Seek Another Person’s Authentic Story
The most precious gift we can offer others is our presence. When mindfulness embraces those we love, they will bloom like flowers.
—THICH NHAT HANH, Living Buddha, Living Christ 1
“Since communication is the glue that holds individuals together in society, I cannot but wonder whether society would run better if communication worked better.”2 So said George A. Miller, president of the American Psychological Association in 1969 in a statement that is as true today as it was then. How can communication “work better,” especially among caregivers and patients where the stakes are so high? It is a truism that there are two sides to every story: the side of the person who is speaking and that of the listener. The aim, when making a true connection, is for there to be as little distance as possible between these two poles—that is, ideally, what the speaker conveys is absorbed, understood, and acted upon by the person to whom the story is told. Sir William Osler has said, “It is more important to know what sort of person has a disease than to know what sort of disease a person has.” To really know the sort of person caregivers are dealing with, they must converse with him about his truths.
This seems an easy goal, but unfortunately, all too often, caregivers fall short. As we’ve seen, unless one is vigilant and mindful, biases and internal clutter can cloud the interaction. And then there are times when a “duologue” rather than a dialogue occurs. This is when people are talking at each other rather than with each other—everyone speaks but nobody listens. Duologue is monologue waiting its turn. Dialogue, on the other hand, denotes meaning running through.
A case in point: Recently, Dr. Michael Stein, an internist and the chair of Health Law, Policy and Management at Boston University, described in the Washington Post how the gap between speaker and listener widened to a chasm for his friend Sophia when she realized that something was “seriously off” with her health and sought help for neck pain and a low-grade fever from an unseasoned physician at a walk-in clinic. Here is how Sophia, who admitted that she rarely visits doctors, described the encounter:
“Would you test me for strep?” I ask.
“You’re overreacting. You just have a cold,” this young doctor says.
Would he have liked to hear me make a bigger deal about how badly I felt? I almost had to beg for the strep test. When it comes back positive, I’m so angry, I can barely speak to him. He was incompetent. Or trying to save money. Or maybe he was just lazy. He was certainly unkind.
Sophia’s young doctor failed her in many ways. His poor bedside manner was matched only by his lack of skillfulness as a diagnostician. But, perhaps most importantly, he violated Sir William Osler’s dictum: Listen to your patient; he is telling you the diagnosis. I also found it interesting that the word “unkind” remained in Dr. Stein’s mind for weeks after he’d heard this story.3 Isn’t that what we all seek from caregivers—compassion and kindness?
Failures in communication such as this one not only hurt patients emotionally but they can also be quite costly physically and fiscally. CRICO Strategies, a research and analysis offshoot of the company that insures Harvard-affiliated hospitals and has a robust data bank compiling approximately 30 percent of U.S. malpractice cases, released a report in 2015 that analyzed more than twenty-three thousand medical malpractice claims and suits in which patients suffered some degree of harm; three out of every ten cases include at least one specific breakdown in communication in which facts, figures, or findings got lost between the individuals who had that information and those who needed it—across a wide spectrum of health care services and settings.4 Hospitals and doctors’ offices nationwide might have avoided 1,744 patient deaths and $1.7 billion in malpractice costs if medical staff and patients had communicated better. These failures to connect involved medical horror stories that no family or professional wants to experience.5 Caregivers’ ineptitude at communicating is largely to blame for the United States’ $3 trillion health care system that results in poorer outcomes when compared with other countries that spend far less on their patients.6
The consequences of poor communication may be disastrous for everyone. How can people avoid these devastating scenarios? The benefits of trust and open sharing on the part of the speaker and what I like to call deep listening on the part of the receiver are manifold. There is no downside. Indeed, when these activities occur in the context of a medical visit or other salutary encounter, not only are grave mistakes avoided but health and well-being can actually be improved. So let’s look at both sides of the story.
