Category: Blog

As a brand new, inexperienced first year medical student, I took the required patient interview course. Actors were hired to portray patients with a variety of medical conditions. On my first day, dressed in my short white coat, notebook in hand, I entered the exam room. “Hi, my name is Dr. Anthony (I was a young, single student at the time),” I began. “What brings you into the office today?” As soon as my patient began her story, I started to formulate my next question while anticipating her possible responses. I heard everything she said, evidenced from the copious notes inked in black on the pages in my hands. But, I really didn’t listen to a word she said. Over the years, I have learned the importance of active listening. As a student, I focused on hearing my patient’s account of her illness, allowing me to gather pertinent details. Now, as an experienced clinician, I have come to appreciate how active listening serves the additional goal of helping the listener gain understanding and trust. I have also come to realize that in most circumstances, how the patient experiences our interaction is as important as what he or she tells me. While my training taught me how to gather details, it did not teach me the practice of active listening. Studies suggest that the brain’s reward system is triggered during active listening. In a 2015 study published in the journal Social Neuroscience¹, researchers selected 22 participants who were video recorded while reading essays they wrote about a variety of their life experiences. Evaluators (actors hired for the study) were instructed to view these videos and demonstrate either active or non-active listening behavior. Researchers then conducted functional magnetic resonance imaging (fMRI) on participants while they viewed the evaluators assessing their video clips. Participants rated both the evaluators who showed active listening and the episodes where there was active listening more positively. The results also showed enhanced neural activation in both the ventral striatum and the right anterior insula when active listening was perceived. These brain areas are associated with motivation and reward. Both results suggested that the active listening process was rewarding in the truest sense of the word. Active listening allows us to gain a deeper understanding of our patients. When we understand our patients, we gain insight into their complex lives. We begin to see beneath the layers of their narrative to the “real” story. When we give our full attention to a person, we are able to maximally receive his or her message while decreasing the interfering “noise” of our own thoughts. The noise is all those activities our brains engage in when we are not listening to the person who is speaking. With active listening, our focus centers on truly and deeply knowing the other, instead of being known. A patient labeled as ‘non-compliant’ for not taking their medication becomes a patient who, after losing his job, is too depressed to get out of bed in the morning and muster the energy to take their medication. When we build trust with our patients, they find comfort and safety as they reveal their concerns. We trust that what they are telling us is their best understanding of what they are experiencing. We are not imposing our agenda on them and are able to receive what they have to share with us. Of course, there are times when our agendas are important as certain details must be clarified and understood in order to allow us to do our jobs. However, active listening helps us forge more holistic relationships with our patients, giving us a clearer picture of the individual sitting across from us. With intention and practice, active listening helps us become attentive and receptive to what another has to say. Your own emotions might shift in response to what is being shared. You will know another person in a way that you didn’t previously, increasing your capacity for sitting in his or her experience or emotions. Active listening engages empathy, also housed within the brain. How good of a job are you doing at bringing active listening into your conversations? The International Listening Association suggests asking yourself these questions to understand whether you are engaging in active listening: Are you giving the speaker 100% of your attention? Are you listening to understand, rather than listening to respond? Have you opened your mind to receive what is being said? Have you rejected the temptation to prepare your response while the other person is speaking? Are you open to changing your mind? Are you aware of what is not being said as well as what is being said? Are you taking account of the degree of emotion attached to the words? Are you aware of any differences, and similarities (such as culture, age, gender) between you and the speaker which may influence how you listen? Are you giving signals to the speaker that you are listening? Are you valuing the speaker and the experience they have gathered in their life so far? Active listening is an important tool in every doctor and therapist’s toolbox. It can help facilitate more trusting and deeper therapeutic relationships. In our professional and personal lives, active listening can lead to more connected and rewarding interpersonal interactions allowing us to experience even greater fulfillment. Resources

1. Perceiving active listening activates the reward system and improves the impression of relevant experiences. (2015). Kawamichi, H., Yoshihara, K., Sasaki, A T., et al. Social Neuroscience.

