Discussion Paper: Four Modes of Listening in Psychotherapy
Author: David B. Klein, Ph.D. Click here to view other discussion papers.
FOUR MODES OF LISTENING IN PSYCHOTHERAPY
David B. Klein, Ph.D.
As our patients speak, how do we listen? For what are we listening? These are important questions, for our primary activity in psychotherapy and psychoanalysis is listening to the patient. We probably spend more time listening than performing any other therapeutic function. More important than the amount of time spent, however, is the fact that our spoken interventions, which are of undisputed import, in many ways flow from our listening. And our formulations, which often are created outside the sessions and constitute our overarching understanding of the patient, are also based on what we have heard as listeners during the sessions. As well, it is my impression that patients seem to recognize that we are, perhaps above all else, listeners, and there is an awareness that feeling well listened to, and understood, is an indispensable ingredient in a healing, growth- promoting treatment.
Nevertheless, during the history of psychotherapy and psychoanalysis, the nuts-and-bolts of how we listen has not been written about particularly extensively. Langs in 1978 noted that “It is remarkable that there are few papers on the listening process in general in the psychoanalytic literature.” Five years earlier, Gray (1973) had written:
“It is a curious fact that the central, most necessary part of psychoanalytic technique [analytic listening] is one of the least discussed, certainly one of the least conceptualized aspects of psychoanalysis.” Since then, fortunately, an increasing number of papers on listening have appeared. A helpful and comprehensive overview is by Meissner (2000).
Different writers have taken different approaches to therapeutic listening, with various degrees of success. For example, a traditional approach has been to emphasize the idea of listening with one's unconscious. Freud (1912), Reik (1948) and Isakower (1992), have all focused in this direction.
A second, related approach has focused on various aspects in the psychology of the listening therapist, using concepts such as trial identification and regression in the service of the ego. Fliess (1942), Kris (1952), Greenson (1967), Spencer and Balter (1984), and H. Smith (1999) are among the contributors in this group.
A third approach has been the study of empathy. There is a now a large and informative literature on empathy, much of it associated with self psychology (for example Kohut (1959), Basch (1983), Lichtenberg (1984), Schwaber (1984, 1998), Fosshage (1998).
A fourth approach describes how to listen differentially to distinct diagnostic categories of patients, utilizing separate theoretical frameworks for each patient category. Studies by Hedges (1983), and Chessick (1992) exemplify this view.
Finally, a number of authors have advanced their own quite individualized frameworks for listening. Langs (1978), Bion (1962, 1970), and Gray (1994) have made notable contributions in this manner.
Of course, no single point of view will be sufficient in itself. In our complicated field of endeavor, any single perspective has the disadvantage noted by Warren Poland (1996, p. 29): looking at something requires looking away from something else. Consequently, I believe an additive approach, provides us with the most effective toolbox for listening to patients. A range of vantage points give enhanced flexibility to hear the patient most sensitively. Such an approach is under-utilized in the literature, although Lichtenberg (1984), Chessick (1992), Meissner (2000), and Helm (2000), are examples of interesting contributions which discuss multiple perspectives.
In this paper I will discuss my own multiple vantage point perspective. I have identified four listening modes through monitoring my clinical work, and through reading in the literature. It is quite helpful to me to be aware of these modes, to familiarize myself with them, and to be cognizant when I am using each.
The four modes are: conversational listening; listening for flow; listening for encoded meaning; and listening within one's self. During sessions I may utilize any or all of these modes, in any order, depending on the clinical material. In this way, I can shift back and forth among these different modes. With some patients, and in some stages of the treatment, I will more frequently utilize certain modes. Agility and flexibility in shifting among these modes is an invaluable asset in our work, although not necessarily easy to attain.
I will discuss each mode in turn, with clinical examples. My purpose is to describe and share this array of listening tools, in as practical a manner as possible.
The first mode I call conversational listening. This is a term I created as a slight variation on Hilde Bruch's description of a conversational approach with patients. Bruch (1988) suggested that the interchange between patient and therapist have the “openness and directness of ordinary conversation”. Bruch encouraged listening carefully to the patient's words, as a close friend would, without undue attempts to speculate or fit the problems into theory. Bruch was particularly concerned with helping the patient to take an active and individual approach in expressing what he or she feels and experiences, to actively explore internal meaning and draw one's own conclusions
I use the term conversational listening in a similar spirit, to refer to the kind of careful listening a friend or confidant might offer. If the confidant is gifted at listening, he or she will essentially function in a mode of conversational listening, as the speaker tries to convey his or her story. While the term conversational listening may strike some practitioners as suggesting a simplistic or very limited approach, I believe this listening mode can be a powerfully therapeutic, and is far more complex than it may first appear.
I have identified three primary characteristics of conversational listening. The first characteristic is that the focus of listening is on the manifest content. We primarily attend to the words the patient consciously discloses to us, which represents the shared picture of his or her mind. It should be noted that psychoanalysis has tended to minimize and underestimate the importance of this conscious experience of the patient. Busch (1999, p. 8) has suggested that a prevailing myth of contemporary psychoanalysis is that work on the conscious surface is superficial. As Grotstein (1984, p.14) has noted, the manifest content may seem obvious or simple for the therapist, but it may be absolutely profound for the patient.
One of the advantages of listening for manifest content is that it helps create an atmosphere of safety for the patient. With the focus on the voluntarily spoken words of the patient, the patient is basically deciding what is acceptable to talk about. As Searl (1936) has pointed out, the patient decides what is too anxiety producing to bring up, and thus the patient's ego serves as a natural filter, making judgments as to what is acceptable to discuss, within a workable range of tension and safety. As well, since the therapist is listening to the patient's words, rather than trying to `figure out' hidden meaning behind the patient's words, there is no atmosphere of suspicion, as Killingmo (1989) has discussed. The therapist doesn't `do' anything to the patient, such as interpreting unconscious meaning; and thus conversational listening, with its focus on manifest content, avoids problems connected with the model of the `patient-as-cadaver'. This evocative phrase, coined by Leo Stone (1961), describes the patient's situation within a model of treatment in which the patient supplies free associations and the therapist takes the role of seer, interpreting deeply into unconscious meaning.
A second characteristic of conversational listening is that it facilitates a progressive verbal elaboration by the patient of his or her experience, with all its nuances, subtleties, and complexities. We are inviting the patient to continually articulate inner reactions, in a series of deepening associative elaborations. Personal connotations, and the individuality of experience, are emphasized, in what Peterfreund (1983) calls a process of discovery.
This ongoing verbalization of inner experience is therapeutic in itself. Katan (1961) discussed how the young child's ego is strengthened through articulation of experience. For instance, verbalization helps strengthen the ability to delay action, through use of articulated thought as trial action. As Krystal (1988) discussed, verbalization helps in the crucial developmental processes of affect identification, differentiation, tolerance, as well as de-somatization of affect. These benefits of articulating internal experience accrue in treatment, whatever the age of the patient. Often significant parts of a person's experience have not acquired verbal representation in his or her mind, as Gill (1984, p.406) points out. In conversational listening, the therapist and patient attempt to clarify and flesh out these areas. I am reminded here of Basch's (1988) discussion on the large number of patients with disavowal of affect - who never learned to identify, label, and consider whole sectors of affective experience. While Basch is talking of a particular group of patients, in my experience this is true to some extent with all patients. The experience of trying to give verbal shape to internal, unnamed sensations, reactions, emotion, images, and sensory experiences is universal and ongoing.
Given this feature of conversational listening, a facilitating intervention is to ask questions, comment, and help clarify, whenever such intervention will help the patient to further identify and verbalize inner experience.. Lichtenberg (1984) notes, “ the analyst may add greatly to the patient's self-awareness by frequently asking him orienting and clarifying questions… may paraphrase or summarize the patient's statements to ensure and promote congruence of meaning. He may name and identify a feeling state or attitude” (p.126) It should be noted, however, that often there is little need for this kind of intervention by the therapist, for the patient may be effectively articulating inner experience without such help, but it is an option.
