Patient Care | September 2022 Hearing Review

Giving voice to the unspoken pain

By Michael A. Harvey, PhD and John Greer Clark, PhD

“I think we all have empathy. We may not have enough courage to display it.”  

— Maya Angelou

In this discussion article, Drs Harvey and Clark reflect on the importance of empathy and compassion. Parents are frequently devastated by the news of an irreversible hearing loss. Older pediatric patients wrestle not only with communication barriers but also with the challenges of fitting into an aural-oral-based social milieu. And adult patients often find it difficult to confront the changed self-image that accompanies the realization that hearing loss is here to stay. Empathy and compassion are key to fostering patient growth beyond the assistance that technology can provide.

Harvey: I’d like to share some non-audiological examples of how our interactions with others aids our healing. I recall when I was scheduled to give a speech four days after my wife, Janet, died of pancreatic cancer. I was going to cancel the trip but, with much ambivalence, decided that it could be a distraction from the haunting images of the ICU. I arrived an hour early in order to get settled, but instead of being ushered into a quiet room as is typical, I was ushered into a full auditorium where a panel of parents were speaking of their haunting images of their children being born with multiple disabilities and deformities. I wasn’t pleased.  

But then came a gift. In addition to the parents’ horror stories, they also expressed how the compassion from the hospital staff continue to sustain and nurture them alongside their pain. As the parents talked, I nodded my head with tears of empathic appreciation in my eyes. A few hours later, at the end of my speech, I shared with the audience the reason for my tears and thanked them for how my coming to speak helped me. It brought me back to the compassion my wife and I had received during her last days.

Another example of how the compassion of others has lifted me occurred when I was sponsored by the German government to take a study tour of post-Holocaust Germany. We spoke of unspeakable atrocities and visited several death camps including what is now called the “Auschwitz Memorial.” I was prepared to alternately feel numb and horrified, but I was surprised to also feel uplifted. Why?  I met many Germans who actively sought to understand our struggle to come to terms with the atrocities. Now, alongside that unfathomable horror, their compassion and life commitment to making the world a better place will also be forever etched in my mind. And for that, I am grateful.  

Janet’s death in the hospital ICU and my post-Holocaust trip both exemplify a coexisting duality of opposing feelings: I left the ICU feeling heartbreak and gratitude and left the study tour feeling devastated and inspired.  

Clark: Indeed, the empathy and compassion we may feel for our patients and their families often have an immeasurably positive impact on their lives alongside their grief – as you said, a coexisting duality. 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.

However, it’s more complicated than it first appears. Unfortunately, our compassion is often not perceived by our patients – often quite the opposite. Audiologists enter their chosen profession with a strong desire to help others, to make a positive impact on another’s life. For most audiologists, the strong internal compassion of the plight that one with impaired communication struggles with daily was strengthened during their academic and clinical preparations as they learned firsthand the psycho-social impact of hearing loss. Yet, this internal compassion contrasts strikingly with what many patients feel in response to our interactions with them. Surveys of both parents of children with hearing loss and adult patients seeking audiological care reveal that often those we serve leave their appointment feeling that the audiologist is insensitive and indifferent, or that the audiologist only wanted to sell them hearing aids.1-3

One reason this impression of insensitivity and indifference arises is when we respond to the surface structure of what patients or parents may say rather than the emotions that run beneath their words. I remember an audiologist working with a parent at her 9-month-old child’s first hearing aid fitting. The mother said softly at one point, “Hearing aids look so large on her tiny ears.” It was said quietly, almost to herself. Her utterance afforded the audiologist an opportunity to acknowledge this mother’s pain beneath her words.  Instead, the audiologist reassured her with a soft smile and replied, “But her hair will grow, and you’ll be surprised how much they will blend in.” As another example, an adult patient being fitted for hearing aids may comment that he thought they were for old people (an acknowledgment of pain) followed by the audiologist’s reassurance that indeed many younger people also use hearing aids. 

