20Q: Audiologist-Psychologist Collaboration

1. I’ve seen your publications in audiology journals, but I seem to recall that you’re not an audiologist.

That is true. I’m a clinical psychologist. I wouldn’t know a “pure tone average” if I tripped over it, but I do know a thing or two about dealing with resistance and navigating around psychological land mines that hinder effective care. My first encounter with audiology occurred about 40 years ago. (Seems like yesterday). An audiologist asked me for a psychological consultation about a patient who had progressive hearing loss. In the past year, the patient had been fitted for hearing aids by six different audiologists, but each time he had returned them weeks later. This audiologist didn’t want to be his seventh victim. On reviewing the history, it became clear that the patient also felt victimized. In his words, “I kept losing more and more hearing and couldn’t control it.” What could he control? He could keep returning those hearing aids that six successive audiologists had prescribed for him. It was his maladaptive compensatory strategy.

2. Interesting. What was the outcome of your consultation?

I recommended that the audiologist emphasize to the patient that he has a choice. That she ask plenty of questions about how and when he wanted to proceed; and that she not rush to fit him with hearing aids. As one audiologist I know tells her patients: “I educate. You decide. Now that we’ve identified your hearing loss, let’s focus on what you’d like me to do to help you do about it.” 

When the patient finally agreed to get hearing aids, the audiologist kept emphasizing that he could wait and, in fact, he may decide never be fitted at all. By the way, this approach is often used when someone is converting to a religion. The religious leader refrains from encouraging the potential convert.

3. This approach actually works?

Often, yes. We can take the so-called ‘one-down position’ without minimizing our expertise. Not like a pediatrician did with my father when I was six months old. The doctor asked my father if he agreed that I needed surgery for a hernia. My dad fired him on the spot. It’s a balancing act between “I have a lot of professional knowledge, but ‘I don’t know a lot about you.’

It’s important to allow and support patients to be the expert of their own experience. For example, you don’t say “I know/understand how you feel.” You can say, “I can imagine/appreciate how you may feel” and then ask the person whether you were correct.

4. In this case, you collaborated by meeting with the audiologist about her patient. Have you collaborated with audiologists in other ways?

Recently an audiologist who was treating a 66-year-old woman for hyperacusis asked me to meet with her patient. The reasons for referral were to help the patient with stress reduction, and to help the audiologist understand the patient’s psychological makeup so she could provide better treatment. Reportedly, the patient was doing well with the protocols up until recently when she began making a lot of excuses about why she couldn’t continue the second phase. This mode of collaboration was for both of us to meet separately with the patient and exchange impressions and recommendations, obviously, with the full informed consent and endorsement of the patient.

It became clear that the patient was eager to please the audiologist (whom she liked) but felt overwhelmed by her suggestions. She was reluctant to share her hesitancy directly with the audiologist even though the audiologist repeatedly asked for them! If you’re interested, I discuss this case in detail in a recent book.

5. Why do you think this communication breakdown occurred?

Hold on, because this is going to get complicated. Enter traumatic transference.

6. You’re right, you’ve lost me already!

I’ll explain. This is a psychological phenomenon that causes patients to feel traumatized by a helping professional’s compassionate advice because they interpret it as abusive. Of note, this patient had a serious bicycle accident that she kept replaying in her mind. She felt blindsided by the accident and struggled with pervasive feelings of helplessness. It appeared to me that she transferred her experience of being blindsided by the accident and its sequalae onto her audiologist. In other words, the treatment regimen triggered Susan’s post-trauma reactions. I discussed this with her audiologist and suggested that she slow down the pace of treatment and take care to emphasize that the patient is in the “driver’s seat’

Traumatic transference is a sequela, not only of earlier trauma, but of the expert, authority stature of a helping professional. Many patients are intimidated by our stature. Metaphorically, patients may “grow down” (the opposite of “grow up”) in the presence of “the doctor.” This is consistent with the so-called “White Coat Syndrome”: when patients’ blood pressure increases in the presence of their doctor. 

7. I notice that in both case studies, the patients felt that the doctor was in the “driver’s seat” and therefore, resisted treatment. Is this common?

Yes. In Western culture anyway, we tend to value autonomy and hold on to It for dear life, sometimes even deluding ourselves that we are acting autonomously. As an example, as a self-perceived act of autonomy, I grew a beard minutes after I turned 18 because my mother didn’t want me to. I didn’t realize that I was rebelling, not acting independently. Thankfully, now, at age 72, although I still have a beard, I’m reasonably sure that it’s my choice.

It’s common for people to hold on to their autonomy as the be-all and end-all:’ I depend only on me, myself, and I. Accepting other peoples’ advice feels demeaning—an assault to one’s self-esteem. Resistance to using assistive technology is a case in point. As one man puts it, “Maybe some people need hearing aids, but I’m not gonna wimp out.”