A third characteristic of conversational listening is that it conveys validating recognition of the patient's inner experience. The therapist conveys the seriousness and worth of what the patient has to say, through the attentive listening and desire to understand the patient's point of view. We try to see things from the patient's perspective, utilizing an affirmative point of view -people behave in a way that makes sense to them, even if they don't understand their own reasons or even if these reasons are misguided. Bettelheim (1987) has described such an approach in child-rearing: he suggests drawing out the child's reasons for any troublesome behavior, to try to see it from the child's point of view. Only when the child has succeeded in communicating the point of view, and feels taken seriously, and understood, will he or she be able to consider alternative views. Perhaps only under such conditions does a person feel emotionally met, and not isolated; whether with a parent or a therapist. Killingmo (1989) suggests that change can only take place under such conditions.
The patient may need help in facing and marking the painful and confusing realities of his or her life. Ultimately, this could be called witnessing. In witnessing, as discussed by Poland (2000), the therapist's emphasis is not so much on helping to enlarge understanding (as with Bettelheim), but on simply recognizing and beholding what the patient is saying, and struggling with. It communicates “profound and genuine respect for the authenticity of the patient's self as a unique other, an other self as valid as the analyst's own.” Loewald (1981) discusses a similar function of analytic therapy: “As is true in infancy and childhood, mirroring recognition is essential in making experience viable. …Validation…affirms and confirms the dignity, the reality and truth of an experience and of its particular mode. It is, one might say, the reality-test of inner experience, of psychic reality.” (p.29)
Clinical example 1.
A teenage girl, Ivy, who lives with her father and sister, came to the session after a day spent visiting her mother, who lives with her three pure-bred dogs. Up to this point in the treatment, Ivy had been very reluctant to say essentially anything about her mother. In this session, she began talking a little about how she and mother watched TV and a video, and went to the yoga studio, but that was about all they did. I sensed that now she seemed more open to talking, so I asked questions to elicit more material, such as about what they ate. Ivy described her mother's strange eating habits, such as only cottage cheese and crackers at each meal, or occasional canned soup. I commented that this sparse diet seemed like her mother's life more generally, which also seemed quite restricted. Ivy immediately shared that her mother didn't have any friends, but just works at her job, which is currently a factory job. And at work, she doesn't make friends, or real relationships, and doesn't have any connections in the union, so when she criticizes or antagonizes someone, there are no personal connections as a buffer, and she is more likely than other people to get laid off or fired. I said that's sad, and that her life seems dreary. Ivy noted that her mother was devoted to the dogs, but that she never dates, and that the phone almost never rings. During her visit, when the phone rang, Ivy and her mother were both surprised. Ivy said that she has been told that her mother was a 5 year old child when Ivy's grandfather was killed in a factory accident and that her grandmother supposedly then became both neglectful and hostile, and favored the two year old twins. As a child and teenager, Ivy's mother avoided home by going to the library everyday for hours. I commented to Ivy that her mother seemed isolated even then as a youngster. Ivy agreed, and noted that her mother's twin brothers are sort of more normal.
What are the characteristics of the conversational listening mode, as illustrated in the above example?
First, the focus is on manifest content- material which is of the utmost meaningfulness to the patient. Throughout this session, as Ivy talked of her mother, Ivy and I were both intensely involved in the conversation. There were none of the uneasiness sometimes seen in adolescent sessions - silences or complaints of not knowing what to talk about, from the patient, or the feeling on the psychologist's part of having to pull hard to get any meaningful material. While Ivy was not identifying and naming affects as she talked, nevertheless she was emotionally involved in a way that was new and meaningful for her. In fact, something occurred in this session which dramatically illustrated to me how intent the patient was on sharing this material:
Partway into the session, there was a loud knock at the door and before I could get up from my chair the door swung open. A delivery man strode right into the room, looked around, and stated that he absolutely needed to make this delivery today to the doctor in the adjacent room, who wasn't in. So I would need to sign the form, he said, and keep the package for the other doctor. The delivery man then handed me a form to sign, and also thrust the package toward me. As I signed he commented that he hoped his son would become a doctor one day, and he then rushed off. I was wondering to myself how this unexpected intrusion would affect Ivy - would it have some particular meaning for her that would alter the session? Would it be cast into transference terms? Instead, Ivy said, “That guy sure was in a hurry”. I nodded, and Ivy added, “I guess he's got to make those deliveries”. She paused momentarily, and then continued developing her observations of her isolative mother.
Essentially, this girl didn't miss a beat when the delivery man interrupted the session: she commented on it briefly and appropriately and then returned to the topic which was affectively gripping her, and which was so important to her to communicate to me.
Second, my listening facilitates a drawing out the patient's experience of her mother. Many of my comments to the patient are attempts to model and aide in this essential task: to help the patient progressively articulate the nuances and fullness of her experience. With this teen, conversational listening which did not include facilitative comments and questions by me would be less helpful, and possibly alienating. With some other adolescents and with many adults, conversational listening can proceed optimally with very few questions and comments.
Third, I am trying to convey a sense of understanding and acceptance of the patient; that she is not alone with her difficult thoughts and observations of her mother. Ivy has felt alone regarding this subject, for years. The treatment can be considered an ongoing effort to help her not only gain understanding, but to feel understood, regarding her internal experience of her mother, and the consequences of these experiences for her current functioning, such as handling of affects and cognitive coping strategies.
The conversational listening approach, as I have described it and as illustrated in the previous example, has significant overlap with what Lichtenberg (1984), Schwaber (1984, 1998), and others using a self psychology framework, call the empathic vantage point. Lichtenberg describes this as orienting one's listening to be from within the patient's state of mind and perspective. (p.116) .Schwaber's mode of empathic attunement places the focus squarely on the patient's subjective reality. The emphasis is on elucidating and empathizing with the patient's subjective experience of the world.
While the term `empathic vantage point' is entirely adequate in conveying the essentials of the conversational listening approach, as I have described them so far, I believe there is a fourth important characteristic of the conversational listening mode, which is not captured by the framework of the empathic vantage point, and which is why I tend to prefer the term conversational listening. This fourth characteristic of conversational listening is that the therapist listens for, and may point out, ego dysfunctions on the part of the patient.
This goes beyond the empathic vantage point, which attempts to “maximize a singular focus on the patient's subjective reality….vigilantly guarding against the imposition of the analyst's point of view” (Schwaber, 1984, p.160). By pointing out ego dysfunctions, I mean any instance where the patient's mind is not serving him well, and which the patient is not aware of. The conversational listener serves as a partner who constructively, and in an affirmative manner, identifies these problems. Langs (1973) would call this confronting the patient. We go from an `inside' position, which is the quintessential empathic position, to an `outside' position, in which we observe the patient from a different vantage point (Fosshage, 1998).
A patient, Ms. Nance, was talking in a dejected manner about a career disappointment - a grant proposal was not funded. After first empathizing with her dejection and utter discouragement, I realized that the degree of her reaction was puzzling, and was almost certainly an over-reaction which was not serving her well. I pointed out to her that she was reacting as if the news about the funding was a death blow to her project, rather than a disappointment or setback. I added that her co-worker seemed to suggest moving on to alternative funding sources, which might be constructive, and so I was puzzled by the discrepancy between that point of view and what appeared to be her internal collapse. Ms. Nance pondered this, and then said she could see that her reaction wasn't fitting to the circumstances. She had some ideas as to what was leading her to react in such a defeated manner, and we began exploring this.
In such an example we are helping the person to see where his or her ego functioning goes off track. This is actually the heart of analytic therapy. Anna Freud (1966, p.4) pointed this out: “From the beginning, analysis, as a therapeutic method, was concerned with the ego and its aberrations: the investigation of the id and its mode of operation was always only a means to an end. And the end was invariably the same: the correction of these abnormalities and the restoration of the ego to its integrity”.
I see a key aspect of conversational listening as listening for ego dysfunctions. By the way, frequently parents, spouses, and close friends or confidants informally listen in this way. For example, a friend might constructively point out to his college roommate, “You've been moping for days, all because that one girl didn't return your call. C'mon, don't you think you'll get other dates?”
Here are two more brief examples involving listening for ego dysfunctions.
Mr. Hamilton once again ate too much yesterday, to the point of feeling physically ill afterward. He says, he is perfectly aware that such overeating has this effect on him. Strangely, whenever he was reaching for an additional helping of potatoes or pie, he was no longer thinking that it would make him ill. I heard this as an ego dysfunction, and I pointed out to him that since he has knowledge of the effects of overeating, he seems to push it out of his awareness, to his detriment, each time he reaches for an additional helping.