Silence often makes people uncomfortable. In U.S. culture, particularly, we are prone to filling up silences in conversations as quickly as possible. One reason for this is that prolonged silence may be interpreted as a sign of discomfort or disapproval. For the same reason, new psychotherapy students often feel a need to jump in and ask questions when things become quiet. At times, this can be a supportive thing to do. But, there are other times when this may signal discomfort, and when a period of silence may be just what a client needs in order to process feelings or to reflect on what has just been said. When a client who is usually verbal begins to fall silent while talking about something difficult, corresponding silence by the therapist is often helpful and supportive. It may convey attention and interest, as well as the therapist’s commitment to not interfere with the client’s need to process what is going on. If the silence continues for a substantial period of time, the pressure to help the client by saying something becomes greater. Therapists differ in how they handle this situation, depending on their orientation to treatment and their own individual style. I, personally, rarely let a silence last more than a minute or two without saying something—even if it’s just “Would you like to say anything about what’s going on?” On the other hand, some therapists have had breakthrough sessions when they gave a client a significant period of attentive silence that no one else had ever offered them. While many clients can use periods of silence productively, there are others for whom silence is not a good strategy. In my experience, older children and younger adolescents generally fall into this latter category. This can present a double-bind because these young clients often do not want to talk but also hate to be questioned. I have worked with many adolescents who have had previous unsuccessful therapies. Their two most common complaints about previous therapists are “He asked too many questions!” and “He never said anything!” Over the years, I have come to the conclusion that while questioning may be painful to many adolescents, silence is often downright excruciating. So, what do you do with an early adolescent who finds questions painful, who can barely handle talking at all, but who also hates silence? Many therapists try to engage such clients by talking with them about things they like to do. This can be a good way to start therapy with an adolescent, but it is not always easy to do, and some adolescents also find it irritating and patronizing. This is especially true for adolescents who know that they are in therapy for serious problems and who may legitimately experience small talk as disingenuous or “fiddling while Rome burns.” I have found that it is often preferable to go a different route with these nonverbal youngsters, taking over most or all of the talking at first by gently describing what you know about the client and then gradually introducing some speculation as to why they may be acting as they do. My first experience with this was in working with a 13-year-old girl who had been hospitalized with borderline features and possible early-onset schizophrenia. She had been acting increasingly depressed, erratic, and withdrawn, and had begun engaging in drug use and self-mutilation. She was barely verbal, responding to questions with one-word answers minimizing her problems, or with silence or shrugging. With my supervisor’s help, I began relying less on questions and spending more time talking sympathetically to her about what her parents and the hospital staff had reported about her behavior, and making some guesses about how she must have been feeling at the time. Before long, she began to acknowledge some of these feelings, and eventually she started talking about other significant issues, including having frightening hallucinations and feeling stress about her father’s alcoholic behavior, which her parents had not revealed to us. Interestingly, very young children often tolerate silences quite well in the context of play therapy. They are used to playing on their own and may feel comfortable with an adult in the room quietly accepting what they do and making only the occasional comment. When they get older, however, children cross a certain threshold—typically around 8 years of age—when they start to become self-conscious about playing but are not yet accustomed to talking with adults, especially about personal issues. A few years after this—at, say, 14 or 15 years of age—they start to become sufficiently verbal to express themselves more easily and to tolerate some appropriate silence from therapists. It should also be noted that not all adults feel comfortable with therapists who are silent, especially adults who come from backgrounds in which it is not culturally normal to share personal information with an unknown professional. With these clients—and indeed with all clients—some preliminary assessment is usually advisable to determine how comfortable they are with a more exploratory approach in which some silences may occur, as opposed to a more problem-solving approach in which they probably will not. Looking back over the silences I have shared with my clients, I am struck by how full and how varied they have been—each with its own special meaning: anxiety, sadness, recalcitrance, closeness, and speechless perplexity, to name a few. Each one is different, and each can lead, potentially, to a greater understanding of the client.