These examples illustrate a fundamental lacking in the manner we are listening and responding to patients, something we can certainly improve to heighten the healing compassion that we would like to convey. The child’s mother certainly was aware that her child’s hair would grow. Such reassurance was not what was needed, but rather a statement that spoke to the gravity of the moment such as, “It must be very painful to see hearing aids on your little girl.” Similarly, the adult certainly knows that children also wear hearing aids. A better response might be something that speaks to the pain or disappointment underlying his statement such as, “It must be difficult when life’s changes are not what we anticipated or desired.” 

Harvey: In this context, not talking about the “elephant in the room”  the pain or disappointment that run beneath patients’ words may lead to perceived dispassion and manipulation. As Nietzsche said, “Silence is poison. All truths that are kept silent become poisonous.” John, how can you “detoxify” patients’ hidden emotions and assure them directly that they are understood and not being manipulated to buy an expensive product?  

Clark: You’re correct that this does need to be broached directly. Unfortunately, often the pain or disappointment that hearing aids are indeed part of the required solution remains unacknowledged, either directly or indirectly; hence, it becomes the audiologist’s responsibility to give voice to that “elephant” possibly with a statement such as, “I’m sure the use of hearing aids isn’t what you really were hoping for.” Such a comment will most often be acknowledged with a shrug or nod or, at other times, the patient may respond more fully. Either way, the ensuing exchange does not take much time, nor does it derail the purpose of the appointment.  Rather, it shows an attunement with the moment and with the patient’s feelings. And when we do this, our displayed compassion is helpful, regardless of whether the patient ultimately follows our recommendations.

Harvey: So, we need to expand the definition of “help.”  Sometimes the “help” may be centered around prescribing hearing instruments, while at other times it may be the so-called warm and fuzzy stuff – aka empathy and compassion. I’m reminded when Janet had just met with her oncologist in the hospital shortly before she died. I telephoned her, anxious to hear what the doctor said. Janet reported that, “He was very nice. Do you know what he did?  He sat next to me.  He didn’t stand.  He sat at my level and …”  I have to admit, I interrupted her. I didn’t show her empathy and compassion as I said, “I don’t give a sh*t if he stood on one toe but, what the hell did he say about …”   It wasn’t my finest moment.  But what Janet was trying to tell me – if I would have only listened – is that the oncologist helped her with his humanity, his compassion.     

Clark: Let me play devil’s advocate here, Mike. You say the doctor helped her, but she died soon after that “helpful” appointment. Can you elaborate?

Harvey: Again, it depends how we define “help.” Paul Kalanithi was a neurosurgeon who died of cancer at the age of 39. He wrote a seminal book, When Breath Becomes Air, published posthumously. In his words, 

“I began to look forward to my meetings with Emma [his oncologist]. In her office, I felt like myself, like a self. Outside her office, I no longer knew who I was. Because I wasn’t working, I didn’t feel like myself, a neurosurgeon, a scientist—a young man with a bright future spread before him.  In Emma’s office, I could joke, talk freely about hopes and dreams.” 4

In my practice, I recall one of my first psychotherapy patients with a terminal illness, a 70-year-old woman named Mary. She immediately informed me on our initial visit that she had about a month to live as her cancer had metastasized.  “What the hell am I supposed to do?” I thought. I modified my internal question to overtly ask her, “How can I help?” A useful script. Mary’s request was for me to teach her imaging strategies that would attack her cancer cells, a version of the then-popular Nintendo game when one plays as Mario and saves Princess Peach by attacking the evil Bowser.

After some hesitation, I acquiesced to her request. I hesitated because killing browser cells isn’t exactly an evidence-based treatment for cancer. And I could imagine the headline: “Psychologist Harvey Brought Up Before the Ethics Board for Practicing Oncology Medicine Without a License.”  However, she appreciated what she called my “emotional support,” as she had asked several other psychologists who had refused her request. For a couple of sessions, we marveled at how her internalized images of Mario effortlessly obliterated her evil Bowser cancer cells. “Thanks for making me feel better,” she would often say. She died a week later.

