By Dr. med. Hans Hermann Ehrat - physician for general medicine FMH / psychotherapy IG.
The method of “idiolectic conversation”.
The extraordinary situation of patients on palliative care wards requires a form of conversation that goes beyond conventional and familiar dialogue.
The method of idiolectic conversation offers a helpful way of meeting this requirement. Many varied situations in my work with nurses and physicians in such institutions have strengthened my conviction that it is worth returning again and again to “idiolectic interviews”. With this form of conversation, which is oriented toward the patient’s own language, access to the patient becomes possible where it would otherwise often be difficult to achieve.
Working with the patient’s own language opens a way to deal carefully and respectfully with the often hopeless situation of those affected. Usual conversational patterns are left behind in favour of an innovative form of dialogue. This form is not an attempt to solve problems through rational thought in the Aristotelian sense. Rather, it is about entering into the complexity presented - listening, not speaking. Complexity always contains ambiguity. Individual, unique links exist between many different elements. What is “right” is therefore not an objectifiable reality, but the emerging ability to make other, new discoveries that enable the speaker, independently or through insights gained by themselves, to become more capable of decision and action.
The point is not to create expected answers. If one nevertheless tries to do so, the solution found is often tied to the person leading the conversation and is oriented toward that person’s own experiences. That is strenuous and often incomplete. The older kind of consultation allowed an expert, bypassing the competence of the conversation partner, to tell the patient how a difficulty could best be solved. Such advice is of course not simply wrong. But the situation of incurably ill people, as experience shows, requires a different access to the complex situation of the person affected.
It must be clarified what this interview form is and which technical aids are necessary to enable such a different form of conversation. The starting point is always the principle that every person is unique. In this uniqueness every person speaks a unique language of their own. If encounters are shaped on this basis, different, personal and unique conversations arise, because this attitude makes the dignity and reality of each person visible and creates authenticity.
Technically, so-called “key words” are used as points of reference in the conversation. These key words are perceived by every listener but too seldom truly accepted as meaningful. They open the possibility of conducting conversations in the client’s own language. They are always the starting point of a relationship between speakers, and they fall to the listener, so to speak, when the necessary openness is present. This openness has to do with composure and requires the listener to set aside their own ideas, concepts and solutions.
Working with key words helps the listener not to cling primarily to the content of the problem presented - a condition without which a genuine encounter cannot succeed. Instead, it enables the speaker, from the outer space of very personal experiences, to gain a free view of possible solutions of their own. Such conversations succeed all the better when one keeps clearly in mind that every person contains a self-organising principle, which D. Jonas calls “inner wisdom”. According to the axioms of idiolectic conversation, this inner wisdom is the only force that helps us live. It also helps us understand that reality and truth are always found with the speaker, never with the conversation leader or physician. Idiolectic interviews make it possible to encounter this inner wisdom; the path toward it is opened.
In view of this, a wonderful sense of lightness and calm can arise between the partners in conversation. The transition from conventional conversation to the idiolectic form is almost a paradigm shift and enables, with surprising ease, a very different form of encounter between human beings. Leaving conventional conversational forms for this paradigm is a major challenge for all advisers, because traditional medical thinking and action follow quite different guidelines. The shift is often marked by understandable fear of losing authority and legitimacy. For this reason one repeatedly observes conversation leaders trying to combine a conventional approach with an idiolectic one, which usually leads to regrettable technical difficulties in the conversation.
Example conversation
“My doctors have told me that I do not have long to live. They said I should prepare myself, look at all the questions that are coming, make all the necessary decisions, especially those that may be important for my family, and also record what should happen when I am no longer here. I think that is easier said than done.”
Do you remember things that have been easy for you? “Being together with my family, perhaps taking a trip, going somewhere to walk.”
Where might that be? Are there places you particularly like? “I very much like being at the Baltic Sea.”
And what do you like about the Baltic Sea? “The endless vastness, nature, and I love seeing the waves come and go on the beach. I have spent many hours there and think of it very fondly.”
What else comes to mind when you think of this scene? “I feel how closely and well I am connected with my family. It gives me strength to know how well my children think of me and how concerned they are for me.”
That sounds wonderful. Would you like to say anything else? “No, thank you for the conversation.”
The effect of such a short “paralogical” conversation can ultimately only be speculated about. In any case we moved within a field clearly shaped by resources; we managed to arrive where the “sun is shining”. Of course, reality has not changed. But the patient found an essential bridge to the recognition of how well her family cares for her and how much these people can probably be trusted to do. The connection to other inner images can unfold effects beyond logically expected possibilities of solution. It is understandable that encounters shaped in this way have very different basic conditions. This is about far more than empathy. Working with key words enables the conversation leader, in Rilke’s sense, to remain at a distance: “I always want to warn and ward off: stay away; I love so much to hear things sing. You touch them: they are rigid and mute - you kill all things for me.”