What if it were possible to detect the moment during sleep when you were about to be woken up by a nightmare, and you could be sent soothing messages (or smells, or sensations) to shift the valence and prevent the dream from waking you up? Or what if you could wake up and actually see a list of topics or even a movie of the images from your dreams from the previous night even if you had no recall? These are just a couple of the dozens of ideas that were raised in brainstorming sessions at the inaugural Dream Engineering Symposium at MIT in January 2019.

Dream researchers from around the world gathered to present findings, while MIT innovators presented what is or could be possible to aid in answering the challenging questions about what dreams are and what they do. The participants in past and current sleep laboratory studies often look like something from a nightmare, with equipment strapped to their bodies and countless wires sprouting from electrodes stuck to their scalp. By contrast, at MIT they are developing lightweight, flexible, wireless sleep masks that can collect sleep physiology data unobtrusively, and even remotely.

I was privileged to be one of the presenters at this symposium. As a former science writer, touring the media lab felt like a familiar part of my former work life, as I used to regularly talk to innovators about their technology. But at the conference I was blown away by what is already possible could be possible in the not-too-distant future. In the two decades intervening since my science writing days the state of the art has changed dramatically.

Much of the technology presented at the symposium was aimed at opening the door to lucid dreaming, in which the dreamer is aware that they are dreaming, because this is an optimal vehicle for obtaining real-time dream data. Dream researchers have the difficult problem of trying to study something that is not amenable to direct observation. All they have to go on is real-time sleep physiology data, and then later, people’s reports of what they dreamt about. But these may not be accurate reflections of the actual dream. To work around this, dream researchers watch for the brain signals that the participant is dreaming and wake them up immediately for dream reports, but this is not an ideal solution because it interferes with natural dreaming.

Researchers are interested in inducing lucid dreaming and establishing two-way communication so that they can get a dream report in real time. The trouble is, it is very difficult to ask someone questions and/or suggest they look around and notice that they are dreaming without actually waking them up. Symposium organizer Dr. Michelle Carr has developed a fairly reliable way to train even inexperienced lucid dreamers to become lucid enough in a dream to signal their consciousness by moving their eyes back and forth while staying asleep. She has used a combination of training prior to sleep followed by sound and light signals during sleep that are intense enough to be tangible to the dreamer, but not so intense that the dreamer wakes up—a very fine line.

My part in the event was to ask if we could direct some of this creative energy towards questions of clinical relevance, and I was the lone voice in the crowd. In my clinical practice, I have found experiential dreamwork to be one of the most efficient and effective ways to promote clinical change. Experiential dreamwork is the practice of inviting the dreamer to re-immerse themselves into their dream rather than standing back and analyzing it from the outside. Examples include telling the dream in first-person present-tense, entering into the subjective experience of a dream element or character, and allowing the dream to continue forward from where it ended. I told the researchers how the elements of dreams, and nightmares in particular, contain the perfect raw material for changing deep implicit memories. Dreams contain intense emotional material that is profoundly personal and relevant to the dreamer. Dreams very often surprise us with paradoxical information that, if truly absorbed, contains tremendous energy for transformation. Fairly recent brain and memory research (within the last 15 years) has shown that implicit emotional memories, which previously were thought to be indelible, can actually be erased and overwritten under specific circumstances. Memory reconsolidation research has shown that if a person holds two incompatible ideas in experiential awareness at the same time, the memory becomes unstable and can be permanently changed.

I have observed this kind of change in clinical practice and would love to have a clearer conception of how this happens so I can repeat it more reliably. For example, one client who worked with me confronting a black dog in her nightmare came to session the next week and said she had been cured of a lifelong phobia of grocery shopping, a wonderful but unexpected outcome. I also worked with a rape victim whose recurring nightmare of this trauma shifted to dreaming of more enjoyable and consensual sex after he reimagined a new dream ending. This coincided with a significant drop in his PTSD symptoms.

The idea that such a change in the dream narrative could be made in real time, while the dreamer is asleep, seemed like a distant prospect, but may not be as far off as I thought.