Janet knew that her doctor’s demeanor wouldn’t cure her cancer. And I suspect Mary didn’t really believe that evil Bowser imagery would be a cure. But regardless, both of them felt better and in that sense were “helped.”  You and I have discussed the important role audiologists have in helping terminally ill patients.5-7 Although a patient’s impending death is often perceived as a taboo subject when openly discussed, this elephant in the room can strengthen rapport and trust and pave the way for improved quality of one’s remaining life.

The story of Mary also illustrates that it’s important for us, as helping professionals, to have compassion for and honor, patients’ attempts to help themselves even though their method may not be rational. Note that we don’t necessarily have to agree with the efficacy of patients’ attempted solutions. In addition to Mary, I also think of Victor Frankl’s book, Man’s Search for Meaning,8 in which he recalls regularly taking care to wiggle his fingers in a certain order while imprisoned at Auschwitz. Certainly, he knew this ritual wouldn’t spare him from the crematorium, but on a psychological level, it became quite important. Like with Mary, it was something he could control.  

Similarly, a patient had been fitted with hearing aids by several audiologists but had repeatedly terminated treatment and returned the aids.  His pattern changed only when, together, he and the audiologist figured out that while he couldn’t control his progressive hearing loss, he sure as hell could exert control by firing a slew of doctors. That audiologist had the courage to go beyond the limitations of what you have termed “Dr Information” by displaying empathy and compassion for the emotional sequelae of the patient’s hearing loss. Accordingly, this patient now happily benefits from hearing aids.  

I’m thinking of Maya Angelou’s quotation at the beginning of this article about not having enough courage to display empathy. It reminds me of the introductory phrase from the original “Star Trek” television series: “To boldly go where no one has gone before.” 

Clark: Courage is the operative word. It can be exercised without violating professional boundaries or opening up a can of worms. In some ways this courage is very applicable to the history of audiology. The profession has its roots in the provision of therapeutic hearing rehabilitation services with the sale of hearing aids left to others. It was a few courageous mavericks who boldly went where no one had gone before to begin dispensing hearing aids in order to bring the full spectrum of hearing rehabilitation under the provision of a single well-trained professional. The fact that hearing rehabilitation services, other than hearing aid dispensing, resultantly (and often, unfortunately) have taken a very distant back seat is a different story. But with that shift, over time, we seem to have lost some of our therapeutic skills which foundationally included a greater display of empathy and compassion. It would behoove many healthcare professionals to embrace Angelou’s call for courage in this regard. 

Harvey: Interestingly, the field of psychology began with influences from psychoanalysis and client-centered therapy which fostered the notion that empathy and compassion would be sufficient to effect change.  It has only been in the last few decades that the field has focused on brief interventions that target specific behavioral change. Although that is largely a positive shift, in some cases, it has resulted in specific treatment protocols taking precedence over the therapist-patient relationship.  

Clark: This is significant as a strong professional-patient relationship is one of the key factors behind patient satisfaction for services rendered.9-10 Another method through which professionals can foster this relationship and better display their concern for their patients would be to embrace the power of clinical silence. We all recognize the discomfort when silence settles into a social context. But, clinically, when the professional pauses before responding when a patient makes an emotionally charged statement, it can provide a moment of reflection for the patient. Similarly, when the clinician is speaking, if the patient breaks eye contact, appearing to process what is being said, a brief pause is often helpful. This “attentive waiting” can provide temporal space for reflection and an opportunity for patients to assume greater responsibility for their own progress. Sometimes what the patient then says at these times shifts the direction of the dialogue from what the clinician was expecting, but in a direction of greater importance for the patient at that moment.

Harvey: The longer you can stay with the present moment and explore where the patient “went” in his/her head, the more pathways to change emerge. For example, I recall a patient who remarked, “You know, I never thought of it that way” and then was silent for several seconds. I waited and then said, “Something just clicked for you. Catch me up, will you? You just went somewhere and realized some important things.”

