Psychoanalytic Listening: between unconscious and conscious

Psychoanalytic listening can be deployed for enhancing the quality of clinical psychiatric practice. As a clinical skill, it should be teachable throughout the years of psychiatric residency. Nevertheless, the teaching of such important faculty is difficult due to the scarcity of a systematic, relatively structured model that can be used as an underpinning of learning that capability. This article is aimed at fulfilling a part of that lack of teaching methodology. The model offered in this article describes psychoanalytic listening as a mental process initiated by the therapist, which then goes through the patient too, which involves a continuing oscillation of unconscious apprehension and conscious comprehension. This rhythmic proceeding of affectively experiencing and rationally considering will expectedly bring about a mutual understanding between patient and therapist which then facilitates further clinical enterprises.


INTRODUCTION
The term "listening" in this article means "psychoanalytic listening", a kind of hearing to the patient in a clinical situation which is attributed to the deployment of Freud's "evenly hovering attention" [1]. It would be reasonable to implicate that way of listening in clinical psychiatric setting because in that field there are many patients with unconscious psychopathological problems that require to be resolved through "unconscious-to-unconscious" Listening is a challenging clinical skill for practicing psychiatrists at large because of the fact that their work field-clinical psychiatry-is being an intersection between two different epistemological areas, each of which is a unique way of how to reach knowing and understanding in that field: the deductive and the hermeneutical. Listening is much more in the hermeneutical than in the deductive area.
Amidst the great propensity of the mainstream psychiatry to position itself as a part of the medical sciences-thus it should be more deductive than hermeneutical-listening tends to not so seriously be considered as an important clinical psychiatric skill. Listening, which is more accounted for the hermeneuticists than to the deductivists, is apt to be categorized as a psychological skill for psychotherapists and clinical psychologists than for psychiatrists [2].
Nonetheless, the hermeneutical element of clinical psychiatry could never be totally omitted by practicing psychiatrists. This is due to the fact that dealing with patients suffering from mental problems means relating and attuning to their subjective, idiosyncratic experience, which in each of the individuals demands to be empathically understood with a very minimum degree of generalization.
In this respect, listening emerges as a very important even essential clinical skill which can be deployed by psychiatrists in order to enhance the quality of their services.  Regarding this issue, Freud exhorts that listening is really not restricted to the patient's spoken words. It also includes paying attention to his silences, and to the nonverbal cues he offers [4], [3]. Listening is not just simply an act of hearing but an attitude that is deeply ingrained in the psychiatrist's mind. Thus, it will be unconsciously reflected by the whole nonverbal presentation of the physician. A listening-helper will unwittingly resonate a body language that attracts people to communicate at large, not confined in merely verbal communication. On the other hand, an internalized attitude of listening in the psychiatrist as a person will inspire himself to create innovative initiatives for communicating beyond talking. The listening attitude of the clinician is a sort of receiving patients, or "getting them", resonating with them implicitly, or nonverbally. Biologically, this is a resonance with or attunement to others through the mirror neuron system [5].

Clinical illustrations that reflect the importance of listening
Following are two short illustrations that show the importance of listening. Sometimes listening is an unreplaceable clinical tool for effectively helping patient; even "the most efficacious medication"-whether such kind of drug be available-is unable to substitute its role. It would frequently be unable for the clinicians to help the patient to dissipate his suicidal thought by medication. It also very difficult for the psychiatrists to overcome the patient's mutism just merely through prescribing drug for him. Only through listening, the clinicians gain access to the meaning of those symptoms, thus they are capable of responding appropriately to that meaning.

Illustration 1
A 21-year-old female patient has been complaining about her willingness of committing suicide since more than two years ago. She has ever met eight different psychiatrists within that period. Each time she was engaging in a therapeutic relationship with one of the psychiatrists, she verbally expressed her suicide ideation to the psychiatrist. What she always got in return following such communication was a sort of immediate advice from the therapist that stressed the importance of maintaining life as a kind of moral obligation that attached to every person's existence. Soon after that, she decided to terminate the therapy, and then she moved to another psychiatrist for seeking other therapeutic experience that deemed more appropriate for her. Just right at her meeting with the eighth psychiatrist she obtained what she needed, that was a need to be listened patiently, basically without any comment at all. She just merely wanted to be treated by a therapist who functioned himself as being a large container for accepting every verbal expression from her, especially pertaining to her suicidal thoughts. She described that she just yearned for being facilitated to elaborate her subjective experience about her inclination to suicide. She felt that this was really a very horrific topic for her, but she had it, and hence she needed to be accompanied by a nonjudgmental, truly listening therapist to work through that kind of experience.
At the end of her session with such listening psychiatrist, she earned a convincing attitude that she will not to ruminate the suicide ideation anymore.