THE THERAPEUTIC VALUE OF TELLING ONE’S AUTHENTIC STORY
I knew Monica to be a kind, joyful person—one who giggled often. She was in her late seventies and had been diagnosed with the common but dangerous trilogy of diabetes, elevated cholesterol, and hypertension. During one of her office visits, I noted that her blood sugars and blood pressure were spiking somewhat alarmingly. Had I not invoked my connection with my patient, I might have lectured her on the dangers of her lifestyle choices and urged her to adhere more closely to her diet and exercise regimen. Or I might have increased the dosages of her medications—probably the most efficient action to take. However, I also knew that this status change among diabetes patients is frequently a reaction to stress. So instead of exhibiting a more authoritarian attitude, I paused and took a breath. Then, I simply asked Monica, “What’s new in your life these days?” When she started talking about her son, I noticed her gaze fell to her lap. Her eyes filled, as if she were about to cry. Her nonverbal behavior prompted me to gently inquire further.
It was difficult for her, but through her tears Monica eventually revealed that her son was acting abusively toward her. I remained silent as she poured out her heart, but I watched her face and listened intently to her words and intonation. I was honored that she was willing to share with me the story of someone whom she loved but who was treating her so badly. Because of the underlying trust between us, she felt safe in conveying a truth that felt shameful to her. And that helped me better understand the effect this situation was having on her emotionally and physically.
When she reached the end of her story, Monica seemed peaceful. Indeed, because our interaction provided her the space to unburden herself, she left my office in a more cheerful state. And over time, her health improved as her sugar and blood pressure markers diminished to less dangerous levels.
My experience with Monica provides valuable lessons. First, people are unlikely to speak their truth or express their genuine emotions unless they feel safe and perceive the listener as trustworthy and caring. Without these structures in place, their words will be shallow, meaningless blather—and their well-being will be undermined. This has been borne out in scientific investigations. For instance, Matthias Mehl asked nearly eighty students to wear electronically activated digital audio recorders that unobtrusively tracked their conversations over four days. He then correlated the students’ well-being and “happiness” with their engaging in less small talk (uninvolved, banal chatter) and more substantive, involved conversations in which meaningful information was exchanged.7 These deeper conversations do matter.
But perhaps even more importantly for our purposes, if people don’t share significant truths, valuable healing opportunities will be lost. Research has consistently documented that talking or writing about emotionally upsetting experiences has physiological benefits. It has been found that meaningful interactions improve physical health over time (as was evident in Monica’s case), enhance immune function, and result in fewer visits to medical practitioners.8
Social psychologist James Pennebaker has studied the health consequences of keeping secrets, expressive journal writing, and natural language. A pioneer in the field of writing and narrative therapy, he has researched the link between language and recovery from trauma. He and his colleagues developed a computerized text analysis program called the Linguistic Inquiry and Word Count that analyzes eighty linguistic categories of speech such as the use of pronouns (whether a person uses “I” or “we,” for instance); psychologically weighted words expressing primary negative affect such as “anger,” “fear,” or “sadness”; and particular topics like relaxation or money. His work builds on previous research establishing strong links between a person’s speech patterns and his or her personality or psychological state. Pennebaker and his teams have used this tool to analyze people as disparate as Al Qaeda operatives and U.S. presidential candidates.
In one of his early studies, Pennebaker and his team interviewed polygraphists (operators of lie detectors) who worked for the FBI and the CIA. In performing these tests, the polygraphists would look for changes in their subjects’ autonomic nervous system responses such as heart and respiratory rates, blood pressure, and skin conductance (the amount of sweat leaking into their skin) for clues of whether they were telling the truth. Pennebaker and his team found, in what he dubbed the “polygraph confession effect,” that readings in these areas dropped significantly after a person confessed. These changes are consistent with those seen when a person relaxes.9
Holding in negative emotions and keeping secrets takes a physiological toll. Investigators believe that actively inhibiting thoughts, feelings, and behaviors requires physical work that results in chronic low-grade stress on the autonomic nervous system, which may then lead to or worsen disease. This inhibition can also trigger dysregulation of the hypothalamic-pituitary-adrenal axis, causing elevations in the stress hormone cortisol that are usually accompanied by weight gain and immune suppression.10
How does this work? Disclosing stressful events transfers difficult repressed thoughts from the unconscious to a conscious level where people can better organize and control them. Talking about these occurrences allows the mind to interpret this previously hidden information and unlocks emotions that can stimulate positive physiological results. It removes the need for chronic low-grade stress to stimulate the autonomic nervous system and the hypothalamic-pituitary-adrenal axis, which can cause a cascade of chemicals and hormones that lead to stress-related symptoms and poorer health outcomes.11
Examples from the aftermath of 9/11 elucidate how this phenomenon actually occurs. Shortly after the destruction of the World Trade Center, James Pennebaker’s team researched New York City residents’ online journal entries two months before and two months after the attacks. They found that the New Yorkers switched in their writings from more egocentric first-person singular pronouns (“I” and “me”) to more communal words that foster relationships such as first-person plural pronouns (“we” and “us”). It seems that this tragedy opened these people to heighten their connections with other members of their community.12 Most interestingly, Pennebaker correlated these findings with visits to health care providers and found that as the people of New York shared more, they made fewer doctor visits during the difficult postattack period.
