When an adjusted hearing aid is only part of the treatment

Psychologist Michael Harvey shares a case of an audiologist who needed his expertise to properly fit a patient with a hearing aid, as well as enable the patient to cope with depression. The author also includes some brief guidelines for helping clinicians to assess when a patient’s repeated requests for hearing aid adjustments are potentially related to the need for psychological counseling.

Can I tell you something off the record?” the audiologist asked me. “I dread when I see ‘Susan Parson’ listed in my appointment book. When I fitted her with hearing aids, she did well, but then she wanted me to change the settings almost every week, and she’s never satisfied, and it has been almost a year. She’s driving me absolutely nuts! Either she gets therapy or I’m sure as hell gonna need it!”

Michael A. Harvey, PhD, ABPP, is a clinical psychologist in private practice in Framingham, Mass, adjunct faculty at Boston University, and consultant faculty at Salus University. His books include The Odyssey of Hearing Loss: Tales of Triumph and Listen with the Heart: Relationships and Hearing Loss (Dawnsign Press, San Diego). He also provides consultation to hearing care professionals and conducts workshops on psychological aspects of hearing loss and motivational interviewing.

This article is a case study of a “difficult” hearing aid patient from the perspective of a psychologist who is using an approach called externalizing conversations. I invite the reader to consider how each of the following psychological questions or interventions can be replicated or modified for appropriate use with audiologic patients to increase patient adherence to recommendations. This case study is also a testament to how a hearing care professional and therapist can work together for a better outcome as a team.

The audiologist and I discussed the best ways to refer Susan to me for psychotherapy. A mental health referral is full of psychological land mines and must be implemented in a careful and compassionate manner, lest it damage the audiologist-patient relationship. I recommended adherence to four issues:

  1. Validate and contain Susan’s feelings (“Susan, your hearing fluctuations have understandably been anxiety-provoking and traumatic.”);
  2. Normalize and de-stigmatize the referral (“There’s a skill set of psychological tools that often help people with hearing loss decrease their anxiety and get more benefit from their hearing aids.”);
  3. Emphasize that optimal treatment of hearing loss necessitates a team approach (“I’ve found it more successful to use a holistic, team approach to help people benefit from hearing aids.”); and finally
  4. Humanize the mental health professional (“I’ve known Dr Harvey for over 20 years. He’s a nice guy, although his office is sometimes a bit of a mess. I think you’ll like him.”).

The process of an audiologist successfully referring to a mental health professional has been described previously.1

My Meeting with Susan

Susan appeared in my waiting room looking much older than her chronological age of 65. She was disheveled and appeared depressed and anxious. Amid tears and trembling, she made a correct assessment that she was “driving Dr Smith nuts.” However, she also disclosed she was driving herself nuts—that her hearing loss of approximately 9 years’ duration completely overshadowed her life. “There’s nothing left of me,” she kept saying. A potent self-indictment that invited further inquiry.

“Can you remember a time when it felt like you had a life separate from the hearing loss?” I asked.

Susan shook her head. Her loss of hearing diminished certain pleasures, such as music and soft conversation, and “spread” to psychologically obliterate her sense of self-competence, self-esteem, identity, and her hopes and aspirations for the future. When her levels of stress and anxiety were running particularly high, she experienced intermittent tinnitus, which she described as a “high pitch squealing noise in my head.”

Susan and her hearing loss had become indistinguishable, which psychologist Beatrice Wright referred to as a “high degree of spread.” That is, a high degree of spread occurs when one’s disability “spreads” to encompass one’s sense of self and causes overwhelming shame.2 Rather than viewing herself as a competent person who is affected by a specific deficit, Susan viewed herself as “one big deficit.” This presentation is quite common among patients who have hearing loss and are working with a dispensing professional. As White3 states:

Many people who seek therapy believe the problems of their lives are a reflection of their own identity. This sort of understanding shapes their efforts to resolve problems, and unfortunately these efforts invariably have the effect of exacerbating the problems. In turn, this leads people to even more solidly believe that the problems of their lives are a reflection of certain “truths” about their nature and their character.

My initial question regarding whether she could remember a time when she felt separate from the hearing loss was an entrée to an externalizing conversation.3 Initiating an externalizing conversation is a powerful psychological intervention that can be utilized by hearing care professionals to illustrate that the person is not the problem, the problem is the problem. As will be illustrated with Susan, the four tasks of externalizing a problem are to:

  1. Elicit a particular “experience-near” description of problem;
  2. Map the effects of the problem;
  3. Elicit the patient’s sentiments about the effects of the problem; and
  4. Elicit the patient’s justifications for one’s sentiments about the problem effects.
1) Eliciting Susan’s particular experience-near description of problem

MH: “Can you imagine that the hearing loss is located somewhere separate from you, even though it affects you? Can you imagine what it looks like, what form it takes, and what you would call it?”

SP: “My hearing loss is like a shadow, like when the moon eclipses the sun. I’d call it an eclipse that leaves me in the dark and cold. It’s an eternal eclipse because it’s not temporary like others. It’s huge, very heavy, and very dark. An eternal eclipse.”

MH: “That’s quite extraordinary. It has to be quite strong to keep the moon in exactly the place so that you’re in the shadows indefinitely. If you would imagine it has a voice, what would it be saying to you?”

SP: “It says, ‘I’m gonna get you. I’m going to keep you in the dark, away from everybody!'”

MH: “So it’s a mean and sadistic bugger, out to keep you isolated in the dark?”

SP: “Yeah, it’s mean all right, and I feel so helpless against it.”