While presenting sophisticated marketing data to her corporation, Ms. Blanton was uncertain about a certain survey technique in her presentation. She said with intensity in the midst of talking about this, “I don't know anything”. I heard this as an ego dysfunction, and pointed out that to be uncertain about a certain area, such as the survey technique, seems quite different than not knowing anything. I added that a secondary problem for her then develops in that she feels like a fake, once she convinces herself of her complete ignorance.
Patients present an infinitely varied array of these dysfunctions, of instances in which the ego is not serving the patient well, and patients depend on us to help them identify these problems.
I have now discussed conversational listening's four main characteristics. Before ending this discussion of conversational listening, I would like to briefly discuss the role of the therapist; the qualities of a `good' session through the lens of conversational listening; and some advantages and disadvantages of conversational listening.
The therapist functions with conversational listening primarily as a developmental facilitator. It is developmentally forwarding for the patient, as the therapist performs these specific functions: facilitating articulation of inner experience; conveying validating recognition and understanding; and identifying ego dysfunctions. These are processes which patients value highly because they provide stimulus for personal growth.
With conversational listening, a `good' session is marked by increasingly open and direct communication from the patient, with appropriate affective engagement. A `good' session does not depend on movement between past and present, nor between transference and external reality. Nor does it depend on intrapsychic depths being revealed or interpreted. Rather, the hallmark of a `good' session can be defined as an affectively true and meaningful, verbalized communication shared with the therapist (Peterfreund, 1983, p.67). This hallmark tallies well with the Novick's (2002) concept of open-system functioning, where there is increasing facility for putting feelings into words, growing facility for expressing feelings and reflections, and where self-esteem is built on such constructive forms of functioning.
What are the advantages, and limitations of conversational listening?
As I mentioned earlier, one advantage is that an atmosphere of safety is fostered.
A second, related advantage is that the patient tends to feel quite active. (This was, of course, a goal of Bruch's in her work with anorexic patients). The patient is the active source of the crucial data, which are the spoken words. And meaning will be primarily established by the patient. This approach is in keeping with what someone with a talented ear would do to help a good friend: invite articulation and let the speaker discover his or her own message. This is often how talented interviewers in other fields work, like the writer/critic Studs Terkel. For his book Working: People Talk About What They Do All Day and How They Feel About What They Do (1974), he interviewed people about their jobs, to facilitate articulation of their subjective experiences. One of the interviewees later said, in trying to describe what it had been like to talk about her subjective job experience, with Terkel, “I never knew I felt that way before” (National Public Radio interview, 2003). This is a very active experience: she had discovered herself in a new way, through Terkel's interviewing. This kind of listening has not had an esteemed place in analytic technique, traditionally. Nevertheless, conscious experience carries a certainty that nothing else can (Gill, 1984, p.406).
A third advantage of conversational listening is that it encourages a relaxed freedom in listening and inquiring, such as a confidant would have in listening to a friend. Arlow (1995) has pointed out that many analysts have a kind of wooden or frozen manner of hearing and especially responding that is not helpful, and he reminds us that treatment is a form of conversation, although an unusual one.
A further advantage is that the conversational listening approach is not confined to any specific group of patients. While it is true that certain groups may particularly need a conversational listening approach, such as adolescents, or adults with turmoil in their lives such as loss of a loved one, or patients in the evaluation or initial phase of treatment, the conversational listening approach should always be available, with all patients, in all sessions. It is a basic modality of listening.
What are the limitations of the conversational listening approach? The main problem may be that the therapist can listen to the manifest content but miss important underlying issues, as well as the resistance itself to revealing more in depth. Important symbolically encoded material can be missed -especially relating to the transference. In fact, the situation can deteriorate into what Eric Fromm (1974, p.117) calls `chatter'. In other words, there is lots of talking by the patient, but without real intimacy and illumination. The talk is being used to avoid communication, by the patient and possibly the therapist as well. (This may be somewhat similar to Inderbitzen and Levy's (1996) thoughts regarding how excess focus on reality events can be used as defense against looking inward at difficult material). Part of the art of listening consists of becoming aware when this is happening.
Listening to the Flow
We now proceed to the second mode of therapeutic listening. Here we are listening not for the elaborated content, but rather for the shifts in the ongoing flow of the communication. This tilts our listening from content toward process. Specifically, we listen for significant switch points in the flow of material. These switch points consist of changes in the directional flow of affect, impulse, as well as content. When we observe a switch point, we are alerted to the likelihood that two things have happened 1) the patient has experienced a sense of anxiety and risk, and 2) he or she has `managed' the situation by effecting some sort of shift in the flow.
Anna Freud tried to turn attention from primary emphasis on the content of the unconscious, which had excited the first generation of analysts, to a focus on observable clashes occurring in the patient during the session. Clash occurs as the patient tries to both express the mind freely, and then tries to squash these expressions. A hypothetical instance: the patient may say, “My boss missed the deadline for the project, she's really lazy, sometimes I feel like throttling her”. Long pause. “Oh, I probably haven't told you how bright she is, and I really admire her too”. Here, there is a shift in the flow of criticism and aggression toward the boss, a change of voice marked by a long pause and a flow in the opposite direction - toward admiration and perhaps a subservient tone.
Anna Freud (1966, p.14) writes of these moments when the ego intervenes with the flow of associations:
“The analyst has the opportunity of witnessing, then and there, the putting into operation by the… [ego] of one of these defensive measures against the id …and it now behoves him to make it the object of his investigations.”
Thus Anna Freud focuses `microscopically' on moments of conflict and defense occurring at the conscious surface. She `listens' for intrapsychic conflict first by hearing a drive derivative being expressed and then by watching for the collision of forces as the ego `objects' to the drive. Manifest consciousness is seen as an operational stage, with the parts of the mind speaking and clashing. Thus the picture of the mind is of voices clashing, and of struggle - all happening in the observable, moment to moment analytic setting. (Pray, 1996)
Anna Freud's approach was influential on Paul Gray's series of papers on ego psychological technique, which began in 1973. Gray and others have expanded on the method of attending to ego defensive processes in action, and this approach is now called close process attention, or close process monitoring (Goldberger, 1996).
As mentioned, I find it useful to think of these moments of breaks in the flow as `switch points'. This makes it very concrete - like a train running down a track in one direction and then suddenly the train heads in an altered direction, as if someone pulled a switch gauge. The ego, of course, is causing this change in direction. Most importantly, these alterations and variations in flow can be heard by the therapist and pointed out to the patient. These demonstrations of the switch point make visible to the patient what is otherwise out of his or her conscious attention. In this way we assist and strengthen the patient's ability to self-observe at the moment of conflict.
Here's an example:
Ms. Greer had returned that day from a computer programming tournament “We lost... In the championship round, the other team cheated”. Pause. “I don't want to talk about this.” (Silence). (I said: “You brought up immediately that your team lost, and that the other team cheated; then you stopped suddenly and are now saying you don't want to talk of it. Seems like a switch, a conflict maybe between starting to talk, and closing that off”) “I don't want to be perceived as whining, and as feeling like a victim”. (“Perceived by whom- me?”) “Yes, by you. And by everyone. I have images of my mother, saying, get over it, don't whine, don't be a cry-baby”.
Whereas in this example we hear the moment when the patient's ego tried to turn the flow switch off, in other examples we hear when the patient turns the switch on.. The switch - the change in voice - occurs when the ego suddenly allows material to emerge.
Ms. Hodges ruminated for most of the hour about work details and tension, a tendency she was aware of both generally and in this particular session. Near the very end of the session, she abruptly began talking of the visit over the weekend of her brother, and how the visit reminded her of her dead sister. Ms. Hodges was suddenly talking in a far more involved, affectively-engaged way. There had been a switch, from the dry, repetitive rumination to this animated involvement. Having heard this change in the flow, I thought that it might be helpful to point it out to her. I commented that she was suddenly sounding engaged in a purposeful way, after the earlier wandering. I added that since she switched to talking in this livelier manner at the very end of the session, maybe she had both a desire to express herself and some fear of doing so. As in the previous example, the emphasis in the listening and intervening is primarily on the flow and struggles with flow, rather than on the content.
