Learning How to Listen in Clinical Encounters

Susan Notess writes: There’s an American sitcom called Superstore, featuring the staff of a fictional big box store in St Louis, Missouri. One of the main characters, Jonah Simms, is a brilliantly portrayed satirisation of a certain stock character: the starry-eyed, idealistic business school drop-out who has listened to far too many podcasts. Jonah’s eccentricities play off the grounded frankness of his fellow staff members at the big box store, as he seeks to build connections and make friends among them. At last another employee, Garrett, comes to Jonah to talk through a personal problem he’s having. Jonah is delighted at this achievement of friendship, and in his enthusiasm he puts on what I call ‘listening face’, says ‘mmhmm’ or ‘okay’ every two seconds, and generally gives such an intense performance of supportiveness that Garrett is forced to pause his story and say, ‘Can you stop active listening?’ Once Jonah subsides, Garrett is able to continue with his story. (This scene occurs in Season 3, Episode 3; watch here at risk of spoilers.)

There is an ineluctable intimacy to conversations about health and wellness, especially in the context of the clinical encounter. When a healthcare provider or therapist is entrusted with the task of responding to a patient’s health concerns, the importance of listening well to the patient can hardly be overstated. But it’s not clear exactly how to explain what makes listening go well. In fact, we don’t have many theoretical frameworks available for dissecting what listening is in the first place. My task is to provide a framework that enables us to get theoretically specific about what listening is and how to do it well. There is no doubt the concept of ‘active listening’ has been of great heuristic value to many practitioners. But as a theorist, I seek a much richer account of what it means to listen well; and as a person who cares about listening and being listened to, I find that the notion of active listening is not always an adequate guide. Indeed, as Jonah shows us, the notion can even send us off course.

Consider the standard contrast case that is colloquially invoked every time someone is about to proclaim the virtue of active listening. Let’s assume a regular conversation, between two regular people. It is assumed that when one person is speaking, the other—let’s call him Jonah—is just waiting for them to stop so that he can have a turn at talking. It is assumed that the default conversational posture that people have is one of selfishness, impatience, and a desire to dominate the floor. It is assumed that whilst one person is speaking, the ‘listener’ is probably paying minimal attention, and is focussed instead on planning what he will say next.

This standard contrast case for active listening is depressing, and it offers a simple solution: instead be an active listener, not just waiting to speak but actually hearing what the speaker is saying. Classic ways to do this involve giving many feedback signals like ‘mmhmm’ and ‘okay’, maintaining eye contact, inclining one’s head and nodding to show empathy, and recapping whatever the speaker says to check understanding. ‘So what I hear you saying is…’ is how that recap starts. All of these techniques make a certain sort of intuitive sense. But as Garrett pointed out, they can also have the unintended effect of smothering a speaker, making it hard for them to get their story on the floor due to the constant interference of the overactive listener.

Here arises a worry for the health practitioner who aspires to incorporate good listening into their clinical encounters with patients. How does she listen well to the patient, without getting in the way of what the patient is trying to say? What does it really mean to listen to someone—and I mean not just the behavioural tics that conventionally signify attention and that are magnified in ‘active listening’ styles—but what is going on that is behind those tics? What are they evidence of?

On a basic level, listening is about being rightly responsive to what a person is saying. To listen is to pay adequate attention to the speaker; to take them sufficiently seriously, to get a reasonably good grasp of what the speaker is trying to convey. These definitions are easy to say, but not easy to flesh out. What is adequate attention? What does it mean to take someone seriously, and how do we know if we are doing that? More to the point, how does the speaker know that the listener is taking them seriously? These are all excellent questions, which I have sought to answer through my research.

Some of the answers I found are rooted in the complexities of how conversations actually work in real time, as studied by conversation analysts and sociolinguists. Their empirical work gives us a basis for doing some myth-busting about default conversational patterns. For example, it is not the case that in a good quality conversation speakers never overlap, and never think about what they will say until a speaker’s turn is finished. In fact, if we were to hold conversations in such a way, there would be time-gaps between every speaker’s turn—time gaps of the magnitude that reliably occur when the conversationalists are about to run into significant conflict. Gaps of 0.7 seconds or longer in the conversational flow give us a visceral sense that we are headed for trouble, unless signalled by metadiscursive cues (like when someone says, ‘hmm, let me think a moment’ and then stares off into the middle distance for a few seconds). The visceral effect of even tiny pauses can have worrisome consequences in the context of the clinical encounter, not heralding conflict but suggesting an unspoken reason for anxiety. But you can read more about this and other conversational myths in Liz Stokoe’s wonderful book, Talk: the Science of Conversation.