A word about definitions: While we are discussing empathy and compassion, we need to remain cognizant of the fact that while many people use these terms interchangeably, technically they are different processes. The definition of empathy is to understand and share the feelings of another within their frame of reference; to put yourself in someone’s shoes.  It’s an internal process.  Compassion is the behavioral or external counterpart of empathy. Compassion is an expression of concern for the sufferings or misfortunes of another while attempting to somehow ease their pain.  

Here comes the challenge. For example, you and I, as males, cannot have empathy for an expectant mother but we can have compassion. Similarly, we cannot fully empathize with patients who have hearing loss, as we don’t have hearing loss ourselves.  Many healthcare professionals err by saying, “I understand how you feel.”  Although, some, patients may react positively – e.g., “My audiologist really gets it!” — at other times, this well-meaning affirmation is received with indignant anger: “How could this doctor know how I feel?”  

A related error that we’re prone to making is telling patients how they feel.  I recall making this mistake with a man who was screaming at his wife in my office, with his face flushed and fist waving in the air.  I said, “You’re angry.” It felt like a safe enough bet.  However, he scowled at me and yelled, “I’m not angry, I’m pissed off!”  For him, there was an important difference. I should have asked him whether he was angry and then reflected back on his self-report.  

So, if empathy is impossible, where does that leave us? It leaves us in a position to make some incredibly powerful interventions via questions.  “Would you tell me what it’s like to be in a crowd of people that you cannot understand?” Or you can make tentative statements, such as “I can imagine how you may feel” or “Let me take a guess about how you may be feeling” and then ask the patient for verification.  

Let’s go back to Maya Angelou’s quotation. Why might one need courage to display empathy? What is the fear? I often hear lamentations about making a major mistake: “What if I don’t empathize correctly with a patient?” or “What if I don’t get it right?”  

But there is good news, and it’s very good news!  It isn’t always necessary or even most beneficial to correctly identify a patient’s emotion.  Our repeated attempts to empathize correctly – to get it right – is the behavioral demonstration of compassion. It’s the sine qua non of treating the patient as a whole person.   Even our empathic failures show our compassion, provided we don’t prematurely give up. It shows a clear attempt to cement the rapport that is so necessary to develop a strong working partnership.  

Pt: (Verbalizes feelings)

A: “Let me see if I’m understanding you right.  (Does reflective listening)

Pt: “No, not quite.”  (Provides clarification)

A:  (Again, does reflective listening)

Pt: “Still not quite right. (Provides clarification)

A: “I really want to understand what you’re feeling, bear with me will you?  (Smile)  (Again does reflective listening)

Pt: “You got it!”  (Smile with solid eye contact)

Clark: I can imagine many audiologists reading this thinking that this goes beyond their professional boundaries by practicing psychotherapy. That is not the case, however. It’s important to distinguish the personal adjustment counseling that an audiologist provides from counseling/therapy by a psychotherapist.  We don’t provide psychotherapy and cannot bill for personal adjustment counseling. And we have limited time. Moreover, the back and forth that you described to get to the precise emotion may not always be necessary.  

However, it’s important to emphasize that the components of personal-adjustment counseling are vital to our work.  When woven into what we do, and not provided as a set aside service, it can be tremendously impactful and typically does not add significant time to a session.11

Harvey: Right. Typically, this back and forth takes limited time, maybe a minute or two.  And showing compassion and empathy hugely increases patient adherence to recommendations and satisfaction toward services rendered. Moreover, although you don’t practice psychotherapy, you make some very powerful psychotherapeutic interventions! As you said earlier, if patients feel that they have been truly understood and accepted, “we will have fostered needed self-esteem and nurtured confidence and readiness to tackle problems ahead.”  I’m reminded of one patient who finally agreed to hearing aids. I asked “Why now?” She said, “The audiologist not only asked me how I was doing but was the first one to show that he really wanted to hear my answer. And you know what? Even before he fitted me with hearing aids, I felt more like a worthwhile person!”

Citation for this article: Harvey MA, Clark JG. The power of empathy and compassion. Hearing Review. 2022;29(9):10-16.


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