This kind of openness takes place naturally for two or three weeks after a tragedy. During this emergency phase, individuals and the media discuss the event frankly. But after about three weeks, conversations decrease, despite the fact that feelings and thoughts have not diminished. This is called the inhibition phase. Research has found that journaling and talking can be most beneficial during this stage when expression wanes but thoughts remain.13
Numerous studies have investigated the positive impact of emotional disclosure (in written or oral form) on the experience of trauma, pain, and also particular health conditions such as asthma, rheumatoid arthritis, fibromyalgia, wound healing, and irritable bowel syndrome. In one study that involved 107 patients with asthma or rheumatoid arthritis, the treatment group was asked to write about the most stressful event in their lives for only twenty minutes over three consecutive days. The control group simply documented daily events. Four months after this singular experience, the lung function of the people in the study group with asthma showed a 20 percent improvement while those in the control group had no change.
The benefit for people with rheumatoid arthritis was even stronger. Those who wrote about stressful events enjoyed a 28 percent reduction in the severity of their disease. Again, the control group showed no improvement.14 Follow-up studies have confirmed these results. In one study that analyzed the effects of verbal or written emotional expression on rheumatoid arthritis patients, researchers found that three months after their initial journaling or discussion, those who disclosed their feelings walked faster when compared with the control group. And at six months, they had reduced pain and swelling in their joints and less doctor-rated disease activity.15 Others have found a statistically significant drop in cortisol and interferon gamma (an inflammatory stimulant) in rheumatoid arthritis patients who participate in emotional disclosure.16
People with fibromyalgia enjoy similar benefits. A 2005 study tracking the effects of writing about trauma showed improvements in psychological well-being, pain, and fatigue.17 Other research has demonstrated that at three months, participants who wrote about their emotions had a greater reduction in the overall impact of fibromyalgia, poor sleep, health care utilization, and physical disability than those who were asked to write about time management.18
Research has established that psychological stress impairs wound healing by down regulating the immune system.19 For instance, in a study of fifty-two living kidney donors, it was found that those who had higher preoperative stress and less optimism had delayed wound healing as compared with those who were more emotionally stable.20 But expressing emotions can mitigate the effects of stress and lead to quicker wound healing by improving immune function. In one British study, for instance, thirty-six participants completed questionnaires measuring emotional distress, loneliness, self-esteem, social support, optimism, and health-related behaviors. The participants then underwent small punch biopsies. One group wrote about traumatic events in their lives while the other wrote about time management. Healing was measured using a high-resolution ultrasound scanner. The first group had significantly smaller wounds fourteen and twenty-one days after the biopsy compared with those in the control.21
See Appendix B for web-based resources and patient instructions on how to journal.
Emotional Expression Characteristics Associated with Health
Therapeutic benefit derives from the expression of the emotions themselves. The following key rhetorical characteristics have been most commonly associated with a shift toward improved health.22
• The writer constructs an evolving story. People who create a story with a beginning, middle, and end do better than those who repeat the same story day after day. Creating a story transforms the event into one that is easier to understand and learn from.
• The writer develops insight and uses more causal words such as “realize” and “understand.”
• The writer develops more optimism, with greater use of positive words and a moderate number of negative words.
• As the story evolves, pronouns changed from first-person singular (“I,” “me,” “my”) to first-person plural (“we,” “us,” “our”), suggesting that with writing, the person has become less isolated and more connected to his or her community.