Let us turn instead to a much more basic insight about good listening that can be unearthed from the exchange between Jonah and Garrett. In his enthusiasm to show Garrett that he is being a good listener, Jonah actually makes it difficult for Garrett to get his story out in the first place. Jonah is trying to ‘listen’ to a signal that has not even come through yet. So we follow the inferences: in order for Jonah to be a good listener, he needs to pay the right kind of attention to Garrett’s story. In order to pay the right kind of attention to it, or indeed any attention at all, Jonah needs to have access to the story in the first place. And Jonah cannot have access to, cannot listen to, Garrett’s story, if Garrett hasn’t told it yet. So for Jonah to be a good listener, the first thing he needs to do is let Garrett tell the story! Jonah needs to get out of the way, so that Garrett has time to get the story onto the floor.

The point here is simple but, in my view, it has radical implications for what we think of as good listening, for two reasons. First, it means that we are going to have difficulty listening well to anyone whose voice has been subject to silencing or systemic smothering, without first alleviating these effects. When listening to vulnerable, silenced, and marginalised voices, it is not enough to just get out of the way and let them tell their story. More is needed to remove the barriers vulnerable speakers face and to create a space in which we can even hear what it is the speaker is saying. And second, it means that listening, in the first instance, is a design problem.

To listen well, we can think like Jonah, and throw ourselves into performing our attention to what the speaker is saying. But we would do better to think instead like a designer: how do we design a conversation in which the speaker not only has the opportunity to get their story out onto the floor, but also in which we can in fact hear what they are saying? For the listener in a clinical setting, there are design questions about how do we get things like implicit bias and stereotypes out of the way, and signal to the patient that they are safe from such interferences for the moment? How do we indicate to the patient that it is worth it for them to try to tell their story, particularly when the patient is in a position of having been subjected to systemic silencing and other injustices? How do we design a diagnostic conversation which gives the patient a clear indication that they have been heard and taken sufficiently seriously?

Sculpture of two bronze men listening at a wall
Image Credit: Pixaby 2209152

Two strategies are needed to answer these questions. One strategy is to find what in fact works in clinical conversation design. The conversation analysts are already at work on this strategy, and are finding design patterns that reliably work at getting patient stories out on the table where they can be listened to. (You can read two of my favourite examples.) The second strategy is to take a deeper theoretical look at how systemic injustices and silencing patterns show up in conversation patterns—this is what I am working on now with the IMH. By applying the results of the second strategy to the results of the first strategy, we can figure out what changes in conversational design are most reliably successful at helping us as listeners to get out of the way, to give speakers time and space to get their story out, and to enable them to find the safety to trust us with a potentially costly attempt at getting heard despite systemic barriers.

Once we have these design challenges sorted, and the patient’s story is at least getting out onto the floor in the first place, then we can begin thinking about how to best attend, and perform our attendance, to what they are saying. Surely there will be some nodding and some ‘mmhmms’, but we can best temper our Jonah-like tendencies to over-listen when we have reason to be confident that we have ensured the speaker’s safe access to the conversational floor and let them get their story out.

Dr Susan Notess is a Research Associate at the Institute for Medical Humanities at Durham University. She defended her PhD thesis on listening and conversational ethics in Spring 2021. She can be reached at susan.e.notess @ durham.ac.uk, on Twitter @SusanNotess, or at susannotess.wordpress.com.

2 thoughts on “Learning How to Listen in Clinical Encounters

  1. What an inspiring project Susan. One of the things I love about conversation analysis is its capacity to shows us how interactional spaces are shaped – who is doing the shaping and how. It highlights the norms and the methods. But how to genuinely share this shaping of talk, how to proactively co-create this – we do need aspirational frameworks. They may seem idealised for some, but we need these ideals if we think that inclusion is vital. I think the issues you mention also thread right back through to the earliest of infant development and the development of inner speech. Will look forward to the next installment!

  2. Especially appreciate your points about how complex speaking up is if you’ve been silenced, Dr. Notess. This is important for inter-professional relationships as well as therapeutic relationships. In teaching a medical improv activity called “Same-Time-Story” with a group of nurses, one responded, “That’s the first time I ever felt heard”. I wondered, how could she be a good listener if she didn’t know what it felt like to be heard? Thanks for your work.

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