The Listening Environment

An important element in the listening environment is the physician's sense of attention with the patient, and whether the patient feels the physician is listening to his or her concerns (Table 14-1). If the physician is running behind schedule, has had several difficult encounters during the day, or is tired from lack of rest, the patient will often pick up on various subtleties in the physician's behavior that communicate a "lack of presence" to the patient (i.e., countertransference). Some patients may feel the need to help a hurried physician and may withhold important information (Pollock and Grime, 2002).

Health care providers generally seek to collect as much information as possible while avoiding unnecessary information gathering that uses up valuable time. However, the interpersonal dialogue during the interview is vitally important, and the additional information often provides essential clues for more effective differential diagnosis and therefore more comprehensive treatment planning and case management.

The following LISTEN paradigm is only a suggestion, and health care clinicians should modify it for their own practice situation and environment. The purpose of the paradigm is to provide a structural mnemonic that moves the conversation logically and holistically throughout the interview. As determined by the clinician, any particular part of the interview may be expanded as the situation warrants, and any part may be minimized. By covering each part at least minimally, the clinician can achieve a general overview of the functioning and strengths of the patient or client, as follows: L: Listening is active and empathie, as the clinician maintains a friendly countenance and good eye contact, while responding in a respectful and affirming way to the person. Active listening includes verbal and nonverbal listening. It means to look and listen, to listen with the eyes and the ears, assessing the person's behavior and facial responses. It includes an assessment of dress, grooming, and observable hygiene, such as apparent body and clothing cleanliness, as well as dental health.

I: Interpersonal communication refers to the quality of the interaction between the clinician and the person throughout the interview. The clinician assesses the fluency and appropriateness of the person's speech and vocabulary. Does the conversation have a natural flow and pacing? Is it tense or strained? Does the person's hearing and understanding appear to be adequate for the conversation? Is the conversation characterized by a sense of mutuality and care, or is it more limited to just question and answer? The clinician inquires about the person's other interpersonal relationships, including familial and social (i.e., family and friends).

S: Somatic, sensory, sense, and sensitivity characteristics are highlighted. The clinician inquires about the person's physical body and behavior habits, healthy and unhealthy, such as exercise or substance abuse. What is the relevant medical history, including behavior? The interviewer assesses the person's sensory experience of the internal world, and his or her perception of the external world. Is the person in touch with internal and external reality? The clinician asks patients how they understand what is happening to them. How do they make sense of the experience of being interviewed or ill? What meaning does it have for them within their own personal history? The clinician is sensitive to the contextual issues such as family, gender, ethnicity, education, religion, and socioeconomic levels because they may influence the interviewing experience and the therapeutic process.

T: The clinician assesses the thinking or cognitive abilities of the person. Are reasoning and problem solving adequate for life decisions and for daily living and self-care? The clinician also assesses intelligence and evaluates whether there are deficits that may hinder adequate decision making.

E: Emotion is another area of focus. As the interview proceeds, the interviewer evaluates the consistency and congruence of the affective and emotional responses of the person during the conversation. How expressive is the person affectively? How well do the nonverbal behaviors match the emotional expressiveness in the person's voice throughout the conversation?

N: Normal and now are considered. The clinician assesses what the normal resources and strengths are for this person. How can these resources be used for collaboration in healing? The assessment is made in the now, in the present: How is this person normal? What positive person strengths do patients bring to the current situation for their potential cooperation in the healing process?

The Ritter LISTEN paradigm provides the clinician a moment-in-time assessment of this person, who is on a journey of growth and change. The conclusions are tentative because they do not indicate how the person will be in the future. Nevertheless, the LISTEN assessment provides information for holistic treatment planning and intervention (see Table 14-1).

The physical environment of the room should be welcoming and inviting, creating a sense of comfort to the patient. Sometimes, a nonmedical picture, such as a group picture of the staff or a family picture, can enhance the conversation.

In initiating the interview, the physician should sit down and strive to maintain good eye contact. By having comfortable chairs for the patient, the intention is conveyed that the physician desires for the patient to be comfortable during

Table 14-1 Ritter LISTEN Paradigm for Interviewing and Assessment

L: Active listening, verbal and nonverbal, eyes and ears, respectful, affirming

I: Interpersonal interaction, mutuality, natural pacing, familial and social

S: Somatic, sensory, sense, sensitivity, body, behavior, healthy and unhealthy, reality, making sense, context

T: Thinking, cognition, intelligence, problem solving, daily living, self-care

E: Emotion, affect, expressiveness, congruence and consistency

N: Normal, now, present, resources, positive person strengths, cooperation in the healing process

Courtesy R. Hal Ritter, Jr, PhD, 2002, and Scott & White Memorial Hospital System.

the visit. Taking notes on what the patient is saying is appropriate, but it should not interrupt the flow of the conversation or break a sense of continuity. By allowing patients to tell their story in the opening minutes of the interview, the physician gains a context for understanding how they view the problem being presented. Sometimes, the seemingly irrelevant information being presented by a patient becomes valuable contextual information for diagnosis, treatment, and compliance.

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