I used to tell my patients that they could express these emotions in the privacy of their own homes, that no one need read their writings. I believed that the core therapeutic process was achieved when they provided their stress with an avenue for verbal expression. However, more recent research suggests that I was wrong in this assumption. We now know that the immune system is strengthened when writers are aware that someone will read their journals. It’s the sharing that’s so important. And that sharing can and should occur verbally as well, to a similar positive effect. People need to know that others are actually listening for these benefits to accrue. This may be another reason why participation in support groups has such a powerfully salutogenic effect on cancer patients.23
LISTENING: THE OTHER SIDE OF THE STORY
What’s the point of sharing one’s deepest thoughts and feelings if the words fall on deaf ears? In one of my favorite classic rock songs, “The Sounds of Silence,” Simon and Garfunkel sing of “people hearing without listening.” I believe they have identified a human experience that everyone can relate to. The fact is, there are actually two kinds of listening: self-focused (hearing without listening) and other-focused (being available and tuning in). Let’s look at these more closely.
Self-Focused Listening
Stephen Covey, author of The 7 Habits of Highly Successful People, has written: “Most people do not listen with the intent to understand; they listen with the intent to reply.”24 If the listener is focused on his own thoughts, filtering through past experiences, history, or assumptions as he formulates his response, he will be distracted and inattentive. Indeed, he will actually be multitasking as he mentally accesses personal stories, his own agenda, or potential explanations and advice. This is the best way to carry on a “duologue,” not a dialogue.
A patient may be in the midst of expressing some useful ideas or may even be on the verge of an important bit of self-disclosure, but if the caregiver is engaged in self-focused listening, his comment, suggestion, or question will cause the former to stop talking, redirect his attention, and consider what has been interjected.25 Interruptions are most often self-focused and inhibit speakers from fully voicing their concerns—and they occur all too frequently in the examination room.
Doctors often interfere with their patients’ self-disclosure with closed-ended (yes/no) questions. It’s their way of controlling the interaction—to the detriment of the people they are charged to serve. Among the many studies examining physician/patient interactions, several have gauged the effect of interruptions. In one study conducted in 1984, fifty-two out of seventy-four patients (69 percent) had exactly eighteen seconds to state their first complaint before their doctor jumped in. In essence, the physicians stopped their patients from sharing more information and blocked the opportunity for them to convey their most pressing fears. Only one of the fifty-two patients who was quickly interrupted got back to his initial concerns and actually finished explaining them to the doctor. Moreover, only 23 percent of the patients listed all of their complaints without the doctor interrupting them. Saving time might have been a motivation for trying to hurry along the interactions, but it usually took only ninety-two seconds for those who made complete statements to get to the end of their list. No one in this study needed more than two and a half minutes for the full disclosure.26
Imagine how much more time is lost if the person in need never gets to fully express the issues he’s facing. All it takes is a little patience for a meaningful conversation to take place. And in the end, this is more time efficient because the listener obtains the information needed to facilitate positive change rather than provide “word fill” about dull topics that carry little meaning or emotion and detract from a person’s well-being.
Moreover, when people have repeated experiences in which they are interrupted and diverted, they become braced for a certain type of unsatisfying interaction, and they alter their own behavior accordingly. Because they feel uncomfortable, they may hold back information they believe is relevant. Or they may phrase it in ways to “win over” the listener—which may not involve saying what they really wanted to say. This is the difference between having a dialogue and being in a debate. Debate means to beat down. It’s like a sporting event. One side is trying to prove that their arguments are superior to the other’s—that their beliefs are more powerful than the other’s. This often includes one person projecting his or her point as “the law” even before understanding the other’s viewpoint.
Other-Focused Listening
When two people talk, it can take work to reach the topics that matter most. And often that requires adequate time and the right kind of listening. Everyone knows how to listen, but do they know how to listen deeply and with compassion? Other-focused (or deep) listening differs from simple everyday and/or self-focused listening by providing a suffering individual with a presence that allows him to feel safe and undefended. This nurturing environment frees him to express his authentic story.
