attachment
Biological impact of social support
environmental impact on central nervous system structure and function

Chapter 1 • Listening to the Patient 21

patient’s story versus becoming preoccupied and stuck with one’s thoughts and feelings
about a particular aspect of a patient (Clinical Vignette 12).

As the verbal interaction with the patient occurs, psychiatrists may find themselves
expressing thoughts and feeling in ways that may be quite different from their usual
repertoire. The following case is an example.

This sort of listening to oneself in order to understand the patient requires a good
working knowledge of projective identification. Projective identification is a phrase

Clinical Vignette 12

A second-year resident, rotating through an inpatient unit that serves the
psychiatric needs of very severely ill psychotic patients with multiple
admissions, dual diagnoses, homelessness, criminal records, significant histories
of medical noncompliance, and, in some, unremitting psychosis, was
particularly struggling with a 33-year-old white woman admitted for the 11th
time since age 19. The patient invariably stopped medications shortly after
discharge, never kept follow-up appointments, and ended up on the streets
psychotic and high on crack cocaine. She would then be involuntarily
committed for restabilization. And so the cycle would repeat itself. The resident
would see the patient on daily rounds. The patient’s litany was the same day
after day: “I’m not sick. I don’t need to be here. I don’t need medicines”. And
regularly she refused doses.

The resident spoke often of her patient to other residents in her class and often
found herself ruminating about the patient’s abject lostness. She began her regular
supervision hours either frustrated or feeling hopeless that anything would change
with this patient because the patient flatly refused to acknowledge her disorder.
The patient’s level of denial was of psychotic proportions. Shortly after a
particularly difficult encounter with the patient concerning her refusal to take an
evening dose of haloperidol, the resident came to supervision with the report that
she had awakened terrorized by dreaming the night before that she had been
diagnosed with schizophrenia. She had been intensely affected by overwhelming
pain, confusion, and despair as she heard the diagnosis in her dream. “IT CAN’T
Be!” she screamed, waking herself with a shaking start. “I’M NOT SICK! I
dON’T Need TO Be HeRe! I dON’T Need MedICINe!” The words of her
patient echoed in her mind as her own echoed in her ears. She had taken the
patient’s story and words home with her and kept them in mind at an unconscious
level to be brought up in her dream, the ultimate identification with the patient.
How more intensely can one be empathic with her patient than to dream as if she
is experiencing the same horrifying reality? The patient and resident continued to
struggle, but after the dream the resident was able to approach the patient and her
story from a position of understanding the patient’s need to maintain a lack of
awareness or absence of insight. To acknowledge the presence of the disorder was
more than the patient’s already fragmented ego could bear. And now the resident
“heard” it.

22 The Psychiatric Interview

used to describe a defense mechanism in which the patient, in an effort to master
intolerably terrifying emotions, unconsciously seeks to engender them in the therapist
and to identify with the psychiatrist’s ability to tolerate and handle the feelings
(Clinical Vignettes 13 and 14).

Clinical Vignette 13

A 45-year-old divorced white woman, being followed for bipolar disorder and
borderline personality traits and stable for several years on lithium, was in weekly
psychotherapy. during the prior weekend, she had moved into another apartment
closer to her work. On the day of the move, she overslept and woke up with a
start. The admonition to herself as she awoke was, “You lazy bitch! You can never
manage on your own”. She had earlier, as a child, experienced a mother who was
needy, engulfing, punishing, hostile, critical, and dependent upon the patient. Her
therapist, having some knowledge of the patient and her background, said, “Your
mother is still with you. It was she in your head continuing to bombard you with
derogatory statements”. The same patient was often 10 or 15 minutes late for
sessions, and her therapist found herself irritated at the patient’s habitual tardiness.
To her own surprise and enlightenment, the therapist also found herself thinking,
“What a chaotic woman! She’ll never manage to be here on time”. She, too, had
heard the voice of her patient’s mother. In the next session, she wondered with her
patient if she found herself wishing to place her therapist in the position of her
mother, wanting at once to be engulfed and punished.

