The importance of empathic listening for making meaning of distress


Psychiatry has failed to provide a definitive explanatory framework for mental illnesses, despite more than a hundred years of scientific and medical research. Its failure results from its dependence on a biomedical model of human development, which purports to explain emotional distress as a biological malfunction.

It seems clear to me that a fundamental paradigm shift is required, away from focusing on the material body and the organic functions of the brain, and toward the existence and processes of the mind. This shift discounts the continuously futile search for a biological explanation and test for mental illness and challenges the biomedical validity of applying physical treatments to what is actually a state of mind.

The psychiatrist currently attempts to fit the content of their patient’s mind into a diagnostic framework, identifying “symptoms” which are assumed to be objective. But, arguably, they would gain more understanding of their patient’s state of mind through listening to its content and working with them to make meaning of their “distress”. This method of support enhances the potential for mutual recognition of the reasons for the emotional and psychological “distress”, potentially signposting a clearer path to “recovery” and mental health.

My conclusions about the causes of madness are drawn from working with people diagnosed with a mental illness, including those deemed the severest forms, such as what is labelled as schizophrenia and bipolar disorder. In my time I have met hundreds, if not thousands, of people diagnosed as “mentally ill”, either professionally as a social worker, team manager, or counsellor, or personally as a friend, mentor, or carer.

A psychiatrist ascribes diagnostic labels to a person according to symptoms, which are assumed to be based on scientifically validated objective criteria. But even in my professional social work career, I have never subscribed to this objectified description of a person, which subsumes their self, character, and identity beneath the diagnostic label. Instead, I have always related to each person according to their beliefs, values, and attitudes, which identify them as unique individuals with a mind of their own. I have, therefore, never addressed a person as “a schizophrenic” or “a depressive”, nor ever described them as such to others.

I have always understood each person’s state of mind to be a result of their personal life experience. I have found no evidence of biological factors underlying, or causing, these diagnosed illnesses or conditions. Nor have I ever found evidence for inherited characteristics, which might confirm the biomedical assumption that madness not only occurs within a family or across generations of the same family but is also inherently a genetic malfunction. I have found, however, overwhelming evidence of how and why madness emerges in individuals over time, through the disturbance, despair, and distress expressed in their feelings, thoughts, and actions, which had been, might be or could be translated into “symptoms” of “mental illness”.

There are always reasons for a person’s particular feelings, thoughts, and actions, but they need to be teased out and understood from the patient’s point of view. Only an empathic response can establish the “truth” and meaning of what the patient says, enabling them to articulate both the conscious and unconscious content of their mind. Even in everyday communication, accurate understanding can be difficult to achieve, as words can have a multitude of meanings, and literal truths are hard to come by. In fact, everyday speech is typically a mixture of words to be taken literally, supplemented by images, similes, analogies, and metaphors to enhance meaning.

Madness is a more accurate description of a person’s state of mind than a psychiatric diagnosis because it suggests a moderate to severe mental crisis without claiming to define specific categories of mental illnesses. The word, therefore, encapsulates for me the whole range of psychiatric and psychological “disorders” ranging from anxiety through to psychosis. Indeed, its accuracy as an alternative to diagnosed descriptions of states of mind is reflected across cultures and eras, and represented in literature and languages, as a person’s loss of self-control over their thoughts, feelings, or actions.  Its lack of defined conceptual boundaries means it can encompass a fluidity of feelings, thoughts, and behaviour, allowing its hallmark of uncertainty to flourish. In such a state of mind we can describe ourselves or others, for example, as madly in love, or mad with anger, jealousy, or hatred, and we can each experience these powerful feelings and thoughts as temporary or more permanent.

Reason does not seem to be the most logical feature with which to understand madness, except that it is understood to be the essence of cognition and is located in the brain. But this reflects a dominant perspective which has become the hallmark of the Western tradition of philosophy and science.  The dominance of this perspective defines madness as unreasonable and irrational, as though there is only one right way of thinking. This traditional perspective is one-dimensional and fails to accommodate the human capacity for developing intuitive awareness and tacit knowledge to provide balance to the human experience. The intuitive qualities of human nature can be understood to represent the unconscious content of the mind.