During such a true dialogue, two people share information that brings forth a deeper understanding. The diversity of thought provides insight to the other that moves one beyond preconceived notions. This is where new discoveries occur in the form of “Aha!” moments. This kind of other-focused listening requires the listener to have a “beginner’s mind.” She has no agenda and doesn’t know (but wants to learn) about what the speaker has to say. She remains quiet as she pays attention to body language, facial expression, and tone of voice. She attunes to the energy and emotions behind the words. Being mindfully present, she also allows for silence, pauses, and space, being aware of details that will allow her to make a more accurate assessment. She takes in as many bits of information as possible in order to absorb as much of the other person’s authentic reality as she can. She is truly available to the other person in a way that yogis may be when they say, “Namaste.” Literally, this translates into “My soul sees your soul.”
If she poses questions, they are in the service of encouraging the conversation to evolve. In that case, they are open-ended queries such as “Tell me more,” or “That topic seems to evoke some emotion.” A question I have found useful in helping my students and patients understand the dynamic interplay between mind and body is “Where in your body do you carry stress?”
I believe that most caregivers have a lot to learn when it comes to other-focused listening. Doctors dread what has been called the “doorknob moment,” when their patients finally blurt out what’s really bothering them in the last seconds of the office visit.27 Often this occurs because the prior discussion has not allowed for the patients to get into their most important issues. Admittedly, many caregivers don’t have the luxury of time. But to have a meaningful conversation, trust must be established in a one-on-one interaction without interruptions, allowing the other person’s truth to flow sooner rather than later.
Caregivers can learn quite a bit from Thich Nhat Hanh, a Vietnamese Zen Buddhist monk. Along with being a teacher, author, and poet he has been a peace activist since the Vietnam War and was banished from his country at that time because of his pacifism. In the 1960s, Martin Luther King Jr. had nominated him to receive the Nobel Peace Prize. Several years ago, I watched an interview that Oprah Winfrey conducted with this holy man about seeking peace, and although his comments had more to do with quelling anger among warring parties, I believe his statements regarding what he called “deep listening” are compatible with other-focused listening and completely applicable to people who render care to others. The following is an excerpt of this inspiring interview:
Deep listening is the kind of listening that can help relieve the suffering of another person. You can call it compassionate listening. You listen with only one purpose: to help him to empty his heart. Even if he says things that are full of wrong perceptions, full of bitterness, you are still capable of continuing to listen with compassion. Because you know that listening like that, you give that person a chance to suffer less. If you want to help him to correct his perception, you wait for another time. For now, you don’t interrupt. You don’t argue. If you do, he loses his chance. You just listen with compassion and help him to suffer less. One hour like that can bring transformation and healing.28
Unfortunately, when most people wait for their turn to talk, they do not listen like Thich Nhat Hanh, with the purpose to help the others empty their hearts. They have their own agendas. Individuals may listen to only a portion of what is being said because they don’t focus their minds on the speaker. It’s difficult to listen deeply to someone’s feelings when laying out one’s next comments or thinking of ways to explain the situation. And the person speaking will surely feel the lack of attunement and clam up.
Some say that learning to listen is more difficult than learning to ask good questions.29 I believe that is quite true. Hearing what someone says and truly listening to them are two distinct activities. Good listening and observation are the highest forms of emotional intelligence. They precede taking proper action.
THE TRUE VALUE OF LISTENING WELL
When in my rural practice, I had thought that the most powerful drugs in my armamentarium were antidepressants. I would go through the steps of the connection with my patient, and then prescribe the magic . . . fluoxetine 20 mg or sertraline 50 mg. I would ask the patient to return in two weeks, conveying to her the expectation that in fourteen days she should start sleeping better and have more energy. It often worked. But to what do I ascribe the credit? As a society, we give all the power to the pill, when in reality, most of it comes through the caregiver and the therapeutic ritual that occurs even before the pill is prescribed.30
Antidepressants and the pharmaceutical companies that sell them have changed cultures. A New York Times article documented how Japanese culture, grounded in the Buddhist philosophy that posits there is a reason for suffering (and if people take time to pause and learn from their suffering, they can transcend it), has embraced depression as a disorder. Until 1999, mild to moderate depression was unheard of in Japan—there wasn’t even a term for it until Big Pharma introduced kokoro no kaze, the notion that “the soul has caught a cold.” Since then, the use of antidepressants has soared. The drug companies believed (and rightly so) that depression was being undertreated in Japan. But were more drugs the answer? Once the companies started to market SSRIs heavily and more of them were prescribed, the high suicide rate declined but the culture shifted. Depression is now seen in Japan as something that needs a pill. And today there is greater dependence on a passive treatment than an active, internal exploration to understand and transcend what may be at the root of a person’s anguish.