Illustration 2
A former mute patient submitted himself since the first minutes of her encounter with the psychiatrist with an attitude of destructing contact between them. The patient sat with an awkward, drooping posture, fidgetingly clapping her palms on the table in front of her. However, the psychiatrist initiated a non-verbal plea to the patient for expressing himself via writing or drawing on a piece of paper. He quietly presented some pieces of paper and a pencil to the patient. Fortunately, the patient met his physician's initiative with a gradual increase of enthusiasm. She asked for more papers to write and draw. And the psychiatrist continued responding to her nonverbally; in addition to offering more papers, he conveyed other responses to the patient through writing and drawing as well.
Apparently, this kind of slightly prolonged nonverbal communication made the patient imbued with an experience of safety and impregnated with a feeling of being understood.
Suddenly she broke her mutism when she spontaneously uttering a short sentence: "I am not confusing anymore!" This occurrence bore the impression that the attuned nonverbal interaction with the therapist facilitated the patient to clarify some of her previously unsaid thoughts, therefore ameliorating her befuddlement.
That was the beginning of a recovered verbal communication. Since that moment, the patient communicated with the helper more verbally than bodily.
And the psychiatrist continued to listen to the patient attentively. He also persisted in observing the patient's bodily expressions unobtrusively.
Hence, listening is deserved to be considered as an important, even essential, clinical skill for enhancing the quality of psychiatric practice. The problem remains how to create a relatively structured way of listening, so it can be teach properly during years of psychiatric training program. This paper is aimed at resolving that problem. Freud's suggestion is very illustrious: for the analysts to be able to connect their unconscious to the patient's unconscious, they need to listen the patient's utterances in an evenly hovering fashion [1]. Bion made another notion on listening: the purest of listening is to listen without memory or desire [6]. What needs to be prosecuted by analysts is just only facilitating the patient to talk and talk, to expand his wording of experience that evolves into a broader verbal revealing, without the analysts adding any idea or feeling from the outside.
Due to its 'evenly hovering' and 'without memory or desire' characters-this unfocused posture opens a large landscape ahead-that kind of listening also provides therapists the opportunity to observe the patient's nonverbal expressions; thus, listening to the verbal and the nonverbal as well. In his classical writing about psychoanalytic listening, psychoanalyst Theodor Reik describes the listening enterprise as "a listening with the third ear". He borrows the term "the third ear" from a passage in Nietzsche's Beyond Good and Evil that discusses the ability to appreciate the musicality of language [7]. What the sensitive therapist hears is not merely the patient's wording but also the nonverbal messages delivered through the prosody of the verbalization. Grasping hunches emitted from the musicality of the patient's language is a sort of unconscious right brain endeavor of therapists which is directed to the patient's unconscious; hence, realizing an unconscious to unconscious listening. Reik suggests that "listening with the third ear" needs to be performed by postponing logical interpretation by therapists until the arrival of its proper timing. It also means that therapists need to suspend their reasoning in order to give way for the emotional undertones of the patient's associations to become clearly audible and distinct as if amplified by a microphone [8]. that opens ways to creatively use that knowledge is an attitude of "it just might be", a flexibility and a humbleness with a maximum receptivity to the patient's experiences [11].
Those previous elaborations of the richness and complexity of listening experience demand to be followed by an effort to provide a systematic and relatively structured framework of psychoanalytic listening, so psychoanalytic listening can be taught and be repeated according to a relatively structured conceptual underpinning. Regarding this requisite, Gavin Ivey recommends a "listening-formulating model for conducting psychoanalytic psychotherapy". He expects that the model will be useful for teaching on how to listen psychoanalytically [12]. In constructing his model, Ivey integrates Sigmund Freud's proposition on evenly suspended attention [1], Nina Coltart's idea about bare attention [13], the concept of free-floating and poised attention by Theodor Reik [14], and Wilfred Bion's notion concerning reverie [15]. This is a real act of listening which essentially has an unconscious characteristic and involves a part played by an attitude of being reverent to the other.
The large mental landscape and extensive affective opennes that have been created through the aforementioned apprehension convey a conducive atmosphere then for a conscious, rational comprehension to conduct its task appropriately, managing a deliberation upon the materials that have been contained before, and then proposes a tentative thought which hopefully will be suitable for the other person. Then the other person will propound his own response to that tentative thought, and the processes of unconscious apprehension and conscious comprehension will cyclically continue. Hence, the mental process always oscillating between unconscious and conscious, between listening/containing and deliberating/proposing, between apprehending and comprehending, between feeling and thinking, and between affectively experiencing and rationally considering. This cyclical mental process will underlie an enduring course of communicative actions towards mutual understanding. In the perspective of a psychotherapeutic encounter, the proceeding is initiated by the therapist, which then goes through the patient too.
Through that particular kind of clinical encounter with a listening-therapist, patients depicting their own subjective experiences as large as possible, so those experiences which are initially unspeakable become speakable, and they together with their analyst grasp a more complete picture of their experiences. This is a process of expanding and clarifying experiences, and at the same time illuminating and understanding them [2].
That is an ongoing unfolding of the unconscious to become conscious, to understand those that formerly couldn't be understood, to re-own experiences that were disowned from the patient's personality in the past, and to re-integrate experiences which were previously fragmented.
The broad apperception of the patient's experiences will result in the arising of a challenge to create a novel future, a new way of being and relating, which emerges from the imagination embedded in such large picture of comprehensible experiences.
Analysts require themselves to be sensitive to that imagination, accordingly they would be capable of encouraging the patient to realize his or her own imagination into a new way of being and relating.

CONCLUSION
Communicating intersubjectively is not merely an act of changing the other, but also a giving of oneself to