Clinical Vignette 14

A psychiatrist was treating a 40-year-old man who was in the process of
recognizing his own primary homosexual orientation. In the course of
treatment, he became enraged, suicidal, and homicidal. After one session, the
psychiatrist, while driving home, experienced the fantasy that when he got
home, he would find his patient already there, having taken the psychiatrist’s
family hostage. The psychiatrist became increasingly terrified, even outright
paranoid that this fantasy might actually come to pass. The patient was a
computer expert who had indeed discovered the unlisted phone number and
address of his therapist. But the psychiatrist realized that this fantasy was far
out of keeping with his own usual way of feeling and the patient’s way of
behaving and viewing him. On arriving home to discover his family quite safe,
the psychiatrist called the patient and scheduled him as his first for
appointment the following morning. When the patient arrived, the psychiatrist
said, “You know, I think I’m only now beginning to appreciate just how
terrified and desperate all of this makes you”. The patient slumped down into
his chair, heaved a sigh, and said, “Thank God!”

Chapter 1 • Listening to the Patient 23

Listening in Special Clinical Situations

Children

Listening to younger children often involves inviting them to play and then engaging
them in describing what is happening in the play action. The psychiatrist pays careful
attention to the child’s feelings. These feelings are usually attributed to a doll, puppet, or
other humanized toy. So if a child describes a stuffed animal as being scared, the psychi-
atrist may say, “I wonder if you, too, are scared when…” or “That sounds like you
when…”. The following case is an example (Clinical Vignette 15).

Geriatric Patients

Working with the elderly poses its own special challenges. These challenges include not
only the unique developmental issues they face but also the difficulty in verbalizing a life-
time of experience and feelings, and, commonly, a disparity in age and life experience
between the clinician and the patient.

It is challenging to elicit the elements of a story, especially when they span
generations. The elderly are often stoic. In the face of losses that mark the closing years
of life, denial often becomes a healthy tool, allowing one to accept and cope with declining
abilities and the loss of loved ones. The psychiatrist must appreciate that grief and
depression can often be similar in some respects (Clinical Vignette 16).

Clinical Vignette 15

A 4-year-old boy was brought in for psychiatric evaluation. He and his father had
come upon a very serious automobile accident. One person had been thrown from
the car and was lying clearly visible on the pavement with arms and legs
positioned in grotesque angles, gaping head wound, obviously dead. The child’s
father was an off-duty police officer who stopped to assist in the extraction of two
other people trapped in the car. The father kept a careful eye on the youngster who
was left in the car. The child observed the scene for about 30 minutes until others
arrived on the scene and his dad was able to leave. That night and for days to
come, the child preoccupied himself with his toy cars, which he repetitiously
rammed into each other. He was awakened by nightmares three times in the
ensuing weeks. during his evaluation in the play therapy room, he engaged in
ramming toy cars together. In addition, he tossed dolls about and arranged their
limbs haphazardly. As he was encouraged to put some words to his action, he
spoke of being frightened of the dead body and of being afraid to be by himself.
He was afraid of the possibility of being hurt himself. He came in for three more
play sessions, which went much the same way. His preoccupation with ramming
cars at home diminished and disappeared as did the nightmares. The content of his
play was used to help him put words and labels on his scare.

24 The Psychiatric Interview

Clinical Vignette 16

A psychiatrist was asked to examine an 87-year-old white man whom the family
believed to be depressed. They stated that he was becoming increasingly detached and
disinterested in the goings-on around him. When seen, he was cooperative and
compliant, but he stated that he didn’t believe he needed to be evaluated. The patient
had faced multiple losses over the past few years. After retiring at the age of 65, he had
developed the habit of meeting male friends at a coffee shop each morning at 7 a.m.
Now, all but he and one other were dead, and the other was in a nursing home with the
cognitive deficits of primary dementia of the Alzheimer’s type, preventing his friend
from recognizing him when visiting. The patient’s wife had died 15 years ago after
many years of marriage. He had missed her terribly at first but then after a year or so
he got on with his life. Several years later, he suffered a retinal detachment that
impaired his vision to the point that he was no longer able to drive himself to get about
as he once had. What he missed most was the independence of going places when it
suited him, rather than relying on his son or grandson to accommodate him within
their busy schedules. He had taken to watching televised church services rather than
trouble his son to drive him to church. His mind remained sharp, he said, but his body
was wearing out, and all the people with whom he had shared a common history had
died. His answers were “fine” and “all right” when questions of quality of sleep and
mood were asked – despite the fact that he had experienced significant nocturia. When
questioned about his ability to experience joy, he retorted, “Would you be?” His
youngest sister had died the year prior to the evaluation. She was 76 years old and had
been on home oxygen for the last 18 months of her life for end-stage chronic
obstructive pulmonary disease. He had been particularly close to her because she was
only 3 years old when their mother had died. He had been her caretaker all her life.

