"After four failed trials, Bruce has finally decided he is receiving benefit from amplification and is consistently wearing the most recent set of hearing aids. I wish you could have seen his broad self-confident smile. He needed to be able to trust in me to not judge him until he got there. Our clinical road is paved with relationships, patience, and trust. Not everyone understands that is the secret to a successful fitting.”*
Why do patients frequently feel judged when they get their hearing evaluated? I asked this question to Joe, a middle-aged man who was recently diagnosed with moderate hearing loss. His response: “I flunked my hearing test, so I guess I didn't study hard enough.” We both laughed at his humor, but it was also obvious that it reflected a painful emotion.
Like many patients, Joe felt ashamed when his audiologist confirmed, in his words, that “I'm defective.” It didn't matter that he had requested the appointment (he wasn't dragged in by his spouse) and that the audiologist was compassionate and positive. All the explanations in the world of why he shouldn't feel ashamed weren't helpful, such as: “Many people have some sensory loss with age;” “It isn't your fault;” “There are many treatments;” “It's only a moderate loss;” “It could be worse.”
Joe's shame had more to do with the psychological context of medical appointments. Metaphorically, people may “grow down” when visiting the doctor. Because of heightened anxiety and helplessness, patients may view the doctor as an omnipotent and omniscient parent-figure, who might also bestow benevolence if, and only if, the parental-figure (doctor) judges them worthy. Not only do many patients feel infantilized in this manner, but they also become terrified of getting indicted with a diagnosis—like they're being punished for being naughty. Hence, the White Coat Syndrome: when a patient's pulse rate or blood pressure rises at the doctor's office but not elsewhere.
I asked Joe if he thinks his pulse rate changes when he's at his audiologist's office. Instantly, he nodded his head and I asked why. “He's very nice and supportive,” he began. “He tries to make me relaxed and to focus on the positive, but I feel defensive with him, like he's gonna keep finding things wrong with me.”
In addition to present psychological factors, there are also historical ones. A loss, such as hearing loss, does not usually exist in isolation. Geriatric patients frequently feel besieged by a seemingly endless array of health-related losses, many of which may have been experienced as traumatic. Hence, a hearing evaluation may trigger the re-experiencing of previous maladies (Hear Rev. 2010;17(3):12). As one patient put it, “When my audiologist told me about my hearing loss, it brought back my terror of when doctors thought I had cancer!”
Although, per Loewenthal's observation, the clinical road is paved with “relationships, patience, and trust,” often it doesn't start off this way. Initially, the “pavement” is frequently full of hazardous potholes. In the psychological vernacular, this dynamic is called traumatic transference—when someone who has been traumatized (e.g., by hearing loss) later finds himself/herself in a situation that is reminiscent of the trauma (e.g., the health care provider's [HCP] office). One transfers the emotions that were associated with hearing loss onto the HCP (Hear Rev. 2010). It wasn't a coincidence that Joe's experience of feeling judged by his audiologist—along with his defensiveness and shame—were identical to how he felt about having lost his hearing.
DON'T BE IN SUCH A HURRY TO HELP
“After four failed trials, Bruce has finally decided… [emphasis added].” I'm reminded of a Dennis the Menace cartoon in which Dennis was trying to help an elderly woman cross the street, but she yelled, “I don't want to cross now!” Dennis could have/should have asked; “When might you want to cross the street? How? Why? What would the pros and cons be? What concerns do you have about crossing?” In this manner, HCPs (and Dennis) can ask “curious questions” without being in such a hurry to help (DiLollo & Neimeyer, 2014). At the outset, it is vital to mitigate traumatic transference, to humanize yourself, absolve yourself of the judge or parent roles, and establish likability as a caring professional who is offering help without demands or pressure (Audiology Today. 2012;24(6):50; Audiology Today. 2009;21(5):36). This can be best accomplished by respectful and curious questioning of a patient's life, including but not limited to hearing loss, humor, or any authentic way of establishing rapport. For example, a 70-year-old woman said that she finally got hearing aids after many appointments with many providers. I asked her, “Why now?” She replied, “That very nice man was the first to ask me how I'm doing and really wanted to hear my answer!”
WHAT WE NEVER LEARNED IN SCHOOL
“Relationships, patience, and trust.” It sounds so simple, so obvious—hardly worth an explicit reference in a professional article. It's not even something most of us learned in school (not even psychotherapists!). Moreover, it's not even deemed a laudable goal in our outcome-driven medical culture. I have a fantasy that I say to a managed care company, “Don't worry about how long treatment takes—it's about relationships, patience, and trust,” to which they respond, “Thank you so much, Dr. Harvey. We never thought of that.” Dream on!
My unrealistic fantasy notwithstanding, these three simple-sounding words are indeed the “secret to a successful fitting.” And there is an additional psychological benefit called an emotionally corrective experience—often the goal of psychotherapy, but it is not limited to that. As I have enumerated in previous publications (Hear Rev. 2010; Feedback. 2010;10(9):13), HCPs have a kind of transformative power:
The ability and means to connect with patients on such a deep, personal level that they share information, their fears, hopes, and dreams with you that maybe they've withheld from others. And, at some point, when they begin to trust you and feel safe and comfortable, they take in your warmth and knowledge, follow your recommendations; and, in turn, they experience a change in how hearing loss affects their lives. And because of this change, this transformation, they feel more in control of their world; and they live happier and more productive lives.
While remaining within the bounds of professional competence, you are often able to make poignant therapeutic interventions. Why is this the case? You meet patients when they are in crisis and extremely vulnerable, when they come face to face with an impending sensory loss for themselves or for a loved one. The apparatus in your office, e.g., hearing testing equipment, models of the ear, sound booth, etc., serve as affective triggers that inevitably accentuate patients’ fears and vulnerability.
Why might this be good? Where is the potential benefit? Certain memories associated with times of heightened anxiety become “imprinted” in one's consciousness (Van der Kolk, 2014). Often these details have to do with the HCP's warmth and compassion. The HCP's words are often forgotten amidst the flood of anxiety, but, as Maya Angelou put it, “the way you made them feel” is forever etched in their consciousness and becomes part of the fabric of everyday life, particularly in reference to coping with hearing loss. Patients internalize your deeming them as worthy. How this happens is via the “pavement” of the clinical road: “relationships, patience, and trust.”
Hence, what often begins as patients feeling judged, defective, ashamed, helpless, indicted, and terrified gradually morphs into a “broad self-confident smile.” Undoubtedly, that smile is partly a result of successful treatment but your help extends well beyond ameliorating impaired hearing. As one audiologist put it, “I hadn't realized that she was coming to see me for more than her ears.”
*This communication was sent to me by Terri Loewenthal, AuD, CCC-A.