If someone is suffering, there is a story to their suffering. Some stories may present themselves as a symptom of pain or depression. This story, when told, can elicit two disparate processes. One is the habitual, reflexive attachment to a treatment protocol for a symptom. If a patient comes in complaining of heartburn, the clinician turns off the acid with an acid-blocking pill. If, as in Monica’s case, blood sugars and blood pressure rise, medications are adjusted accordingly. On the other hand, the caregiver can listen for meaning in the story . . . What is eating up this person inside? Why is she so stressed out? Why is he eating himself to death? One approach addresses the physical symptom, the other addresses the deeper meaning beneath the symptom. The first path is linear while the second is circular.
FROM LINEARITY TO CIRCULARITY
Art used to be flat and two-dimensional—consider Egyptian paintings, Greek friezes, and medieval representations of biblical scenes and saints. But then, during the Renaissance, artists discovered how to design a centering point that created three-dimensional perspective—and people came to see the world in a more complex way. Newtonian physics is also linear. Gravity pulls the apple from the tree, and it falls. Today, with the advent of string theory, physics has evolved our understanding of the universe as being subject to multiple realities or perceptions. Indeed, few things in nature are simply linear. Consider the circular patterns of a Fibonacci sequence that occur in the eyes of hurricanes, in conch shells, and in the whorl of seeds around the center of a blooming sunflower. Nature repeats this circular equation multiple times.
Medicine is undergoing a similar transition in thought. Attaching a drug to a symptom is linear. If a patient has pain that’s traced to too much acid in his stomach, the physician will turn off the acid pump with a drug. For the person with heartburn, this linear approach of simply turning off the acid will improve symptoms and help the clinician get on to the next patient, but it can also have negative long-term effects. Chronic acid suppression has been associated with an increased risk of heart disease,31 kidney disease,32 and memory loss.33
Healing, by contrast, is circular. It is a continuous dialogue between two people that results in a deepening spiral of connection toward meaning that allows caregivers to understand and facilitate self-healing mechanisms. This meaning often results in the release of emotions that motivate patients to move toward salutogenesis. Listening to patients’ stories and the context of why they have an upset stomach is much more dynamic than simply turning off the acid pump with a drug. In the final analysis, the healing process requires deep listening, not the habituated reflex of only writing a prescription or ordering a test.
I have had the honor to work with the Veterans Health Administration on a project called Whole Health led by my colleague Tracy Gaudet that is geared toward empowering veterans to be active participants in the health care they receive so it can be organized around what’s most important in their lives. The strategy is to use this internal motivation for positive change by integrating the medical care into the context of their lives. We start with different questions, such as “What do you want your health for?” “Where do you feel you need to start to get there?” and “How can we use our expertise in support of your health mission?” I have had the gift of working with many passionate people in the VA health system, one of whom is psychiatrist David Kopacz at the Veterans Administration hospital in Seattle, Washington. He has further delineated the difference between a linear treatment and circular healing.
| Linear Treatment | Circular Healing |
| Pathological process | Natural process |
| Treatment | Transformation |
| Restoring old state | Achieving new state |
| Disease based | Health based |
| Biomedical model | Health model |
| Hierarchical | Collaborative |
| Passive | Active |
Caregivers must ask themselves whether they listen to patients in order to fit them into their box of knowledge (as in the linear process) or to help them find their own box (the circular process) that connects them to their deeper meaning. The former gives patients what clinicians know and pulls them into their caregivers’ beliefs—the latter explores the patients’ connection to themselves, which leads to an authentic healing action. In fact, I believe that this second scenario is where true healing occurs. It requires that patients have the freedom to express an authentic truth that helps them understand how to best move forward. In this process, people always want to get back to the person they were before the illness occurred. But this is never possible because the disorder changes them. If they take time to listen to their own inner thoughts and feelings, they will learn from their illness in a way that can result in a stronger and wiser perspective—and their lives will evolve into a “new normal.”
