Dell Medical School’s Carrie Barron, MD, collaborated with Phillip Barrish, PhD, Tony Hilfer Professor of American and British Literature in the UT Austin College of Liberal Arts, to author the following commentary. Barrish leads the informal working group “Medical Humanities: Close Reading, Expressive Writing” sponsored by the UT Humanities Institute. The group meets with Dell Med students monthly.
“The most important thing in communication is hearing what isn’t said.”
Management Consultant, Author & Educator
Sometimes what is not being said is more important than what is being said. This applies to both clinical interviews and literary texts, such as poems or short stories. A patient may tell you all about her skating awards and the chocolate chip cookies her mom made after school, but fail to mention the cyberbullying in middle school that made her think about suicide. Maybe the memory arouses shame, pain or fear of judgement. Maybe suppression is a healthy choice because contemplation could bring “feelings that make me fall apart.”
Then again, there may be a need to bring a troubling story to the fore in order to process and contain it. A colleague once told us, “Write about that trauma to get rid of the story, so it can no longer hurt you.”
Signs of What’s Not Said
But how do we hear what is not being said? Recently, someone shared an anecdote about a family practice doctor who had treated a woman for 30 years. Typically, she took great care with her clothing and makeup. One day, she was not wearing lipstick. He knew something was wrong. Tests later revealed that she had cancer.
A psychoanalyst described a person who had been in therapy four days a week for two years. One day, he lifted his head from the beige velvet pillow and began turning it over and over, almost beating it into position. In the session, he revealed that he was upset about a fight he had with his father. By gently inquiring about the pillow; his paleness; a wince; or his fast-paced speech, tremulous tone, jittery hands and beating gesture — those little things in the body or behavior that stand out — we can find out what is not being said.
Another way is to pay attention to one’s inner reaction. If you feel like crying and the person with you is not crying, it is possible that they are feeling inner despair and communicating it to you through a psychological projection.
A Literary Analogy
Literary works can help train us to listen for that which a patient doesn’t say but may still be deeply important to her. Writer Ernest Hemingway used the metaphor of an iceberg to explain his own famously spare short stories: “The dignity of movement of an iceberg is due to only one-eighth of it being above water. If a writer of prose knows enough about what he is writing about he may omit things that he knows and the reader, if the writer is writing truly enough, will have a feeling of those things as strongly as though the writer had stated them.”
Hemingway’s four-page short story “Hills Like White Elephants” is a powerful example. A couple at an outdoor café has a vague discussion about the shape of clouds, their drink orders and the possibility of an unnamed but “awfully simple operation.” This somewhat circular conversation is the one-eighth of the iceberg visible above the water. By paying close attention to what is and isn’t said, the astute reader gradually understands that the woman is pregnant and the man wants her to have an abortion, though neither the words “pregnancy” nor “abortion” appear in the story.
Beyond the pregnancy itself, attuned readers of the story also come to grasp — that is, in Hemingway’s phrase, to “have a feeling of … as strongly” as if it were directly stated — how the situation has affected the couple’s relationship. Because the woman keeps asking her partner to stop talking about the operation, we know we are hearing only part of a discussion has been going on for several days, maybe weeks, and she’s wrung out by it. Because the man ignores her request to stop talking about it four times, even after she has begged him, and instead repetitively insists “but I don’t want you to do it unless you really want to,” we grasp that he very much does want her to have the abortion but isn’t willing to fully own his desire not to be a father. Perhaps he doesn’t want to be the kind of man who has pressured his partner into having an abortion. Things will be emotionally easier for him if she takes responsibility for making the decision to abort.
When she finally asks him, “and if I do it you’ll be happy and things will be like they were and you’ll love me?” he quickly replies that he loves her now. But her question speaks volumes about the subtle emotional pressure she has been experiencing, beneath the surface, to make the choice he prefers. More and more of the emotional iceberg that underlies their awkward conversation at the café — the iceberg’s shape, its weight, its feel — becomes tangible to the reader as the story goes on, even though none of it is openly described. Silence, too, speaks: the first time the man brings up the “awfully simple operation,” the woman simply stares “at the ground the table legs rested on.”
Implications for the Clinical Context
Returning to the clinical context, keep in mind that people may have their reasons for not bringing something up. Tread lightly or send out a trial inquiry to see if expression will be helpful. Sometimes the person is not quite conscious of the cause of the distress. It can manifest in a physical symptom, an uncharacteristic action or a change in manner of relating. Paying close attention to what is not being said verbally, but is being said in someone’s body, behavior, silence or absence, can deepen our understanding and ability to help.