The examples just mentioned have been an analysis of moment-to-moment shifts. This is the realm of close-process-attention. But it is also useful to listen for a second kind of change in flow. We listen for sequences of broader patches of material, as Busch has discussed. I believe that we are still listening for changes in the flow, but our ear is responding to broader swatches in the movement of the material.
A patient came in and wanted to talk about being charged for a missed appointment. Ms. Wallace said she didn't understand my rationale, and wondered if something could be worked out, to reduce the charge. She also wondered about a sliding fee scale, and some insurance issues. She talked at length of these issues, and when I explained my position, and told her that I wouldn't agree to change the policy, she said O.K., she could respect that. She also asked about the policy when I was away, which I explained, and I also told her of an upcoming week when I would be away. She said O.K., and paused briefly. Ms. Wallace then said she wanted to talk now of an issue regarding she and her boyfriend. She said that they didn't have sex that often; maybe once every few weeks, or once a month or even less. Talking to him makes it worse, as does confronting him; he gets sort of defensive and makes it a big deal, and she fears that might spoil sex when they do have it. She says she'd like to have sex a couple times per week. When I asked her how she felt as she was telling me this, she said she felt resentment and frustration with him.
As I listened, I realized that there were essentially two swatches of material in the flow of the session, with a rather sudden shift from one to the other. The first swatch was the material about fees, insurance, missed appointments, and my vacation; the second swatch was about the sexual issues.
The meaning of this shift was not clear. I had some fleeting ideas, such as wondering if the issue of fees, missed appointments, and vacation represented a sexual rejection in the transference, but I didn't feel strongly that this was what I was hearing. What was clear was that she seemed to be spontaneously producing a sequence of two broad swatches. The beauty of listening in this way is that the therapist doesn't have to know what it means, but can just point out the patterning, and learn together with the patient.
So I did this with Ms. Wallace - I pointed out the shift from one broad section to the other broad section, and wondered out loud whether there was a link. She immediately blurted out “Yes! Talking to you about the fee and the charges for the missed appointment is a confrontation, and I'm afraid it will make things worse between us, and if I'm angry over the fee, it will be disrespectful to you, and you'll react insecurely - like my boyfriend gets defensive and insecure. I feel resentful and frustrated with you over the fee thing, but I actually feel better now for having said it. I'm still afraid you'll pull away from me.”
In this session, once I heard the sequence of the two swatches, and asked if there was an associative link, Ms. Wallace took it from there. This mode of listening lifts the burden of trying to figure out what is `really' going on, as if the therapist should aspire to know what everything means. Pointing out the sequence creates a shared, accessible observation which the patient can then readily attend to - what Lichtenberg (1984, p.127) calls an `observational platform'. The spirit is that of joint work, which encourages further self-observation and the creation of satisfying insight by the patient.
So far I have been discussing listening for the flow of words: first, in the micro-moments of close-process monitoring, and second, in the sequences of broader patches of material. A third arena for listening for these patterns of flow is to listen primarily for the patient's manner and tone in presenting the material. When Wilhelm Reich (1949) studied character analysis, he recognized that a person's typical `way of being', the manner in which he/she relates, was highly significant. He noted, “The how of saying things is as important… as is what the patient says” (original emphasis). David Shapiro (1989) paraphrases this as: Pay attention not only to the words but also to the speaker.
I think of this in the following way: as the material flows, is the patient's manner of relating, in particular the affective tone, congruent with the content? When there is a discrepancy, it is important to hear this. If it is occurring for defensive reasons, one way of thinking of this is that that a switch point has occurred - out of sight - in which the affective component of the flow was diverted and substituted with another affect.
For example, in the initial sessions Mr. Wellman was talking of multiple problems and stresses, but was continually smiling and chuckling as he described these. Listening in terms of flow, there is a clear discrepancy between the affective flow and the content. Most likely, a switch point has occurred out of sight, probably before the sessions began, in which the affective flow of painful feelings was diverted and substituted with display of positive affects. I pointed this out to him, with fruitful results.
Here's another example: a young man, Mr. Clark, talks of problems at his carpentry job, of the stress, and his negative feelings about it. He says he knows that he is a glass half empty sort of person. He feels he is going over the same material over and over. In listening, I am struck by the discrepancy between the unhappy content and the manner in which he is talking. The manner is relaxed and even casual, his physical posture is sprawling as he essentially lounges on the couch, limbs extended freely in all directions. I share this observation with him, though he doesn't respond to it as meaningful. He talks of a bicycle accident when he was 16 years old, and of his subsequent problems in school due to missing weeks of convalescence, being made fun of by other kids, due to his injuries. As I listen, I am further aware that Mr. Clark is supplying content yet there is still some clear interference in the flow of affect. The subject matter continues to be discrepant with the speaker's large, sprawling manner and his energetic and confident, even muscular tone, like an athlete enjoying a post-victory drink. It appears that the emotional flow has been diverted throughout the session, and substituted with another quite different affect. So I again mention to him how I'm puzzled about this discrepancy, between his strong, muscular, confidently victorious demeanor, versus the content of his words, and wonder how he's feeling as he is talking. He then said, “If I were to start crying, what good would it do?” This of course opened the door to a whole piece of valuable work on his history of hardening himself emotionally, of losing his access to conscious sadness, and his pre-conscious premise that sadness is not constructive to reveal.
We have been discussing listening to different patterns of flow: whether they be moment-to-moment switches, as focused on with close process attention; or switches in broader pieces of the material, or discrepancies in the entire tone and manner of the speaker as he or she presents material. What are the strengths and weaknesses of this mode of listening?
The main strength is that the focus of attention (as in conversational listening) is near the conscious surface: the content listened for is the manifest content, and even when the patient's manner is commented on, as in the last example, it refers to surface mannerisms that are readily observable by the patient.
By listening for surface characteristics, which can be observed by the patient, the patient is accepted as a full partner in the observational process. The “observational platforms” are demonstrable shifts and switches which the patient is invited to actively review. The patient does not need to accept the therapist's point of view as true on grounds of higher authority, nor reject it out of hand. Rather, the patient is invited to work with the pointed-out-patterns. Thus the analyst is strengthening the ego's autonomous functions - such as self-observation abilities. The patient can utilize these tools on his or her own, at other future times.
By staying close to the conscious surface, the therapist is significantly relieved of the task of trying to decide what is permissible in consciousness. The patient decides this, utilizing an internal ego filter (Searl, 1936). The therapist generally defers to the patient's filter on decisions related to how much to bring to consciousness.
In other words, we work horizontally rather than vertically. As Busch (1999) describes, the material to be worked with resembles pieces laid out for a jig saw puzzle. We don't need to worry what is below the surface, rather we utilize a two dimensional space consisting of pieces, comprising patterns. I would see this horizontal space as the constant flow of the material through the session. As Searl (1936) notes, we become aware of the possibilities of re-arrangements, re-groupings, and previously unknown relationships between the parts.
How will we get to deeper material? Due to the safe atmosphere, and through learning about fears and defenses, the patient can gradually allow more material into consciousness. Thus with this type of ego-psychological approach, as Fenichel (1941) points out, material will keep bubbling up from within as the ego increasingly allows it.
A cliché in the field has been that in treatment we keep peeling the successive layers of the onion, going deeper into the onion. I think it is more apt to say that we just keep working at the surface layer of the onion, with the patient as observing partner, in the safe treatment atmosphere, and new elements keep rising to the surface layer from within the inside of the onion. All we need to do for the most part, with most patients, is stick to our job of assiduously and patiently working with the surface layer.
I have not explicitly addressed the issue of resistance analysis. Is it helpful to think of listening for breaks in the flow, as listening for resistance? I believe there are many similarities. Resistance refers to creative safeguards against revealing new, dangerous seeming material in the session. I find it helpful and comfortable to utilize the terminology of listening for switches in flow, rather than listening for resistance, due to the connotation resistance sometimes has, as opposing or negative, not only to the self but to the therapist. Listening for the patterning, the shifts in the communicative flow, has a more positive, affirmative quality, which as Schafer (1983) has pointed out is an important aspect of the optimal analytic attitude. Thus it helps the therapist to maintain the affirmative attitude in his or her own thinking, as well as in comments to the patient.