Patients define their own path with the help of someone who cares. Health consumers in this nation are not getting their money’s worth because physicians are not listening or perhaps more accurately, they’re not afforded the time to listen for the all-important story that’s at the root of the symptom. And when clinicians don’t take time to listen, they “cover their asses” by ordering more tests and prescribing more things.34 These things (frequently, drugs) have side effects and often just suppress a symptom without resolving it. But if they take the time to deeply listen, the cause of the symptom often comes forward, as it did for my patient Monica, and the solution may not be far behind.35
ESTABLISHING TRUST WITH MINDFUL LISTENING
The old adage, “We have two ears and one mouth and we should use them proportionally,” is so true. Of all the communication skills essential to rapport, the ability to listen well is probably the most important. The best questions in the world will be useless and the information that caregivers glean will be of limited value if they don’t know how to listen deeply to the answers. On the other hand, as I explained in Chapter 8, caregivers need to listen with their eyes as well as their ears.
As caregivers listen, along with helping others to unburden their heavy hearts, their goal is to gain insight into their patients’ needs and issues. They let their patients know with nonverbal cues that they’re available by positioning themselves in a state of readiness: eyes soft and face open, torso slightly bent forward as they make eye contact. (Conversely, cues indicating disinterest can interfere with the other person’s willingness to talk if caregivers avert their eyes, read or write notes, attend to their smartphone, or appear bored.) It is important not to “act” but rather to be mindful about the task of listening.
The words “medicine” and “meditate” come from the same root—med—which means a thoughtful or knowledgeable act to create order. In a mindful, meditative listening state, caregivers can be hyperaware and tuned in to what’s happening in the present. They’re dropping in, listening with compassion, with their whole heart. They’re receiving the information they need to help their patient reach his higher purpose and goals, a state that will facilitate the healing effect. They act thoughtfully to create order.
The key is to let go of any preconceived agenda . . . there’s no need to say anything—or to answer feelings with facts. If caregivers sit openly and allow the people they want to help to feel comfortable, they will speak their truths. The caregiver’s deep presence gives patients permission to reveal their innermost thoughts and express their meaning.
One of the mysteries of nature is that the closer one gets to something real and authentic, the more beautiful it becomes. The more carefully we examine a flower, a piece of granite, or a cell, a new beauty is revealed with each higher magnification. In deep listening, caregivers uncover another mystery. If what they are listening to is real, beauty starts to unfold . . . the beauty of authentic truth. This is hard to define, but people feel it when it happens. However, that beauty may be illusive unless they turn toward their patients’ suffering.
Those who hold on to painful memories try to distract themselves. This is a normal and useful defense mechanism. But it’s not until they stop and listen to their own story that they see the authentic cause or need for healing. As caregivers listen to their patients’ suffering, they are witnesses to the emptying of their hearts. Indeed, listening to another person’s pain requires courage and a willingness to be present with it. This means that caregivers remain undeterred by their own discomfort, fear, anger, or frustration in the face of another’s suffering.
THE WISDOM OF SILENCE
Sometimes, it’s better to say nothing. The French war hero and president General Charles de Gaulle acted as if silence was the ultimate power tool. He controlled his audiences by looking at them, maintaining eye contact, and keeping his mouth shut. Courtroom lawyers depend on silence when cross-examining witnesses. Often their taciturnity provokes people on the stand to surrender more information or details than they’d planned to. After having asked a question and received the answer, attorneys will stop talking as a way to indicate that the witness must have more to say. And often he or she falls for this ploy and spills some of the beans.
But silence can also have therapeutic benefits, especially when giving a person room to unburden. In What to Do When Someone You Love Is Depressed, psychologist Mitch Golant wrote about the value of silence when someone is hurting. “Your role in these moments,” he explained, “is to be a beacon of light, flashing the proximity of the shore without comment. The beacon does no harm. It simply says, ‘I’m here; I’m listening; I care.’ It offers a semblance of connection, showing the way toward safety.”36 Indeed, not only does the beacon do no harm, I believe that it does a lot of good when the person who is hurting knows someone is there and cares.