Although he denied feelings of guilt, he said that it “wasn’t right” that he had
outlived the youngest member of his family. His family said that he had taken her
death especially hard and was tearful and angry. The focus of his anger during the
final stages of her illness was at the young doctors whom he perceived as having
given up on her. After her death, it fell to him to dispose of her accumulated
possessions as she had no children and her husband had preceded her in death many
years before. At first, he said that he couldn’t face the task. Finally, some 2 months
later, he was able to close her estate. during that period of time, he had significant
sleep disturbance, reduced energy, and his family often experienced him as crotchety
and complaining. They and the patient attributed it to mourning her loss. However,
recently he was emotionally detached, not very interested in life around him, and
they found it particularly alarming that he had said to his son that he was “ready to
die”. What did all this mean? Was he depressed? Was he physically ill, creating the
sense of apathy and disinterest? Was he grieving? He was not suicidal. He did not
suffer negative thoughts about his own personhood. He was not having thoughts that
he had let anyone down. Together, he and the psychiatrist decided that he was indeed
grieving. This time, he was grieving for his own decline and imminent death. He, in
fact, was in the final acceptance phase of that process. In a family meeting, in the
discussions about the feelings of each member of the family, it became apparent that
he was facing the end of life, which evoked many emotions in those who loved him.

Chapter 1 • Listening to the Patient 25

Chronically Mentally Ill

Listening to the chronically mentally ill can be especially challenging, too. The unique
choice of words characteristic of many who have a thought disorder requires that the phy-
sician search for the meanings of certain words and phrases that may be peculiar and truly
eccentric. Clinical Vignettes 1, 10, and 12 are examples of this important challenge for the
psychiatric listener (Clinical Vignettes 17 and 18).

Chronically psychiatrically disabled patients may have a unique way of presenting
their inner world experiences. Sometimes the link to the outer world is not so apparent.
The psychiatrist is regularly challenged with making sense of the meanings of the content
and changes in intensity or frequency of the psychotic symptoms.

Physically Ill Patients

In consultations with a colleague in a medical or surgical specialty, one is evaluating a
patient who has a chronic or acute physical illness. The psychiatrist must listen to the
story of the patient but also keep in mind the story as reflected in the hospital records and
medical and nursing staff. Then the psychiatrist serves as the liaison not only between
psychiatry and other medical colleagues, but also between the patient and his or her care-
givers (Clinical Vignette 19).

Clinical Vignette 17

A young man with schizotypal personality disorder and obsessive–compulsive
disorder presented for months using adjectives describing himself as “broken and
fragmented”. Only after listening carefully, not aided by the expected or normal
affect of a depressed person, was the psychiatrist able to discern that his patient
was clinically depressed but did not have the usual words to say it or was unable
to discuss it.

Clinical Vignette 18

A 32-year-old black woman who had multiple hospitalizations for schizophrenia
and lived with her mother was seen in the community psychiatric center for
routine medication follow-up. Her psychiatrist found her to have an increase in
the frequency of auditory hallucinations, especially ones of a derogatory nature.
The voices were tormenting her with the ideas that she was not good, that she
should die, that she was worthless and unloved. Her psychiatrist heard her say that
she had wrecked her mother’s car 2 weeks previously. The streets had been wet
and the tires worn. She had slid into the rear of a car that had come to an abrupt
stop ahead of her on a freeway. Although her mother had not been critical or
judgmental, the patient felt overwhelming guilt as she watched her mother
struggle to arrange transportation for herself each day to and from work.

