Where Does Listening Fit in the Medical Model of Disease?
Pressure to diagnose disorders may crowd out space for non-judgmental curiosity.
Posted Nov 02, 2018
The Adverse Childhood Experiences study, originating in a collaborative effort between the Center for Disease Control and Kaiser-Permanente, a large California HMO, offers powerful evidence that when bad things happen to us early in life, we are likely to have a wide range of health problems, both physical and emotional. At a recent conference attended by over 850 professionals, lead author Vincent Felliti gave a presentation in which he explained the roots of the original discovery. When he learned that many of the patients in his obesity clinic had experienced sexual abuse, he developed a questionnaire about childhood trauma—now widely referred to as an "ACE screen"—that was incorporated into routine care. He describes a remarkable 11 percent decrease in emergency room visits following this change.
He noted that patients filled out ACEs questionnaires in the comfort of their homes, followed up by an appointment with their doctors who asked, "'Could you tell me how these things have impacted you later in life?’ And we listened, period.” That interest made a difference: ”Patients told us that they had told the darkest secret of their life to the doctor and the doctor was still nice to them, and wanted to see them again,” he said. The act of listening and acceptance, said Felitti, “turns out to be a previously unrecognized, remarkably powerful tool.”
Now that this groundbreaking study has finally gotten the attention it deserves, an ACEs movement has taken hold, with universal screening as a primary objective. It is heartening to see listening take up its rightful place at the core of healing. Felitti's statement makes me wonder if one value of the ACE study lies in bringing this concept, already foundational in other disciplines, such as Buddhism, psychoanalysis, and infant mental health, to the medical community.
Primary care physicians are notoriously pressed for time. But for listening to exert its healing powers, time is critical, as captured in this beautiful description by Buddhist monk Thich Nhat Hahn.
"When communication is cut off, we all suffer. When no one listens to us we become like a bomb ready to explode. Restoring communication is an urgent task... When we listen with our whole being, we can diffuse a lot of bombs... If there is someone capable of sitting calmly and listening with his or her heart for one hour, the other person will feel great relief from his suffering."
When practicing general pediatrics during the time of discovery of "childhood bipolar disorder," concurrent with an explosion of diagnosis and prescribing of medication for ADHD in younger and younger children, I experienced a deeply disturbing standard of care that served to silence the stories of these children and their families. Looking back, I wonder if my own outrage at the situation got in the way of my listening to my editor, Merloyd Lawrence, who encouraged me to write a book about listening. I was too focused on the silencing to take in what she was telling me, and so I stubbornly insisted upon the title, The Silenced Child. The book has its origins, however, in a kind of "aha" moment when my brilliant editor asked me, in conversation about ideas for my next book, what was responsible for meaningful change in my practice, and I answered "space and time for listening." "That's it!" she cried, practically jumping out of her seat.
In a chapter entitled "Space and Time for Listening," I describe the research of neuroscientist Steven Porges, who's work trauma expert Bessel van der Kolk captures in the introduction to Porges' first book:
"Porges... gave us an explanation why a kind face and a soothing tone of voice can dramatically alter the entire organization of the human organism—that is, how being seen and understood can help shift people out of disorganized and fearful states."
I describe the impact of time in my own practice:
When, a number of years ago, I shifted from my general pediatric practice to focus exclusively on behavioral pediatrics, the only thing that changed was the length of the visits, which went from fifteen minutes to a full hour. But that simple change brought dramatic results. A family and I could settle into our work. Often, once parents had time to escape from the frenetic pace of life, and could talk and be heard, the change in their demeanor would be dramatic as they went from tense and angry to soft, calm, or even sad. I found myself literally taking a deep breath, bringing myself into the moment. Children went from chaotic exploration to calm, engaged play. Sometimes a child would respond to his parent’s changed tone by spontaneously running to give him or her a hug. In these powerful moments of re-connection I would feel a tingling in my arms and tears in my eyes. By using our time together not for behavior management, parent training, or parent education, but simply to listen, transformations, for the parent and child, and for me, occurred in our body and brain.
Often physicians are called upon to enter a room, rapidly assess a situation, make a diagnosis, and take action. This is the value of the medical model of disease. Listening to a person tell the story of his or her life experience, as Dr. Felliti describes in his presentation of the impact of the ACE study, calls for a different kind of presence. I wonder if a central implication of the ACE study is the need for a complete reorganization of primary health care. The findings call out for such a radical shift, with opportunity to create a model of primary prevention. ACEs are incredibly common. A model of care that focuses on screening, without concurrent attention to protecting time for listening, is insufficient. Rather than referral of an individual with a high ACE score to a professional listener, the person on the front line of healthcare should be that listener, with ample space and time for healing through connection.