A weakness of this mode of listening is that not all patients can benefit from it. For example, I have found that children and adolescents may be unable to utilize flow-based observation, due to age-based cognitive and emotional limitations. As well, certain adults - such as adults in crisis, and adults who have not yet coalesced a sense of a self, seem unable to utilize such observations. The therapist risks alienating these patients, with continued use of these process-oriented observations.
Listening For Encoded Meanings
The third mode of listening is listening for the unconscious, encoded messages from the patient. This is the mode of listening which has been traditionally emphasized in psychoanalysis. The therapist tries to hear meanings which are outside the patient's awareness, are dynamically repressed, and which only surface in disguised forms.
Freud, of course, was the first psychoanalyst to address this task, and he viewed the analyst's work in this regard as using his own unconscious to apprehend the unconscious of the patient. He used the metaphor of a telephone receiver:
[The analyst] must turn his own unconscious like a receptive organ towards the transmitting unconscious of the patient. He must adjust himself to the patient as a telephone receiver is adjusted to the transmitting microphone. Just as the receiver converts back into sound waves the electric oscillations in a telephone line which were set up by sound waves, so the doctor's unconscious is able, from the derivatives of the unconscious which are communicated to him, to reconstruct that unconscious, which has determined the patient's free associations. (1912, pp.115-116)
Other analysts, such as Fenichel (1926) and Reik (1948) viewed the unconscious communication from the patient as consisting of minimal, implicit and unusual signals, which would not normally be noticed or understood by a listener. The therapist, however, must listen using altered forms of attention, to comprehend the hidden meaning of these signals. Isakower (1992), in his work on the `analyzing instrument', described a boundary permeability or merger which develops between patient and analyst as they enter in parallel fashion an almost sleep-like, state of hovering attention. This mutual, controlled regression toward an altered state of consciousness allows both for the patient to share primary process material, and for the analyst to recognize such material, resonate to it, and create complimentary images which can enhance understanding.
In listening for encoded meaning, I have found three key features. First, the derivatives, which Freud referred to, are what we strive to identify and decode. Derivatives sometimes consist of a few words or a single image, sometimes they are more extended metaphors. They are two-sided, containing both a manifest surface and the hidden, latent one. I have found it helpful, if fanciful, to think of these derivatives as resembling the floating toy duck in the carnival game, with a prize message on the bottom of the duck, concealed under the water. The part of the duck visible above the water corresponds to the verbal, and sometimes non-verbal, manifest communication. It is a symbol with a unique meaning for the individual, but the individual is not consciously aware of what it symbolizes. The message on the bottom of the duck, below the water surface, consists of the hidden, encoded, symbolized meanings. Specifically, these hidden elements are likely to consist of impulses, affects, memories, introjects, and fantasies. The mind utilizes ego defenses, such as repression, to keep these hidden elements, the contents of the unconscious, from direct expression in awareness. The concealment is only partial, however, for the mind is a mind in conflict, and the individual not only wants to conceal but also wants to express these aspects of self.
Second, it is helpful to try to identify what Langs (1973) called the adaptive context, the immediate circumstance which is leading to the use of the derivative material. This is essentially what Freud (1900) meant by the day residue for dreams. A more current term for adaptive context is trigger (D. Smith, 1998), a term which is simpler and perhaps more descriptive. These triggers are events (external or intrapsychic events) which provoke unconscious response. During the session the person is processing the triggering event, working it over on an unconscious level, and communicating about it through derivative material. While it is useful to listen for the trigger, as a means of identifying or decoding the derivative communications, it is not always possible to identify the trigger during a session. It may be unknown to the patient, or withheld consciously or unconsciously.
Third, it is useful to be familiar with the language of the unconscious, which is the primary process (Freud, 1900). This language differs from conventional communication, which is dominated more by the logic and organization of the secondary process. The language of the unconscious is characterized by a number of features: a) increased use of visual and other sensory, concrete imagery; b)increased use of the mechanisms of condensation, substitution, symbolism, and displacement; c) increased use of prelogical forms of thought, such as egocentrism, magical thinking, and especially associational connections, often based on similarities of small attributes or details; in contrast to connections based on formal classifications and logical relationships.
Here are some examples from listening for encoded meaning:
Mrs. Miley starts to comment on her hand placement during the session. Her hands have drifted into a certain position, she notes, mid-body, clasped gently together. She wonders about this unusual position. Suddenly, what pops into her mind is: it's like a body in a coffin. I asked her to elaborate, and she says she pictures her father in a coffin like that. She has another thought: today is a warm spring day, and today is one week before the day her father died - which was also a warm spring day. Mrs. Miley then has numerous memories about the circumstances of her father's dying.
In this example, the derivative is initially a nonverbal one, consisting of the unusual clasped hand position. After wondering about the encoded communication expressed in the body position, she is able to decode this in steps, first by associating to a body in a coffin, then to her father in a coffin. She then identifies the trigger, which is the anniversary of the father's death. The patient was able to bring this into awareness herself, without much prompting. We can identify a number of elements of primary process mental functioning in this communication: the salience of specific visual and bodily imagery; and the symbolism and substitution of a dead body image for the father.
The associational connection to the father's death seems to have taken place largely through the shared attribute of the warmth of a spring day, rather than through a more formal connection. In terms of prelogical thought, there may be magical thinking in terms of taking the place of the dead father, although this is not clear.
Russell, a high school senior didn't show up for his appointment. I decided to call him at 10 minutes into the session. Russell answered and said “Uh-oh, I forgot, OK I'll be right over”. He arrived 5 minutes later, apologized for forgetting, and then started to talk of how well he and his step-father were working together. Yesterday they put together a huge cabinet. His step-father listened to him well, and seemed to recognize that he - the son - had skills and things to say about the job.
While the patient didn't identify a trigger, I assumed that my phone call to him was a likely one. Consequently I was listening for encoded commentary in response to the call. The positive images depicting he and another person working together well, struck me as derivative material regarding his positive feelings about our work together, especially with the immediate stimulus being my phone call to him. The message that the son was well listened to and recognized as having things to say, seemed a further derivative communication to me: that he felt my call confirmed that I thought highly of him and wanted to hear him out. The presented images of Russell and his step-father working together well constituted the top of the metaphorical duck, so to speak, and the implied images of he and I working together well constituted the concealed portion of the duck. I decided not to interpret this transference message, because he had not yet volunteered any explicit reference to me.
Russell then talked of some things he needed to do that day, and then he started to talk of how he holds back with people, in fact with everyone. Sometimes it amounts to a conscious decision to not tell someone something. When I asked, he denied that he was withholding with me now, but he feels he does it in so many places, this hardening of himself emotionally. In fact - and he was now starting to talk animatedly - he does it with everyone, and he exclaimed “that's exactly why I'm here. I work everything over and over in my mind, and it accumulates.” At the end of the session, as he reached for the door, he turned to me and said, “I really appreciated your call”.
With this parting message, Russell finally put into explicit form, the hidden half of the derivative material about the step-father - the appreciative affect and the impulse to thank me. In terms of the language of the unconscious, the derivative material utilizes visual imagery (the images of constructing the cabinet) and uses displacement (the feeling of harmonious, effective interaction with me displaced to harmonious interaction with step-father).
The final example:
In the middle of a session Ms. Bigard associated to her recent nightly habit of reading a long magazine article about a favorite composer. She was very excited about the article; strangely, however, she would always put it down after 15 minutes, and she wouldn't read it during the day. She didn't know why, maybe it was too exciting somehow. Then she stopped her narrative and said, there's something about putting the magazine down, that may be related to the treatment here. However, she didn't know what it was, and fell silent. I pointed out to Ms. Bigard that she had been talking in the previous session about a tentative plan to move out of state for a few months. I suggested that by moving out of state, she would be putting down the exciting treatment and her feelings about me, as she put down her exciting magazine. She said yes, she sees the analysis as potent - it's been helpful to her in important ways, and she wants to get away from it, and from the analyst. She said she doesn't know why.