26 The Psychiatric Interview

Growing and Maturing as a Listener

Transference/countertransference influences not only relationships in traditional psycho-
therapy but also interactions between all physicians and patients and is always present
as a filter or reverberator to that which is heard. However, even the most experienced
of listeners are not always aware of the ways in which their patients’ stories are impacted
by countertransference. Patients come, too, with tendencies and predispositions to expe-
rience the listener, the other person in the therapeutic dyad, in familiar but distorted
fashion. The patient may idealize and adapt to interpretations. She or he may be hostile
and distrustful, identifying the psychiatrist in an unconscious way with one who has been
rejecting in the past. Listening to the “flow of consciousness”, the psychiatrist discerns a
thread of continuity and purposefulness in the patient’s communications. As the psychia-
trist becomes more and more familiar with his or her patient, he or she will discover the

Clinical Vignette 19

A 35-year-old woman was hospitalized for complications of a pancreas/kidney
transplant that was completed 20 months previously. Prior to surgery she had been
on dialysis for over a year awaiting a tissue match for transplantation. That year
she had been forced to take a leave of absence from her job as a social worker
with a local child and adolescent community center. At the time of this
hospitalization, she had been back at work for only 8 months when she developed
a urinary tract infection that did not respond to several antibiotics. Her renal
function was deteriorating and her doctors found her to be paranoid, hostile, and
labile. Her physicians dreaded going into her room each morning and began
distancing themselves from her.

Psychiatric consultation was sought following a particularly difficult interaction
between the patient and her charge nurse, the leader of the transplant team, and
the infectious disease expert. She was hostile, blaming, agitated, circumstantial,
refused further medications, and pulled out her intravenous lines. The consultation
requested assistance in hospital management.

When interviewed, the patient was lying quietly in bed but visibly stiffened
when the psychiatrist introduced herself. She very quickly exhibited the
symptoms described in the consultation. This patient had struggled with juvenile
onset diabetes since the age of 9. despite the fact that she consistently complied
with diet and insulin, control of blood sugars had always been difficult. As
complication after complication occurred, she often developed the belief that her
physicians thought that she was a “bad” patient. And now, the hope that her life
would normalize to the point that she could carry on with her career was dashed.
She felt misunderstood and alone in her struggle with long-term, chronic illness.
The psychiatrist resonated with the story emotionally and listened for ways to
address symptoms from a biological standpoint as well. The patient felt reassured
that someone was there to appreciate the tragic turn that her life had taken.

Chapter 1 • Listening to the Patient 27

connections between threads and the meaning will become apparent. This awareness may
come as a sign and symptom, fantasy, feeling, or fact.

There is an increasing recognition that to be a healing listener one must be able to
bear the burden of hearing what is told. Like the patient, we fear what might be said.
A patient’s story may be one of rage in response to early childhood attachment ruptures
or abuse, of sadness as losses are remembered, or of terror in response to disorganization
during the experience of perceptual abnormalities accompanying psychotic breaks.
The patient’s stories invariably invoke anger, shame, guilt, abject helplessness, or
sexual feelings within the listener. These feelings, unless attended to, appreciated, and
understood, will block the listening that is essential for healing to take place. every
insight is colored by what the listener has known. It is impossible to know that which is
not experienced. The psychiatrist comes with his or her own experiences and the expe-
riences he or she has had with others. To listen in the manner we are describing here is
another way of truly experiencing the world. The experiences include the imaginings
of how it must be to be 87 years old as a patient when one is a 35-year-old doctor just
finishing residency, to be female when one is male, to be a child again, to grow up
African-American in a small white suburb of a large city, to be an immigrant in a new
country, to be Middle eastern when one is Western european, and so on. One comes to
know by listening with imagination, allowing the words of the patient to resonate with
one’s own experiences or with what one has come to know through hearing with imag-
ination the stories of other patients or listening to the thoughts or insights of supervisors
(Clinical Vignette 20).

The best psychiatrists continue all their professional lives to learn how to listen
better. This may be thought of not only as a matter of mastering countertransference but
of self-education. One must learn to recognize when there are impasses in the treatment
and to seek education, from a colleague or, perhaps, even from the patient. Consider these
two examples.