8. A patient comes to your office for help, yet rejects it due to threats to his/her autonomy and doesn’t tell you? Did I get this right?

That’s often the case. Now, with medical emergencies, holding onto autonomy goes out the window. Someone’s having a heart attack and does exactly what the doc says and pronto! But that isn’t typically true with hearing loss. A patient may be ambivalent, may have made an appointment with you only to mollify his/her spouse, for example. Unfortunately, the initial office appointment may be characterized by the following psychological dynamics:

From the patient:

People tell me I need help, but I disagree.

Therefore, I will ask for help, but not accept it.

The doctor explains how treatment will help.  

This makes me angry, but I cannot show it

because that will make the doctor talk more.

So I’ll nod my head and plan my escape. 

From the health-care provider:

It’s clear that the patient needs help.

If I explain this thoroughly enough and convey my expertise,

then the patient will trust me and accept my help.

I know I’m succeeding at this

because the patient is nodding in agreement.

9. Trying to understand all this is giving me a headache. Can you give me some specifics regarding what to do?

Take a couple of aspirins. After you do that, perhaps the most important guideline is to first ask your patient permission for a discussion. “I’d like to talk with you about your hearing test results. Is this a good time for you?” “I know you came in for this appointment, but we don’t need to discuss it now if you don’t want to.” A positive response makes it more difficult for the patient to protest the discussion. If you receive a negative response, ask for a better time.

10. Why is asking permission so important?

Blindsiding someone when beginning a difficult conversation often sets the stage for a sparring contest. I learned this the hard way from my children when, without warning, I told them “It’s time for bed.” How helpless I felt when my kids looked me square in the eyes and asserted their voluminous "NO!" I then lectured them on all the reasons why; and they lectured me on all the reasons why not. One of us would become quiet only to plan more advanced strategies for the next battle. I should have given them a heads up for this verboten topic.

The act of empowering a person with a disability to permit a difficult discussion about assistive technology, for example, mitigates the disempowering effect of their disability. In other words, “I cannot control my hearing loss, but I can control when and how to talk about it”. As an example, a husband said to his wife, “I’d like to talk with you about using a loop system at church. Is this a good time?” She responded, “No, but we can discuss it for 6 minutes tomorrow at noon, but only in the dining room.” This was her way of exerting control and her autonomy.

11. You’ve discussed how autonomy affects a patient’s willingness to get their hearing tested. Are there other ways autonomy is helpful to people?

The experience of autonomy is relevant to how audiologists can help patients with their emotional management of tinnitus. As you know, in many cases, its causes are unknown. (Mazevskik, Beck, & Paxton, 2017). Therefore, patients often create their own explanatory narratives (Harvey, 2018). As an example, one patient was convinced that the cause of his tinnitus was divine punishment for having had an extra-marital affair. (Farfetched, but I couldn’t prove him wrong). Therefore, he compulsively prayed. At first, his explanatory narrative had given him a sense of control, but then he felt “besieged” by self-condemnation for not praying hard enough.

12. How did you resolve this?

I shared the patient’s maladaptive explanatory narrative with his audiologist and we came up with a plan. At their next appointment, his audiologist asked the key question: “Given that your belief can’t be proven or disproven, would you be willing to come up with a better one - a useful narrative, one that would help you live a more fulfilled life?” After some discussion and mulling it over, he nodded his head. He modified his narrative to “Tinnitus was ‘God’s plan,” independent of his affair. Admittedly, his new narrative probably wouldn’t quality as evidence-based, but it made sense to him and facilitated a more fulfilled life.

13. Wasn’t that patient’s audiologist venturing into practicing psychology?

Thank you for asking. About 30 years ago, the president of what was then called the Association of Dispensing Audiologists invited me to give a keynote address at their annual convention in Bermuda! Heck, I would have lectured on the mating behavior of termites for a free visit to Bermuda! My lecture was entitled ‘The Transformative Power of an Audiology Visit (Harvey, 2000).

14. Sounds interesting. How did the talk go?

Pretty good, I think. I began by defining what I meant by transformative: “that you, as audiologists, have the ability and means to connect with patients on such a deep, personal level that your patients 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.”

As an example, an audiologist, whom I’ll call ‘Dr. Smith, told me of having seen the parents of a three-year-old boy whom she had diagnosed as having a hearing loss. I told her about my speaking at the “Bermuda convention.” She sent me a card to read to the audience:

When Mike told me about your convention, my first thought was that Dr. Smith deserved to be there. But then I realized that all of you are a ‘Dr. Smith’: you touch peoples’ lives through some very difficult moments. You give people a sacred gift for which I don’t have enough words to properly say thank you.