In this session, while the patient was initially talking about her recent habit of putting down the article, I was listening quite intently to the manifest content, in a conversational listening mode. Ms. Bigard was quite animated. However, when she stopped suddenly and suggested that there was a link to the treatment, I switched to the mode of listening for encoded meaning. I put together in my mind an encoded message, which I shared with her. In this session, the trigger was her tentative plan to move out of state, for several months, and then return. The visible part of the derivative was the putting down of the exciting article; the hidden message was the putting down of the exciting analysis and her feelings about me. The language of the unconscious here included visual imagery, symbolism, displacement, and substitution of the composer who was the subject of the article, for me.
An advantage of listening for encoded meaning is that it significantly expands the scope of comprehending the patient. If used in a spirit of collaborative decoding, the patient can feel sensitively held and more thoroughly understood. Listening for encoded meaning is especially helpful in hearing transference manifestations, which are often heavily defended and are often communicated in symbolized, displaced images and metaphor. Consequently, listening for encoded meaning is particularly useful in psychoanalysis, which typically utilizes transference as a central feature of the work. Nevertheless, I do not mean to minimize the usefulness in psychotherapy of listening for encoded meaning. Transference takes place in psychotherapy as well as psychoanalysis, and in any case not all encoded meaning is transference based (as shown in the above example of Mrs. Miley's encoded body-in-a-coffin).
There are a number of potential problems that can arise through utilizing listening for encoded meaning. First, this framework can put a strain on the listener. One can try so hard to identify in one's mind the hidden elements - such as triggers, derivatives, unconscious meaning - that one loses the relaxed receptivity which is optimal in clinical listening. Second, if overused, the patient can feel that there is a devaluing of what he or she is explicitly saying, in favor of a search for what is concealed. At its worst, a spooky atmosphere of suspicion can be created. This reminds me of a summer travel experience I had when a college age student. After crossing the border from West Berlin into East Berlin, I found an address on the main street which my Travel Book indicated was a travel information stop. I walked into a large, deserted, room, and went up to the solitary man, perhaps a government official, standing behind a counter. I asked him for a map of East Berlin. He looked straight at me, and said, in a rather ominous tone, “What is it you really want?” I felt quite unnerved and retreated back to the street. With patients, we certainly don't want them to feel as I did - that one's words are seen as a mere disguise for the real message.
Listening Within The Self
The fourth mode of psychoanalytic listening is what Lichtenberg calls `listening within'. Here the analyst's attention is briefly changed from focusing on the patient, as in the other three modes, to focusing on the self. The therapist turns inward to listen to an internal state.
This mode seems to utilize archaic, persisting forms of sensing, based in the developmentally early communication between mother and infant. In the mother-infant matrix, affects, sensations, intensities, rhythms and movements, are conveyed and experienced through the body. In the therapist, awareness related to this level of experience usually will initially appear not so much as secondary process, such as intellectual ideas, but as states emanating from the body, as `embodied' messages (Kumin, 1996). Jacobs (1973) uses the term “body empathy” to describe these corresponding experiences in the therapist.
The first three modes of my listening repertoire utilize primarily verbal language and symbols. Sometimes the language is explicit, sometimes encoded. As Lichtenberg (1983, p.210) has suggested, most communication in treatment can be apprehended on the symbolic level, i.e. utilizing language as the main coin of exchange. In contrast, a distinct feature of this fourth mode of listening is that the communicative exchange is largely presymbolic.
An appreciation of Spitz's (1945, 1965) developmental concept of coenesthetic communication is relevant here. Coenesthetic sensing represents the original communication between mother and infant. Coenesthetic response is largely visceral and generally experienced in terms of totalities, such as whole body reactions, rather than delimited perceptions. Affective experiences are salient; in fact Spitz sometimes interchangeably uses the term `emotive system' for the `coenesthetic system'. Communication is sensed through experiences related to bodily equilibrium, muscular tensions, posture, temperature, vibrations, skin and bodily contact, and in global qualities like rhythm, intensity, tempo, which Stern(1985) would call vitality affects.
Spitz believes that these body-based responses are gradually discarded, and atrophy, as they are replaced by the increasingly dominant perceptions through specific sensory modes, such as vision, and then communication through language. This sensory system, sometimes called the diacritic system, is characterized by localized, circumscribed perception, increasing cognition, and a sense of intentional functioning. In contrast, the coenesthetic mode is experienced as diffuse, visceral responses which happen to us, like bodily-sensitivities or affects surging. It is difficult for most adults to imagine what the coenesthetic experience of an infant is like. Spitz suggests the example of seasickness in the adult, as a vivid instance of coenesthetic stimulation of the body, experienced as an unpleasant visceral reaction, which includes diffuse gastro-intestinal upset, and dizziness. Spitz believes that the dormant coenesthetic communication system in adults, while basically replaced by the sensory mode, can be normally activated, for example by pregnant mothers and mothers of newborns, and by certain people such as artists. He also suggests that it as a tool for the psychotherapist.
More recent researchers, such as Stern (1985) (p.67), do not reject the idea of the global coenesthetic response but emphasize that the infant also has formidable capacities to begin to process and distill experience. From the earliest weeks after birth, the infant is gradually beginning to order, and connect elements of experience. An example is the capacity of infants for intermodal perception, which is the capacity to take information received in one sensory modality and somehow translate it into another sensory modality. For instance, laboratory experimentation shows that infants orally feeling a shape, by sucking an object such as a nubby pacifier versus a smooth pacifier, will then seem to visually know what the nubby pacifier looks like, as opposed to a smooth pacifier (without having seen either one before). Thus in this experiment, information received through oral tactile means has somehow been translated by the infant into visual functioning. This process of intermodal perception appears to be a capability which helps organize the often global quality of experience. Stern believes these early archaic forms of experience can continue through life, and be experienced at any age. He suggests that this subjective world of emerging organization forms the bedrock for human subjectivity, and can be used as a source for ongoing affective appraisals of events.
To describe what the experience of a pure intermodal response is like for an adult, Kumin (1996, p.86) offers an example: the sound of fingernails scraping across a blackboard evokes shivers immediately running down one's spine. Kumin also suggests that projective identification may be a form of intermodal exchange, as an almost concrete transfer of affects and sensations occurs between individuals.
I would now like to give clinical examples which include Listening Within the Self. In the first example, I have an essentially coenesthetic response; in the second example I have an intermodal response.
Mr. Terry, was talking of memories of his first girlfriend, in some detail. He talked energetically, in a declarative fashion. However, I found myself feeling increasingly restless, fidgety, and out of sorts, in a visceral way. It was a painful feeling, as if I was almost sick. Once I had registered this reaction consciously, and realized that it was not subsiding, I could try to appraise it and utilize it. I considered: Am I truly sick? I monitored my physical state for a moment and realized that I was not in fact sick. . I considered: am I tired? No, I had a reasonable night's sleep Am I distracted by personal issues? No, I didn't think I was. I figured then that I could be having an archaic but important internal response to something in the way Mr. Terry was talking. I couldn't put my finger on it other than that he was talking without context, and somewhat non-specifically, in a sense. I decided to share my line of thinking with him, and asked him how he felt about the way he was talking. He asked me what I meant. I responded, perhaps somewhat awkwardly, that it wasn't clear why but I found it hard to listen comfortably as he was talking, and I wondered if it could be something in the way he was communicating. I added that possibly he sounded somewhat pressured, but in any case it wasn't easy to grasp what was leading me to feel uneasy as he talked. After the briefest of pauses, he practically shouted out “It's impersonal! I do this all the time. It happens without really knowing it. It affects my relationships. I feel pressured, somehow, and feel that to do well in the relationship I need to talk as if I'm outside of me somehow, like I'm studying myself, I'm observing myself.” I told Mr. Terry that this sounded important, and that his whole manner of speaking to me had changed. I also noted to myself that I no longer felt the out-of-sorts feeling. This was the beginning of a long period of productive work with Mr. Terry on this subtle pattern of interpersonal detachment.
I had used my global bodily reaction as a helpful cue. My upset visceral sensations remind me of Spitz's seasick reaction, and it also reminds me of infants in experimental situations, where the experimenter or parent is acting odd emotionally, and the infant becomes upset. My response seems to be an illustrative example of coenesthetic reception. Consistent with such archaic sensing, my reaction was not initially mediated by thought or language, nor did it feel focused or intentional.