There is much to be said about the wisdom and even the pain of silence, but caregivers don’t always heed this maxim. When interactions between physicians and patients are analyzed, it becomes obvious that doctors do most of the talking. However, when asked, physicians usually think the reverse is true.37 It’s a subtle dance. The less the physician talks, the more the patient will say, as if to fill the void. In fact, a caregiver’s silence can be as effective as direct questions to draw out meaningful information.
Caregivers must watch their timing, though. They can remain silent if they’re fairly certain the patient has more to say, and their silence is useful if he is more inclined to fill the gap than they are. He can indicate this nonverbally by steepling his hands or using the other gestures outlined in the previous chapter. If the silence is coupled with caregivers shifting in the chair or nodding and smiling as if to say, “Go on . . .” they can be more effective in eliciting information than if they actually say those words. In fact, verbalizing encouraging statements such as “Go on,” can be distracting, and may interfere with an individual’s willingness to share more.
There are different kinds of silence. The easy quiet between intimate partners or family members is special to witness, as a room can fill with love and compassion without the jumble of words to interfere. However, in our small-group discussions with medical students in The Healer’s Art course, there can be rather long periods of silence. This generally makes the medical students (and the faculty leaders) squirm. But that’s a method of teaching. . . . Why do people feel uncomfortable in silence? Why do they feel they need to fill the void with words?
DEEP LISTENING AND CULTURAL COMPETENCY
Much has been written about developing caregivers’ cultural competency because the most effective interventions occur when we match the best evidence-based therapies to patients’ beliefs and culture. That is the goal. But so many cultures exist in the world—no one can truly be expert in every one of them. There are even many subcultures within our own society that may feel foreign to individuals such as those of people who have been raised in different parts of the country, those who belong to the LGBTQ community, those whose religious beliefs and practices differ, and those of immigrants or other minorities. Everyone wants to be culturally competent and to respect all the people with whom they come into contact, without knowing every politically correct fact so as not to offend. This is a difficult task at best.
However, I feel that deep listening helps caregivers jump the barriers that cultures may artificially erect in front of them. When caregivers practice it, they can get a read on individuals’ true inner selves that honors their culture because they are connecting human to human. When they pause, get out of their heads, and listen compassionately, they make strides toward seeing life through the patients’ unique lenses. They become culturally competent because they resonate with others beneath their skin color, history and heritage, and the behaviors that might evoke anxiety or judgments, beneath what I like to think of as their cultural overcoats.
To appreciate what others need, caregivers must first become aware of how they see the world so they are careful not to project what they “know” upon others too quickly. Only by self-awareness and compassionate, deep listening will they be able to transpose their own perceptions toward an understanding of how patients see their world. Then caregivers will be able to recruit their expertise in service of the greater good. And together with their patients, they can then develop action toward health.
I recently had the experience of connecting with a couple that had just moved to Wisconsin from Saudi Arabia. They had been in the States for only five weeks, and the wife was about to deliver their second child. Her husband spoke English, but she did not. Knowing how people from that region of the world value a woman’s honor and privacy, I had some trepidation about attending this birth. But my initial fears were ill founded.
When I have the opportunity to deliver a baby, it’s a great moment for me to practice mindful presence. This time, the baby came quickly and emerged with a single big push. The cord was wrapped around his neck. We slipped it off and placed the infant on his mother’s chest. She immediately broke into loud chanting in Arabic. I understood the intent but not the words; she was offering a prayer for her newborn. The father began crying, and the nurse and I paused. We all connected, feeling the couple’s joy and the realization that this was a beautiful moment we could share. Despite the language and cultural issues, I knew this woman appreciated that I was fully available to her. In fact, just then, culture didn’t really matter to any of us. I cut the cord and let this mother breast-feed her newborn son—a look of rapture slowly spreading on her face as she gazed into his eyes.
This birth reminded me again that there is much more to all of us than we realize. We all can become “culturally competent” by simply connecting to that other human being in a deep, compassionate, and respectful way.