In madness, the combination of explicit and implicit meanings can prove difficult to understand. This is because the meaning can be disguised or deliberately concealed, or because the literal and metaphorical descriptions reflect a combination of feelings and thoughts that are conscious and others which emerge from the unconscious content of a person’s mind. When a person’s feelings, thoughts, or actions are diagnosed as delusory or hallucinatory, it is because they are understood only as symptoms of a disease. A more accurate meaning depends on an empathic exploration and analysis of the mixture of the conscious and unconscious content.

In my experience, the content of any diagnosed “delusion” or “hallucination” springs from a mixture of the person’s imagination and their reality, not from extraneous material unrelated to their experience. The distinction between an imagined and real self is a critical fulcrum around which madness revolves as the self, in terms of identity and personality, disintegrates into confusion, because the unconscious imperatives surface, and overwhelm the conscious mind with powerful contradictory feelings and thoughts. The unconscious content can then transform the person into someone unrecognizable even to friends and relatives, as feelings and thoughts and actions are seen and judged as “out of character”, or “not in their right mind”, or “crazy”.

The unrecognizable character is no longer validated by their family and friends because they are seen as no longer the same person. Family and friends wish and hope and even expect the person to pull themselves together and become their normal self again. But reintegrating the self depends on resolving the contradictions, ambiguities, and ambivalence which fuel the disintegration.  An integrated “self” defines the recovered “sanity”, and a person’s resolution of their internal and external conflicts, which have resulted in their madness, are reflected in the compromises they are prepared to make within their “self”, and within their social circumstances, however difficult these adjustments might be. You can change yourself in relation to the world and others, but you cannot make others or the world change, however much you wish them to do so.

It is this tacit knowledge which emerges from the unconscious to radically alter the person’s conscious state of mind. The content of the unconscious is a mixture of hidden and embedded feelings and thoughts which help shape characteristic patterns of attitudes, values, and beliefs into an identity. This tacit knowledge is available to the conscious mind if it can be interpreted and understood. When a person goes mad it is this content which emerges, revealing the thoughts and feelings that have been suppressed, either knowingly or unwittingly. In this state of mind the unconscious content has no conscious boundary to keep the thoughts and feelings under control, and so they are expressed.

Ironically, the meaning of a person’s madness is plain to see, but the lack of obvious reasons for the uncharacteristic state of mind obscures an explanation. In fact, the evidence of what the person has been suppressing in their unconscious is now evident when their loss of conscious control exposes the raw feelings and thoughts they have kept hidden even from themselves.

As the content of the unconscious gradually merges with the conscious content, what is real and what is imagined are merged in the process. Family, friends, relatives, colleagues, and mental health professionals are then left with their own confusion, contradictions, and ambivalence about how to cope with, understand and help them. The person’s state of mind can be quite maddening for other people as well as for themselves. It can also be frightening to witness someone’s apparent loss of control over their thoughts, feelings, and actions, and to engage with the person even when you are close to them, so it is sometimes easier to dismiss or shun them and the content of their madness. The uncertainty of the madness generates uncertainty among family and friends, and it can make people unsure as to how to react and what to say. There exists a fear of what the person, who has lost conscious control of their feelings and thoughts and actions, might do to themselves or to others.

The fear of losing control over our feelings, thoughts, and actions challenges our confidence and threatens to undermine the self-esteem which is the bedrock of our identity. Circumstances can conspire to threaten our self-confidence, leading to a sense of insecurity and losing one’s mind. Once fear has taken hold in someone’s thoughts and feelings it is difficult to shift. A common representation of this in films and literature is the fear of being followed, pursued, watched, threatened, or poisoned.