Rex was an antagonistic18 year old, referred by the Court, who was prone to violence and acting out. The transference had heated up rapidly, and at one point the patient leaned forward, looked me in the eye, and said, “You're going to get hurt”. What is notable here is my bodily- based response: the hair on my neck stood on end. In response to his total message, which included strong postural and expressive elements, as well as the words, I had a specific physiological reaction. This could be viewed as an intermodal response, in which information taken in through certain sensory means, such as vision and hearing, became transposed into the dermatological/tactile sensations on my neck. Though I wasn't sure intellectually if I should be concerned, my body was telling me that I should be. I used this archaic body based experience as a cue: I decided that the intensity of the transference had become overwhelming to the patient, and that he was not able to constructively manage the intensity of his impulses to me at that time. I immediately modified the treatment structure to bring in the father to the subsequent sessions, for a certain number of weeks. This helped to cool off the patient's overly intense reaction to me, and to provide assistance to his beleaguered ego in managing the intense rage responses. We were subsequently able to resume use of the individual sessions productively. In this example, as is often the case, Listening Within the Self serves as an initial step, when it is used to initiate cognitive considerations about the patient.
In the final example, the therapist cycles through all four modes of listening during the session, beginning with Listening Within, in response to the material and the communicative sequences which develop between patient and analyst.
A graduate student starts the first session of the week by telling me about her four day trip to another part of the country, where she attended some lectures in her field, visited museums and saw friends. Ms. Carney, traveled alone, although she has lives with a boyfriend in a rather detached, passionless relationship. She talks about the museums, the sights, and so on, but as I listen to her talking of these events I increasingly feel restless, somewhat disconcerted, and even slightly sick. I also feel vaguely irritated. I let myself focus on this fidgety, out-of-sorts reaction, which is Listening Within the Self. I don't know what this puzzling visceral, coenesthetic response means, but in pondering it I decide that it is probably related in some way to the manner in which my patient is talking to me. So I comment to Ms. Carney on the Flow issue: I say that that it is a little difficult to follow along, and that something seems different in her manner of talking to me today, that it is disconcerting although I can't identify what it is. The patient is silent for a moment, then looks very directly at me and says there is something else. (I took this as an indication that I was on to something by suggesting to her that the flow was in fact different in some way). She then begins a long, intense description of one of the evenings: she looked up a young man in the city, whom she vaguely knew from a graduate school connection. She took him out to dinner at an elegant restaurant, they talked intensely and openly, and they spent the night together. She describes how she went out of her way to be gracious, complimentary, and appreciative of this man, and how they had sex which was wonderful. But the main thread in the conversation was the tender emotion she felt for the man. During the encounter, she and he seemed to feel a deep, though transient emotional bond of caring and admiration for each other, which is a rare emotional experience for this woman. As I listen, I am in the Conversational Mode - listening intently to the manifest content, quite captured by the intensity of her story. I essentially try to follow along closely, without being judgmental, and I also help clarify the main thread in the story, which is the patient's gentleness and caring for the self-esteem of the young man. In this sense I am taking an affirmative point of view, for I sense that there is something importantly positive and enhancing in this encounter. The patient at times in her narrative has a twinge of guilt or self-doubt for what she has done, and knows that for various reasons this can only be a one-night stand, but the main affect is the mutual affection she created in the encounter, the aliveness. Her communication with me seems affectively open and intensely involved. However, near the end of the session she starts talking about a particular aspect of the encounter: the patient, who is financially well off, wined and dined the young man, and paid for a fine hotel room. She says that she knows that he could never have afforded these expenses himself, and she comments that in this sense the evening was `bought' by her and the feelings may be real but not completely honest. She continued to talk about this issue of whether the `bought' feelings were genuine. Now I was listening in a different mode - for encoded meaning. I was wondering to what extent she was indirectly referring to her relationship to me, a `bought' relationship, yet a relationship full of feelings which she had difficulty talking of directly? It seemed like there was increasing overlap to her relationship with me, and she could be talking in displacement of the treatment relationship. However, since there was not yet any explicit reference to me, and I wasn't aware of what the trigger was, I thought I could best help Ms. Carney by not intervening at this point. I kept my conjectures and possible interpretations to myself, and the session ended, but in the following sessions these latent themes involving her relationship to me became a more explicit focus. Thus in this session I cycled from Listening Within, to Listening to the Flow, to the Conversational Listening which then constituted the longest part of the session, to Listening for Encoded Meaning at the end of the session. It is interesting that during the Conversational portion, I was intellectually aware that there might be significant latent meanings gradually developing, but the material was so affectively gripping, and the patient seemed so engaged and affectively involved as she talked with me, that I thought I could help most by being content to stay within the conversational listening mode in an unhurried fashion, in order to resonate empathically to the intense spoken story, and help her elaborate it.
I have presented four modes of therapeutic listening. It is useful to me to be aware of these different modes, and to be able to orient myself within the session in terms of which mode I seem to be operating with. It is variable as to which mode or modes will be utilized during a given session, and in what order.
A compelling argument could be made that the conversational mode of listening, akin to the empathic vantage point (Lichtenberg, 1984), is the foundation of our listening, the workhorse of psychotherapeutic work. (This may be more true in psychotherapy than in psychoanalysis, which maximizes the transference relationship and analysis of encoded meanings). In any case, I believe that each mode is vital in its own way. I am also open to the possibility that there are other modes, not discussed here, which are also important.
Some practitioners may be able to listen on multiple modes simultaneously. For me, this has felt too arduous. I have felt most comfortable, and best able to offer the patient a relaxed receptivity, by listening in one mode at a time.
Through familiarity and practice, these modes can be integrated into one's working pattern, so that the selection of a listening mode, and the switching from one mode to another, occurs without appreciable self-consciousness and with a sense of creative freedom in listening. I believe that the patient benefits from the practitioner utilizing such an array of listening modes. Enhanced listening goes a long way toward providing the patient with an optimal, growth-promoting experience in treatment.
