Listening in the Mental Health Setting

This week we hear from 3rd year rep, James Slaven

I have chosen to discuss this topic not because I feel that those with mental health issues are abnormal and that they must be listened to very carefully in a bid to decipher their words. I instead feel that the way we listen to one another in general can be improved in certain contexts and that there are inherent qualities in the way that we interact with one another that can be negatively impactful, irrespective of our mental health.

I will start by drawing on my own experience, with regards to what I have learnt whilst communicating with patients in the acute psychiatric setting. Not by any means do I claim to be an expert or a voice of authority on the matter of interpersonal communication or psychiatry.

First and foremost, I believe that listening is the most important communication skill. It is something that almost everyone is no doubt very familiar with; I was confident in my abilities when I first started working in mental health. It is during my time in this setting that I have learnt to value the true importance of listening properly to another person. I use this word, properly, as I believe that some of the listening that takes place in general conversation is not entirely thorough. Having had the opportunity to reflect, I am guilty of not always actively listening. For example, there is a difference between listening and simply not talking when another person is. I feel that to actually listen to another person depends entirely on what is happening in your own mind as they speak. Many times, I have been in conversation with others and in my mind, I am drawing on a memory in anticipation of my opportunity in the dialogue to share; which means I am not processing as much of what the other person is saying as I could be.

I have found that those who are struggling with their mental health are often reluctant to share details of their experiences or feelings with those they do not know or trust. Sometimes people will display signs of mental struggle in the way they talk or the words they use, or do not use. Other times, they will detail exactly how they feel or draw on potentially traumatic events that they have experienced. In each case, it is paramount that you listen to what they have to say. If an individual is talking about something difficult and you show signs of not being engaged, this can break down the trust and rapport that you have with this person. It is also important to listen to how they say things. For example, you may hear changes in their tone when approaching certain topics, or the use of more offensive language in their speech, or differences in the speed at which they speak; you may even notice that they simply do not wish to speak at all.

There are a number of examples in particular that I often reflect on. For example, I was working a night shift on an acute psychiatric ward and was performing the general observations. I had knocked on one patient’s door and poked my head in, as normal, to ask if she was okay. Whilst her response was “yes”, something did not sound right. There was a delay in her response; it sounded quieter than normal and her tone was melancholic. These features caused me to stay and ask further questions, which I may never have done had I not been processing her response. In this instance, she was struggling with her mental health and was in need of more support. In another example, I was sat with a young patient on an eyesight observation one night. We had built up a rapport and the patient began to tell me about her past experiences in the healthcare system. She recounted some negative experiences, which had caused her lasting distress. She also outlined how she tends to react to certain thoughts and what things usually cause her to have said thoughts. By taking the time to sit and listen to her words and how she spoke about certain staff members she was not fond of, instead of interjecting, I was able to better understand how I could support this patient in the least-triggering and most beneficial way. I was then also able to speak to my colleagues and the nurses in charge about what I had learned from the patient, so that we could all learn about the things that caused her particular distress and how to better manage incidents if they occurred. It could be said that these are two different types of listening, with the first being perhaps more analytical and the second being more empathetic.

The literature outlines different terms for the different styles of listening, with context provided. For example, there are resources online that outline how to be a good, empathetic listener. Mental Health First Aid USA suggest that for a person experiencing a mental health problem, having an empathetic listener can be calming, reassuring, and even healing. (1)

They say that the first way to begin diffusing a tense situation is to start establishing a rapport with the individual who is experiencing distress. Before you begin trying to rectify the problem and attempt to identify solutions, take a moment to quietly listen to the person. This shows them that you have recognised they are in distress and that you are validating their experience. The person may feel more confident in speaking without judgement from you and you can take the opportunity to listen to and understand the issue at hand.(1)

The educationist and mental health activist Neerja Birla states that “active listening is when you have your full focus on what someone is saying, while making conscious effort to hear not only the words being said but more importantly, the complete message being communicated through non-verbal aspects of communication as well”. She also suggests that by all of us electing to become more active listeners, who are sensitive to the mental health needs of others and not judgemental, we can begin creating “mind-positive communities”. Listening without judgement and bias can help to eliminate stigma in our communities and alleviate the loneliness felt by those suffering with their mental health.(2)

Montare behavioural health also offers tips for listening to someone who has a mental health illness (3):

• Even if you disagree with the person’s interpretations of reality, for example in the even that they are experiencing psychosis, make an effort to understand their point of view and their experiences

• Avoid reactive listening. Listen to understand them and not to challenge them. This involves avoiding interruptions, criticism, and giving advice whilst they are talking to you. Also, try to move past the individual criticising you, instead of reacting to it

• It may be helpful to set the limits on when, where, and how long you can listen. This gives you the opportunity to choose a setting where you can listen well. If there reaches a point that you cannot continue to listen well, disengagement may be appropriate. This can keep things safe for both parties and ensure you can remain calm whilst listening

If we refer to the ten elements of mental health from Macdonald and O’Hara, some of which are shown in Figure 1, we can see that by neglecting to help people to develop and express emotional life, we are demoting their emotional processing. If signs of stress are missed and not addressed, then it could be argued that a lack of active listening can also demote an individual's self-management ability. (4, 5)

Figure 1 – A table adapted from Macdonald and O’Hara’s Ten Elements of Mental Health (4,5)

I believe that these skills can be applied outside the context of mental health also. Firstly, we cannot truly know how the person we are speaking to is feeling within, so we should not reserve active and empathetic listening for only those who are open about their mental health. Secondly, I feel that building relationships and positive rapport with others is a great source of enjoyment in life. Surely by demonstrating good listening skills with others, you can better understand one another; support one another, and build stronger relationships. As I mentioned, I am not qualified and hence the vast majority of this piece is based on my own experiences and interpretation of the literature. I have referenced the information about the different listening types; this is from genuine, reliable sources.

References

1. Mental Health First Aid USA. The Quiet Power of Empathic Listening 2017 [Available from: https://www.mentalhealthfirstaid.org/2017/07/quiet-power-listening/.

2. Birla N. Words Matter: A Time to Talk and a Time to Listen 2019 [Available from: https://thriveglobal.in/stories/words-matter-a-time-to-talk-and-a-time-to-listen/.

3. Montare Behavioral Health. What is Therapeutic Listening? [Available from: https://montarebehavioralhealth.com/resources/therapeutic-listening/.

4. Hall S. Supporting mental health and wellbeing at a whole-school level: listening to and acting upon children's views. Emotional and Behavioural Difficulties. 2010;15(4):323-39.

5. Macdonald G, O'Hara K. Ten elements of mental health, its promotion and demotion : implications for practice. Glasgow: Society of Health Education and Health Promotion Specialists; 1998. 39 p.