A man in his 30s, whom I counselled and whose family I supported, felt betrayed by a person he had taken into his apartment to help him out but had then taken advantage of his kindness. The man he had “befriended” invited his own friends to the apartment and they took over. He felt trapped, isolated, and bullied, gradually fearing for his physical safety. He was both angry and frightened, not knowing what he should or could do. Unable to change his circumstances, he left, abandoning the apartment, all the furniture he had bought to create a home, and most of his belongings. He took with him the fear the man and his friends had generated, afraid they would follow and search for him. He believed they had access to his internet connection and mobile network, and so he disconnected himself from both, whilst still living in fear that they knew where he was, even after he moved to a neighbouring country.

This man had no evidence that the other men had followed him, or that they had been able to locate him and visit his new apartment and poison his food. But he firmly believed this to be the case. His fear diminished and dissolved only when he felt confident and reassured that these men would not pursue him.

But the process to get to this point was in itself tortuous and complicated. His parents became enmeshed in his practical, financial, emotional, and psychological difficulties. They each helped him financially, and when he encountered the police as he moved through the country, his mother intervened and rescued him when his passport and bank cards were stolen from him.

My role was to facilitate the changes in this man’s mind that enabled him to restore his “sanity”. This entailed spending several hours with him of empathic attending, listening, and responding in a counselling role. But I also employed my empathic skills and knowledge with his parents as I attempted to allay their fears for their son’s mental health. I tried to explain how and why circumstances beyond his control had resulted in an overwhelming fear, which was manifested in a loss of conscious control over his feelings, thoughts, and actions.

But they found my explanation difficult to understand and rejected it in favour of seeking a psychiatric diagnostic explanation. They were frightened that he might be suicidal and that his evident anger towards them, and everyone else, might lead him to become dangerously aggressive towards them and others. Whilst they were desperate to help their son they felt powerless to do so. They tried to get him into a psychiatric hospital but he did not see himself as mad and evaded their several attempts to achieve this. His parents’ intended support inadvertently drove him further away, geographically and emotionally.

This man’s struggle for “sanity” revolved around his ability to recognize and then articulate the meaning of the tacit knowledge available in his unconscious thoughts and feelings. Although his feelings, thoughts, and actions were rooted in real experiences, his imagination had exacerbated the fears into a state of mind which could be diagnosed as “paranoid”, “psychotic”, “delusional”, and even “hallucinatory”. But a diagnosis of mental illness would then render the real experiences meaningless, as though the events resulting in his fearful state of mind were not then recognized as “real”.

Even though with hindsight, it was clear that the men had no reason to pursue him, he did not have the confidence or sufficient sense of security in himself to believe this. Only with geographical distance and the elapse of time could he look back and separate the tacit generalized unconscious fears from the reality of his frightening situation. This process of separating and being able to articulate the real fears from those exacerbated through imagination is key to restoring “sanity” through conscious awareness and control.

The empathic relationship I established with this man went some way to help him restore his “sanity” and get on with his life. But my frequent contact, conversations, and consistently supportive role with his parents were crucial also because the eventual restoration of his “sanity” resulted in their gradual relief, reassurance, and confidence in his recovery.

I have always found that this involvement in the context of a person’s life is crucial to the restoration of “sanity”. It was essential that I believed this man’s account of the circumstances surrounding the onset of his fear, and this entailed hearing about how he had come to be in the apartment, and to know him as a person with his unique identity. I focused exclusively on being empathic and gradually getting to know the attitudes, values, and beliefs that fuelled his feelings, thoughts, and actions.

Empathizing and validating the client’s experience isn’t new; the humanistic tradition of counselling relies on just that. But it has seemingly been forgotten in the scramble to label everything as a “brain disorder” and seek a biological fix for any distress.

A paradigm shift, which promotes a truly psychosocial model of madness, can only be brought about if psychiatry no longer translates a person’s feelings, thoughts, and actions into symptoms of an assumed disease. The people I have worked with would have benefited enormously from this shift. These people have been driven crazy trying to overcome disturbing, distressing, and destructive barriers in life. But these barriers to mental health are made worse once the psychiatric diagnosis is applied because their identity as a patient requires compliance with the power and authority vested in the representatives of the psychiatric system. It becomes impossible, therefore, to have an independent, and certainly not a critical, voice.