Clinical Vignette 20

A Jewish resident was treating an 8-year-old Catholic boy who came in one day
and mentioned offhandedly that he was about to go to his first confession. The
psychiatric resident made no particular note of the issue and kept on listening to
the boy’s play and its themes. He noted that guilt, which had been an ongoing
theme, was prominent again. When he presented the session in supervision, the
supervisor wondered about the connection. It emerged that there was a large gulf
between the therapist and the boy. Jewish concepts of sin and atonement are
different from Christian ones, and the rituals surrounding them have rather
different intentions and ideas of resolution. The resident had missed the
opportunity to explore the young boy’s first introduction, within his religious
context, to the belief in a forgiving God, a potentially important step in helping
the child to resolve his ongoing struggles with guilt over his own greedy
impulses.

28 The Psychiatric Interview

How can the psychiatrist’s demeanor convey to the patient that he or she is safe to tell
his or her story, that the listener is one who can be trusted to be with him or her, to worry with
him or her, and serve as a helper? Much is written about the demeanor of the psychiatrist.
The air, deportment, manner, or bearing is one of quiet anticipation – to receive that which
the patient has come to tell and share in the telling. Signals of anticipation and curiosity may
be conveyed by such statements as “I’ve thought about what you said last time”, “How do
you feel about…?”, “What if…?” (Clinical Vignette 21).

efforts of clarification often serve as bridges between sessions and communicate
that the listener is committed to a fuller understanding of the patient. Patients have the
need to experience the psychiatrist as empathic. empathy describes the feeling one has
in hearing a story which causes one to conjure up or imagine how it would have been to
have actually have had an experience oneself. How does one integrate all this so that it
is automatic but not deadened by automaticity? How does the psychiatrist continue to
hear the “same old thing” with freshness and renewal? How does one encourage the
patient with consistency, clarity, and assurance in the face of uncertainty and occasional
confusion? Not by assurance that everything will be all right when things might probably
not be. Not by attempting to talk the patient into seeing things the clinician’s way but
rather by the psychiatrist’s having the capacity to hear things his or her patient’s way,
from the patient’s perspective.

Psychiatry is one of those rare disciplines where the experience of listening over and
over again allows the listener to grow in their capacities to hear and to heal. Hopefully, we
get better and better as the years advance, become smoother, and develop a style that
blends with our personality and training. We are renewed by the shared experiences with
our patients.

To hear stories of the human condition reminds the psychiatrist that he or she, too, is
human. There is time to make discoveries in the patient’s stories from previous times, and
maybe in previous patients. Patients will always endeavor to tell their stories. The psychi-
atrist continues to grow by being the perpetual student, always with an ear for the lesson,
the remarkable life stories of his or her patients.

Clinical Vignette 21

A psychiatrist began treating a Nigerian native who was suffering from
posttraumatic stress disorder (PTSd) after being assaulted at work. After several
sessions, the psychiatrist felt a sense of being at a loss in terms of what the
patient was expecting out of their work and how the therapist was being seen by
the patient. He then took several sessions to inquire of the patient about his
tribe, its structure, family roles, definitions of healing, ideas of illness and
wellness, etc. After this exploration, the psychiatrist adopted a different stance
with the patient, heard the patient’s communications very differently, and the
therapy proceeded much more smoothly and comfortably to a successful
conclusion.

Chapter 1 • Listening to the Patient 29

References

Binswanger L (1963) Being in the World. Basic Books, New York.
elkin I, Shea MT, Watkins JT et al. (1989) National Institute of Mental Health Treatment

of depression Collaborative Research Program: General effectiveness of treatments.
Archives of General Psychiatry 46(11), 971–982.

Kay J and Tasman A (2006) Essentials of Psychiatry. John Wiley & Sons, Inc., Hoboken.
Peteet JR (1982) A closer look at the concept of support: Some application to the care of

patients with cancer. General Hospital Psychiatry 4(1), 19–23.
Schore AN (2001) The effects of a secure attachment relationship: Right brain development,

affect regulation, and infant mental health. Infant Mental Health Journal 22, 7–66.

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