A guidebook for doctors systematizes an often misunderstood subject

Most people, at one point or another in their careers, will read a book on communication. As a former management consultant, I certainly received my share of advice on how to talk, present, dialogue, and in general convey information and opinions to others. What’s more, though I was often advised to “listen to the client,” I was never explicitly told how to do this in a systematic way. Listening was one of those “soft skills” that one somehow either brought to business or learned along the way. In retrospect, it’s interesting that while countless authors are ready to teach you how to communicate, no one seems prepared to teach you how to listen — at least until I came across a small book by Salman Akhtar, M.D. called Psychoanalytic Listening (Karnac, 2013).

Dr. Akhtar (a professor at Jefferson Medical College and supervising analyst at the Psychoanalytic Center of Philadelphia), wrote a book aimed at psychoanalysts. In his book, he lays out his ideas about the role of listening and silence in psychoanalysis. It is a technical book aimed at professionals, and so I will not comment on it from that perspective. I will suggest that this book is something everyone who depends on listening in their profession should read cover to cover (and that is most of us, I would imagine).

Akhtar starts his book by noting that, in his view, there are four types of listening, each with its own goals and methods:

1) Objective Listening: This mode of listening “places the analyst in the position of the detached observer and an arbiter of “reality” and, when it comes to analytic listening, prompts a certain amount of skepticism regarding the patient’s verbal productions.” In this mode, your starting point for listening is almost disbelief, and, like an interrogating detective, you are on the lookout for any sign, verbal or non-verbal, that what you hear is wrong or unreal.

2) Subjective Listening: “Standing apart from the analysts who listen ‘objectively’ are those who rely a great deal upon their subjectivity in their attempts to understand what the patient is trying to communicate. To such analysts, understanding often comes in the form of inspiration with no (or very little) conscious efforts to put the ‘two plus two’ of the situation together.” In this mode, you are trying to build a co-understanding, a perception or conclusion that is a joint creation of both speaker and listener. In this mode, an imperfect initial creation is accepted as part of the co-creation/communication process.

3) Empathic Listening: Here, Akhtar notes, “the analyst’s task is to seek the inner world of the patient, and there is no better way to do so than to listen from the patient’s perceptive. The analyst must avoid foreclosure, the temptation to guide, and to help the patient see “hidden meanings.” His recognizing the patient’s inner state — his “getting it” — is in itself good enough. In this mode, your main goal is to not just to hear but to experience what the speaker is saying, shifting as Ahktar notes, from a position of listening from “the outside” to a position inside the speaker’s perspective.

4) Intersubjective Listening: “The intersubjective paradigm proposes that no mental phenomena can be properly understood if approached as entities existing solipsistically within the patient’s mind. The analyst’s perception of the patient’s thoughts, feelings, and fantasies, etc., is always shaped by the analysts’ subjectivity. Therefore, the patient’s psychology — the ‘material’ for analysis — is itself con-constructed.” In this mode, your goal is almost to use your mind and that of the speaker to create what is called “an analytic third.” This analytic third is a “unique dialectic” created, and re-created, each time you communicate with a person, i.e., when we communicate in this way we create a third entity that represents our joint understanding, and it’s that new entity that allows for perception and meaning to be transferred from one to the other.

After describing each mode, Akhtar notes the benefits of each one:

The four models of listening give rise to different questions in the analysts’ mind. “Objective listening” directs one’s attention towards syntax, shifts in the direction of association, parapraxes, and so on. “Subjective listening” intensifies vigilance towards the countertransference experience. “Empathetic listening” facilitates a deeper grasp of the patient’s narrative, especially in its conscious and preconscious aspects. “Intersubjective listening” spurs curiosity about the two partners’ influence upon each other and upon mutuality itself.

In addition to fully describing his view of these four types of listening, Dr. Akhtar goes on to examine other related topics such as the eight (!) types of silence, listening to actions, how to listen to oneself, the impact of culture on listening, and even the impact that deliberate refusal to listen (“RTL”) can have in specific situations. He also examines how these four modes overlap and how often the ideal listening strategy is a combination of, or modulation among, the four modes. In all, this short book is a serious and deep dive into a critical (though often mysterious) part of human interaction.

Thought Ahktar wrote this book for psychiatrists, the more I read the book, the more it made me think about listening in other situations. I began to wonder if, in past conversations with clients or colleagues that had not gone so well, I should have thought as much about how I was going to listen as what I was going to say. I thought about how often I had not fully considered how I was being heard by others and if their particular mode of listening was effective for what I was trying to communicate. In short, the more I read Ahktar, the more I began to rethink everything I thought I knew about listening to clients, colleagues, and everyone else. This is because in a business setting, I think most professional’s default listening mode is “objective.” In other words, they listen critically, looking for ways to “improve” the analysis or argument in question. Most people in business are good at this type of listening, but we are often not so good at the others. Different professions, interestingly, emphasize other modes. People in the performing arts, for example, are often good at intersubjective listening since so much co-creation and collaboration is involved. Teaching and counseling, on the other hand, often emphasize subjective and empathetic listening, respectively.

Dr. Akhtar’s book suggests we make a conscious effort to improve those modalities in which we are weak. This is something I would recommend to anyone who thinks that listening is a key part of their professional life. This immensely interesting book is a great way not just to understand how to listen deliberately but also when to apply each specific mode. Lastly, it’s also a good book to remind us when it’s time to stop listening analytically, for as Dr. Akhtar himself notes in his closing words, it’s also important to know when not to listen like a psychoanalyst at all:

In domestic life, we should try to put analytic listening aside as much as possible and not let technical jargon crowd out the vernacular of “ordinary” human conversation. Such restraints on the use of our analytic minds paradoxically sharpen their edge. Remember, a surgeon would not use his scalpel for pruning shrubs in his garden nor would a cardiologist his stethoscope to hear songs from a CD player. Everything has its time and place and psychoanalytic listening is no exception to this rule.

Posted by:Carlos Alvarenga