Subjected to psychiatric “reason”, the patient’s voice and views are inevitably ignored, contradicted, disbelieved, or overruled, because their diagnosis defines their lack of reason or sense. This invalidation of a patient’s voice and opinion requires them to be obedient and compliant, because any objection or challenge to, or disagreement with, the authority vested in the psychiatrist can only have negative consequences.

The patient cannot realistically challenge the “expert’s” diagnosis or the logic of its criteria, because it has been ascribed in the best interests of the patient, and the medication prescribed for their own good. In fact, when the psychiatrist questions the patient on their health, the assessment will be with regard to the checklist of symptoms that have been diagnosed. This might mean, for example, that the patient is questioned on whether they have heard voices since their previous consultation, and whether the patient thinks the voices are better or worse. If better, the medication might be deemed effective, and the same dosage maintained and, if worse, the dosage might be increased. It is ironic that the psychiatric judgement which claims to be objective relies entirely on the patient’s estimation of their own mental health.

The system’s invalidation of the patient’s voice has worrying consequences because the intended benefits of psychiatric treatment are not borne out by the evidence. The medication prescribed for depression and psychotic symptoms are unquestionably very powerful and can have a detrimental physical impact on the major human organs, particularly if taken at a high dosage and over long periods of time. The powerful organic impact of the medication and its side effects are acknowledged in the research and practice, whilst typically justified as less serious than allowing the mental illness to remain “untreated”.

The silencing of a patient’s voice is inevitable when a diagnostic map is applied to their feelings, thoughts, and actions. The man’s account illustrates the complexity of the mind, the content of which remains unfathomable when scientific and psychiatric attempts are made to reduce it to biological components of the brain.

Each person I met and spent time getting to know told me equally fascinating, terrifying, depressing, and uplifting stories of the difficulties they encountered in their life as they journeyed through the minefield of potentially explosive obstacles strewn across their path. Many of these obstacles were deliberately strewn by others, and emotional, physical, and sexual abuse can fall into this category. Discriminatory attitudes, values, and beliefs can also be strewn by others or collectively by societies and cultures, designed to demean and demolish the confidence, self-esteem, and identity of those subjected to them.

There are so many pitfalls in the development of a person’s self-confidence, self-esteem, and identity that it is surprising when a person can claim to have achieved a state of mind that they, or anyone else, can define as one of mental health. Is there such a perfect state of mind, or are we each continually striving to achieve it, as we get up each day, and face the trials and tribulations of everyday life? If we think we have achieved it, then we must look around us, and see what features and factors our context and our relationships are contributing to this state of mind.

To sustain this belief in our mental health we must also imagine other people in a different context, perhaps one of war or climate change, of floods, famines, or fires destroying lives and livelihoods, as well as our natural environment, and then realise with some empathy the difficulties others might face. With that in mind, we might be able to more readily understand the many features and factors in life, as we grow up and try to achieve and sustain our mental health, which can and does drive people crazy.

I have learned a lot about madness from literature, such as Shakespeare’s plays, because the reasons for a character’s feelings, thoughts, and actions are both made explicit and implicit within their social and political context. The portrayal of the characters is rooted in the description of the motives for their actions which flow from their attitudes, values, and beliefs. The skilled narrative requires the listener or reader to be empathic so that the reasons for the madness of Hamlet, the jealousy of Othello, and the suicide of Juliet can be understood. The complex reasons for their respective madness, jealousy, and suicide emerge from their unique personal context, and the powerful destructive and self-destructive forces which result in their respective deaths.

I see each person as the central character in their own play. When I am asked or expected to understand them and to help them to restore some sense of normality and “sanity”, from the chaotic feelings, thoughts, and actions of their madness, I have worked hard to see their world from their perspective. Although the biomedical diagnosis is claimed to reflect a scientifically refined definition of human nature, in fact, it mistakenly oversimplifies the complexity of a person’s state of mind.


Editor’s note: this post was originally published on Mad in America and is re-posted here with permission

These posts are designed to serve as a public forum for a discussion about the mental health system and related interventions, critiques and alternatives. The opinions expressed are the writers’ own.