Let me try anyway... Thank you for your technical expertise: your ability to explain what all those knobs do and what they mean and what they’re for. But most of all, thank you for being there, for listening, for your comfort and for your patience - for giving me the confidence that I’ve never had, even as a child.

I bet your patients bring you to meetings like I still do without you even knowing it; and that your spiritual presence in their lives helps make everything okay.

With much love, Joan

15. “Giving me the confidence that I’ve never had, even as a child,” “spiritual presence”? That all sounds like something patients would say to their psychotherapists.

You’re correct. However, patients often reap profound emotional benefits from audiologic care beyond the diagnosis and treatment of their hearing loss. As one audiologist put it, “I sometimes feel that much of what my patient talks about is outside of my scope of practice. She often becomes sidetracked due to talking about her feelings. I hadn’t realized that she was coming to see me for more than her ears.”

16. Are you suggesting that audiologists should practice outside their scope of practice?

No, I’m not saying that at all. I’m saying that empathy and compassion have an emotional, psychotherapeutic healing effect beyond the practice of diagnosing/treating hearing loss. You can see (Harvey, 2021) for a review of this.—

This issue has also been covered extensively in a seminal book by audiologists John Greer Clark and Kristina English, Counseling-Infused Audiologic Care. The title says it all. As Clark and English noted, “Personal-adjustment counseling is fully within our professional domain and audiologists must be comfortable providing this form of counseling to patients as a normal part of clinical exchanges (Clark & English, 2019).

Clark further noted that “The empathy and compassion we may feel for our patients and their families often has an immeasurable positive impact on their lives, alongside their grief. When patients, or parents of the children we see, leave an appointment feeling that they have been truly understood and accepted, we will have fostered needed self-esteem and nurtured confidence and readiness to tackle problems ahead (Harvey & Clark, 2021).

Audiologists have a psychotherapeutic impact on patients without practicing psychotherapy. John Greer Clark and I kicked this up a notch to address the emotional benefits that audiologists can provide for terminally ill patients (Harvey & Clark, 2021; Clark & Harvey, 2021).

17. What exactly are these emotional benefits?

I was hoping you’d ask that. As Clark noted, “if done judiciously, questions about one’s impending death may prove to be quite supportive to patients and helpful for their audiologic care. When we keep the goal in mind of helping patients more successfully cope with and adjust to their hearing loss, while remaining attentive to issues that may merit referral, we are practicing the care of audiology to its fullest.” (Clark & Harvey, 2021).

18. I think I get it: You’re saying that “practicing audiology to its fullest” necessarily includes discussing a myriad of feelings about one’s life and even impending death. It’s a mouthful. But aren’t there times that these discussions should spark a referral to a psychotherapist?

Absolutely. A common and valid concern among audiologists is “opening a can of worms” and destabilizing a patient. Bounded open-ended questions are helpful in this regard. For example, you can ask, “In about a minute or two, can you at least give me a snapshot of how you’re feeling about . . . ?” or “We only have a few minutes, but would you at least give me a quick sense on what’s going on?”

It’s important to have a referral list of mental health professionals who are also familiar with hearing loss. But it’s wishful thinking to assume that simply suggesting to patients that they get mental health counseling will result in follow through. Unless the referral is made in a careful and compassionate manner, it will likely result in non-adherence by patients and may damage the audiologist-patient relationship. A few years back, I wrote about the steps that can be used to initiate this referral (Harvey, 2008).

19. I’d like to hear them.

• Validating the patient’s feelings. For example, “Many people also say that they feel anxious about their hearing loss. This makes sense.”
• Normalizing (de-stigmatizing) the referral. Be careful when using loaded words such as therapist, mental health, etc. Instead, you can say “There are audiological ways of helping with hearing loss and there are also psychological techniques. The first is something I do; the second is another professional I know.”
• Humanizing the mental health professional. The more patients know about who they are being asked to see, the less anxiety and fear of the unknown they will experience.  For example, “I’ve known Dr. Smith for over 20 years. She’s nice, been practicing psychology for over 30 years. She has a dry sense of humor. I think you’ll like her.”
• Emphasize the value of a team approach. You can refer to the mind-body connection or terms such as “holistic or ‘multi-disciplinary approach” which are recognized and accepted in today’s culture. The team can be framed as a partnership between audiology and psychology.  

20. We’ve made a full circle to the beginning of our discussion: the benefits of inter-disciplinary collaboration. Two heads are better than one.

Well put. (smile) One of my favorite quotations is: ‘Collaboration divides the tasks and multiplies the success.’ (anonymous).