Academic journal article American Journal of Psychotherapy

In Defense of Listening

Academic journal article American Journal of Psychotherapy

In Defense of Listening

Article excerpt

This paper makes a case for listening and its role in establishing and maintaining meaningful psychotherapeutic relationships. Further, it examines those factors that have contributed to the devaluation and current decline of listening in mental health care. These factors include the abuses of managed care, the marketing and misuse of psychotropic medications, the growth of brief, manualized, empirically supported treatments (ESTs), and the lack of appreciation for unconscious processes and countertransference in the appeal, development and delivery of these interventions.

INTRODUCTION

A host of socio-economic pressures led to the emergence of managed care. Alongside managed care came the development of manualized empirically supported treatments (EST's), other therapies that were brief, directive and didactic and the explosive use of psychotropic medication. Together, these developments have fostered attitudes and interventions that threaten the psychotherapist's two greatest capacities, his/her willingness to listen and ability to understand. In this paper we hope to make a case for listening and its role in establishing and maintaining the therapeutic relationship. We will then consider the impact of managed care and brief therapy, biological psychiatry, manualized ESTs and unconscious processes on listening in psychotherapy (with forays into listening in primary care).

Rather than launch into an ad hominem attack on managed care medications and brief psychotherapy, we would like to provide a context for our concerns about these developments. As clinicians working in a medical center and university clinic and proponents of brief therapy, we welcomed (a) the idea of managed care (to create greater access to health care); (b) the development of brief therapies (we have seen them work with those for whom they were appropriate); (c) the application of clinical research (to enhance treatment and to strengthen psychology's place in primary care); and (d) the development of new, safer, more effective medications (for patients who could benefit from them). We have simply become disillusioned by managed care, disheartened by the indiscriminant use of brief therapy, and discouraged by the fusion of brief treatment, psycho-education, and manualized approaches within the EST movement. How could one be anything but shocked by the marketing and staggering overuse of psychotropic medications? Separately and together, we view these developments as endangering the role of listening in psychotherapy, and therefore, the therapeutic relationship itself.

A BRIEF CASE FOR LISTENING

The ubiquitous role of the therapeutic relationship in psychotherapy outcome has been strongly established in the professional literature (Lambert & Barley, 2001). Regardless of therapeutic orientation, the therapeutic alliance continues to be a consistent and powerful predictor of psychotherapy outcome (Gaston, Thompson, Gallagher, Cournoyer, & Gagnon, 1998; Samstag, Batchelder, Muran, Safran & Winston, 1998; Strupp, 1996). Even when comparing psychotherapy to medication, the therapeutic relationship prevails. In their summary of the NIMH Treatment of Depression Collaborative Research Project, Krupnick et al. (1996) reported that the strongest predictor of positive outcome, regardless of treatment (psychotherapy or medication) was the quality of the treatment relationship.

If the foundation of successful psychotherapy is the therapeutic relationship, then the mortar of the therapeutic relationship is listening. Accurate empathy conveyed through listening transcends theoretical orientation and connects many successful psychotherapies (Greenberg, Elliot, Watson & Bohart, 2001). While a majority of today's streamlined approaches to mental health convey sympathy, which Nichols (1995) refers to as the presumption of understanding, empathy involves the hard work of understanding (Nichols, 1995). Kohut (1984) defined empathy as, ". …

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