Arlow, J. (1995) Stilted Listening: Psychoanalysis as Discourse. Psychoanalytic Quarterly 64: 215-233
Arlow, J.A. (1979) Metaphor and the Psychoanalytic Situation. Psychoanalytic Quarterly 48: 363-385
Bacal, Howard A. (1998) Optimal Responsiveness and the Therapeutic Process. In Optimal Responsiveness: HowTherapists Heal Their Patients Howard Bacal (ed.) Aronson: Northvale, New Jersey. pp. 3-34
Balter, L., Lothane, Z., and Spencer, J. H. Jr. (1980) On the Analyzing Instrument. Psychoanalytic Quarterly, 49:474-504
Basch, Michael F. (1983) Empathic Understanding: A Review Of the Concept and Some Theoretical Considerations. Journal of the American Psychoanalytic Association 31:101-126
Basch, Michael F. (1988) Understanding Psychotherapy: The Science Behind the Art. Basic Books: USA
Bettelheim, Bruno (1987) A Good Enough Parent: A Book on Child-Rearing Alfred A. Knopf: New York
Bion, W. (1962) Learning from Experience. In Seven Servants. New York: Aronson, 1977
Bion, W. (1970) Attention and Interpretation. In Seven Servants. New York: Aronson, 1977
Bruch, Hilde (1974) Learning Psychotherapy: Rationale And Ground Rules Harvard University Press: Cambridge, Massachusetts
Bruch, Hilde (1988) Conversations with Anorexics: A Compassionate and Hopeful Journey through the Therapeutic Process. Northvale, New Jersey: Aronson
Busch, Fred (1999) Rethinking Clinical Technique Aronson: Northvale, New Jersey
Chessick, R.D. (1992) The Technique and Practice of Listening in Intensive Psychotherapy. Northvale, NJ: Aronson
Fenichel, O. (1926) Concerning Unconscious Communication. In The Collected Papers of Otto Fenichel, Volume I. W.W. Norton: New York, 1953. pp.93-96
Fenichel, O. (1941) Problems of Psychoanalytic Technique. New York: Psychoanalytic Quarterly
Fliess, R. (1942) The metapsychology of the Analyst. Psychoanalytic Quarterly 11: 211-227
Fosshage, James L. (1998) Optimal Responsiveness and Listening/Experiencing Perspectives. In Optimal Responsiveness: How Therapists Heal Their Patients Howard Bacal, (ed.) Aronson: Northvale, New Jersey pp. 117-139
Freud, Anna (1966) The Ego and The Mechanisms Of Defense. Revised Edition. International Universities Press
Freud, Sigmund (1900) The Interpretation Of Dreams. Standard Edition of the Complete Psychological Works of Sigmund Freud. Volumes IV, V. Hogarth Press: London
Freud, Sigmund (1912) Recommendations To Physicians Practicing Psychoanalysis. Standard Edition of the Complete Psychological Works of Sigmund Freud. Volume XII, pp. 109-120. Hogarth Press: London
Fromm, Erich (1974) seminar transcript, In The Art of Listening (1994) Continuum: New York
Gill, Merton M. (1984) Robert Langs on Technique: A Critique. In Listening and Interpreting: The Challenge of the Work of Robert Langs. Raney, James (ed.) Pp.395-414. Aronson: New York
Goldberger, Marianne (ed.) (1996) Danger and Defense: A Festschrift in honor of Paul Gray. Aronson: Northvale, New Jersey
Gray, Paul (1973) The Capacity For Viewing Intrapsychic Activity. In The Ego And Analysis Of Defense. Aronson: Northvale, New Jersey. 1994
Gray, Paul (1994) The Ego And Analysis Of Defense. Aronson: Northvale, New Jersey
Greenson, Ralph R. (1967) The Technique and Practice of Psychoanalysis Volume 1. New York: International Universities Press
Grotstein, James S. (1984) The Higher Implications of Langs's Contributions. In Listening and Interpreting: The Challenge of the Work of Robert Langs. Raney, James (ed.) Pp3-20. Aronson: New York
Hedges, Lawrence (1983) Listening Perspectives in Psychotherapy. New York: Aronson
Helm, Fonya Lord (2000) A Continuum of Listening and Interventions. Psychoanalytic Psychology, 17:730-749
Inderbitzin, Lawrence B. and Levy, Steven T. (1996) External Reality as Defense. In Danger and Defense: The Technique of Close Process Attention. Goldberger, Marianne (ed.) Pp. 193-220. Aronson: Northvale, NJ
Isakower, O. (1992a) The Analyzing Instrument: Further Thoughts. Journal of Clinical Psychoanalysis, 1, 200-203
Isakower, O. (1992b) Preliminary Thoughts on the Analyzing Instrument: A faculty discussion - October 14th, 1963). Journal of Clinical Psychoanalysis, 1, 195-199
Jacobs, Theodore J. (1973) Posture, Gesture, and Movement in the Analyst: Cues to Interpretation and Countertransference. Journal of the American Psychoanalytic Association 21:77-92
Katan, Anny (1961) Some Thoughts About the Role of Verbalization in Early Childhood. Psychoanalytic Study of the Child 16:184-188
Killingmo, B. (1989) Conflict and Deficit: Implications For Technique. International Journal of Psycho-Analysis 70:65-79
Kohut, Heinz (1959) Introspection, Empathy, and Psychoanalysis. Journal of the American Psychoanalytic Association, 7: 459-483
Kris, E. (1952) On Preconscious Mental Processes. In E. Kris (Ed.), Psychoanalytic Explorations In Art. (pp.303-318). New York: International Universities Press.
Krystal, Henry (1988) Integration and Self-Healing: Affect, Trauma, Alexithymia. The Analytic Press: Hillsdale, New Jersey
Kumin, Ivri (1996) Pre-Object Relatedness: Early Attachment and the Psychoanalytic Situation. The Guilford Press: New York
Langs, Robert (1973) The Technique of Psychoanalytic Psychotherapy, Volume I. New York: Aronson
Langs, Robert (1978) The Listening Process Aronson: New York
Lasky, Richard (2002) Countertransference and the Analytic Instrument. Psychoanalytic Psychology 19:65-94
Lichtenberg, Joseph (1983) Psychoanalysis and Infant Research. Analytic Press: Hillsdale, New Jersey
Lichtenberg, Joseph (1984) The Empathic Mode of Perception and Alternative Vantage Points for Psychoanalytic Work. In Empathy II (ed. Lichtenberg, Joseph; Bornstein, Melvin; Silver, Donald). Analytic Press: Hillsdale, New Jersey, 1984. pp.113-135
Loewald, Hans (1981) Regression: Some General Considerations. Psychoanalytic Quarterly 50:22-43
Meissner, W.W. (2000) On Analytic Listening. Psychoanalytic Quarterly 69:317-367
Novick, J., and Novick, K.K. (2002) Two Systems of Self-Regulation. In Psychoanalytic Approaches to the Treatment of Children and Adolescents. Special Issue, Journal of Psychoanalytic Social Work. 8, 3-4, pp.95-122
Peterfreund, Emanuel (1976) How does the analyst listen? On models and strategies in the psychoanalytic process. In Psychoanalysis and Contemporary Science, Vol.4 ed D.P.Spence. New York: International Universities Press, pp.59-101
Peterfreund, Emanuel (1983) The Process of Psychoanalytic Therapy: Models and Strategies The Analytic Press: Hillsdale, New Jersey
Poland, Warren S. (1996) Melting The darkness: The Dyad and Principles of Clinical Practice. Aronson: Northvale, New Jersey
Poland, Warren (2000) The Analyst's Witnessing and Otherness. Journal of the American Psychoanalytic Association 48:17-34
Pray, Monroe (1996) Two Different Methods of Analyzing Defense. In Danger and Defense: The Technique of Close Process Attention. Goldberger, M. (Ed.) Aronson: Northvale, New Jersey. Pp-53-106
Reik, T. (1948) Listening With The Third Ear:The Inner Experience of a Psychoanalyst. New York: Farrar, Straus, and Giroux, 1983
Reich, Wilhelm (1949) Character-Analysis. Orgone Institute Press: New York
Schafer, Roy (1983) The Analytic Attitude. Basic Books: New York
Schwaber, E. (1984) Empathy: A Mode of Analytic Listening. In Empathy II (ed. Lichtenberg, Joseph; Bornstein, Melvin; Silver, Donald). Analytic Press: Hillsdale, New Jersey, 1984. pp.143-172
Schwaber, E. (1998) From Whose Point of View? The Neglected Question in Analytic Listening. Psychoanalytic Quarterly 67:645-661
Searl, M.N. (1936) Some Queries On Principles Of Technique. International Journal of Psycho-Analysis 17:471-493
Shapiro, David (1989) Psychotherapy Of Neurotic Character. Basic Books: USA
Smith, David Livingstone (1998) The Communicative Approach. In Current Theories of Psychoanalysis. Robert Langs (ed.) International Universities Press. Pp.297-324
Smith, Henry (1999) Subjectivity and Objectivity in Analytic Listening. Journal of the American Psychoanalytic Association 47:465-484
Smith, Henry (2000) Countertransference, Conflictual Listening, and the Analytic Object Relationship. Journal of the American Psychoanalytic Association 48:95-128
Spencer, James H., Jr., and Balter, Leon (1984) Empathy and the Analyzing Instrument. In Empathy II (ed. Lichtenberg, Joseph; Bornstein, Melvin; Silver, Donald). Analytic Press: Hillsdale, New Jersey, 1984. pp. 289-307
Spitz, R.A. (1945) Diacritic And Coenesthetic Organizations: The Psychiatric Significance of a Functional Division of the Nervous System into a Sensory and Emotive Part 146-162
Spitz, Rene A. (1965) The First Year Of Life: A Psychoanalytic Study of Normal and Deviant Development of Object Relations. International Universities Press: New York
Stern, Daniel N. (1985) The Interpersonal World Of The Infant: A View from Psychoanalysis and Developmental Psychology. Basic Books: New York
Stone, Leo (1961) The Psychoanalytic Situation: An Examination of
Its Development and Essential Nature. International Universities Press: New York
Terkel, Studs (1974) Working: People Talk About What They Do All Day and How They Feel About What They Do. Pantheon: New York
David B. Klein, Ph.D.
e-mail: [email protected]