As I noted in a previous article in The Hearing Journal, I had a patient, Joe, who shared that his pulse rate would always rise each time he visited his audiologist. I asked him why he thinks this happens. “He's very nice and supportive,” he responded. “He tries to make me feel relaxed and to focus on the positive, but I feel defensive with him, like he's going to keep finding things wrong with me.”
“Have you shared your feelings with him?” I asked, already suspecting his answer.
“Of course not!” he immediately responded. “He probably already thinks I'm a basket case.”
Joe wasn't a basket case, and his sudden situational anxiety isn't unusual for patients who visit a health care provider. He described what physicians refer to as white coat syndrome—when patients experience a rise in pulse rate or blood pressure in the doctor's office but nowhere else. Physicians are keenly aware of the high prevalence of this phenomenon since they can physically monitor patients’ vital signs and don't need to depend on a patient's self-report. But this is not the case for audiologists.
“Who else do you imagine thinks of you as a basket case?” I asked.
“You very well know that my mother does.”
He was right. As Joe's psychologist, I did “very well know” about his difficult relationship with his mother; that Joe viewed her as judgmental, critical, and condemnatory; and that the childhood diagnosis of Joe's hearing loss added more tension to their already strained relationship. Although this psychological information was extremely relevant for his audiologist to better understand the dynamics of their relationship and facilitate Joe's adherence to his amplification recommendations, eliciting this information would have been inappropriate and beyond his scope of training.
While I am not suggesting that standard hearing evaluation protocols include these psychological inquiries, I am noting that versions of this dynamic are common. The audiologist didn't know that although on one level Joe experienced him as “nice, caring,” etc., on another level, he experienced him like his mother, who will keep finding things wrong with him; and that Joe therefore continually kept his guard up, with an increased pulse while doing his best to appear relaxed. He was caught in a catch-22: he depended on his expertise, but was terrified of Joe's vulnerability and dependence.
The process of diagnosing and treating a person's hearing loss often catalyzes the re-experience of painful emotional reactions that had been associated with earlier losses or trauma. To the extent that incurring a hearing loss is experienced by a patient as psychologically traumatic, an audiology visit is likely to trigger a complex series of post-trauma psychological reactions as it did with Joe. This kind of post-trauma reaction is called traumatic transference, an unconscious dynamic that happens when someone has been traumatized and is later in a situation that reminds him or her of that trauma. One transfers the emotions that were associated with an earlier traumatic situation onto a present-day situation that is perceived as similar. Metaphorically, transference is when one uses an outdated road map.
What is an audiologist to do? Answer: Lessen your power. Adopt a one-down position with respect to learning about how your patient experiences his or her hearing loss. I am reminded of psychologist Carol Gilligan's guidance:
“How do you listen when you want to discover another person's inner world, as opposed to figuring out where someone falls on your map of the world?… I strive to work from a position of not knowing… defined as something I'm genuinely curious about, so in that sense it's a real question, something I don't know the answer to.”
Note that this mode of inquiry is the opposite of the traditional expert stance. It is appropriately termed an appreciative ally, one of respectful curiosity or collaborative inquiry. For example, an audiologist may say, “I know a lot about hearing loss, but not about how you experience it. Would you help me understand what it's like for you?”