Each of us has our own personal so-called “experience-near” metaphors for our victories, challenges, problems, etc. Susan’s audiologist referred to her loss as a “bilaterally symmetric, moderate-to-severe, sensorineural high-frequency hearing loss, concomitant with 84% word recognition scores bilaterally.” But Susan knew it as a “dark shadow from an eternal eclipse.”

It would be important for me and the audiologist to converse with her via her personal metaphor; to match Susan’s experience-near language in order to convey a deeper understanding of her emotional experience, and therefore, increase the probability that she will ultimately accept our help.

A common psychiatric “experience-near” description of her problem would be Major Depressive Disorder, coded as “296.32” in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), the official listing of psychiatric disorders. But this diagnosis would be about as psychologically helpful to Susan as was the audiologist’s explanation of her audiogram. For Susan, what came closer to her experience-near problem definition was an image of desperately holding on to whatever she could control. But finally, we arrived at an image that most resonated:

SP: “I try to get rid of the shadows, but they always follow me.”

During the above conversation, I was tempted to try to persuade her that the shadow wasn’t as huge as she thought, that she truly does have an identity apart from her hearing loss, and that she should do x, y, and z in order to make her life more meaningful. But here’s the rub: Had I set out to give Susan helpful advice at this stage, I would have joined the audiologist who set out to help by adjusting her hearing aids every week for over a year, only for the both of them to be “driven nuts.”

Instead, the audiologist and I could help more by not trying so hard to help. I would become an investigative reporter whose task is to be curious and to learn about Susan’s relationship with the shadow. Investigative reporters ask many questions, as opposed to giving advice and attempting to exert influence; they rarely interrupt; they use less words than the interviewee.

Stated differently, it is important to deliberately adopt a particular relational stance with patients—to intentionally decide how to relate with patients. The relational stance that usually does not work with resistant patients is the “expert relational stance” from which we render our diagnoses and make treatment recommendations. I’m reminded of a Dennis the Menace cartoon in which Dennis was trying to be helpful to an elderly lady by leading her across the street. She was yelling, “I don’t want to cross!”

Dennis, like me (and like Susan’s audiologist), could adopt a curious, investigative reporting stance—a relational stance of an appreciative ally. The appreciative ally stance is one of respectful curiosity or collaborative inquiry. This means that, as helping professionals, we resist our temptation to help too soon.

Hearing care professionals can ask bounded open-ended questions that are designed to elicit a limited narrative of the patient’s emotional world, thereby not “open up a can of worms” and not practice psychotherapy. For example, an audiologist can ask, “In about a minute or two, can you at least give me a snapshot of how you’re feeling?”

Back to my meeting with Susan. The second step to externalizing a conversation is mapping the effects of the problem: inquiring about the historical and current effects of the problem through the various life domains of living, in which complications are identified: personal identity, familial relationships, school/workplace, peer contexts, and hopes and dreams about the future.

2) Mapping the effects of the eternal eclipse shadow

MH: “What does the eclipse shadow get you to think, to feel?”

SP: “I feel cold, lonely, sad, away from people, and worthless.” Susan spoke of variations of these themes and began to cry.

MH: “What relationships does the shadow mostly affect?”

SP: “It shuts me out from my grandchildren because I can’t understand what they’re saying. Same with my boss at work, and I’m afraid of losing my job. It makes me feel hopeless, that there’s nothing I can do. It cuts me off from everybody!”

MH: “What do you envision for your life if the shadow doesn’t go away?”

Susan remained silent, slumped in her chair, and shook her head. “It darkens everything,” she said.

MH: “But help me understand something, will you? How does it do that? What are its tactics? Where does it get its power to take away every possibility to be happy, whether with your grandchildren, your boss, your hopes and dreams for your future? How does it darken all of that?”

SP: “It’s very strong and mean, I guess.” She made eye contact, and I imagined she considered at least making a sarcastic smile.

MH: “Does it ever get tired? I mean, it must get tired sometimes to hold a huge moon in place for an eternal eclipse just to make your life miserable?”

SP: “Ha! If I were holding the moon in place, I’d sure get tired.” She smiled for the first time.

MH: “Can you recall when it may have been tired and got a little careless, when you outsmarted it even for a little while?”

SP: “I managed to have fun with my granddaughter last week.”

MH: “Where was the shadow then?”

SP: “It was there, but I ignored it. I lit up some space with my granddaughter.” Second smile.

MH: “How did you get the strength to outsmart and ignore it and light up some space?”

SP: “We played games that didn’t involve a lot of conversation.”

MH: “The shadow gets real frustrated with non-conversation. Are there other times this happens?”

SP: “I think when I’m home, maybe watching TV and having a glass of wine, it gets lighter. It’s when I’m out in the world that it gets dark.”

MH: “So, trying to have conversations with people makes the shadow darker and avoiding people makes it lighter?”

SP: “Yeah.”

MH: “So, how does all that affect what you want for yourself, your future, your goals? What makes your life worth living?”

SP: “I’ve always been an extrovert and have enjoyed being part of the hustle and bustle of life that has included a lot of people. So it kind of takes away all that.”

MH: “The shadow tries to take what is dear to you. But does it ever give anything to you? Does it sometimes protect you from the hustle and bustle that you’d maybe not want to be part of?”

SP: “Yeah, I must admit that sometimes peace and quiet are nice,” she nodded.

An important caveat: beware of eliciting only the negative effects of hearing loss, as it is only one side of the patient’s inevitable ambivalence. This is a common error of helping professionals when there’s a seemingly obvious solution to a problem: if you’re depressed, go to therapy; if you’re sick, go to the doctor; if you can’t hear, get hearing aids, etc.

One of Sigmund Freud’s correct statements was that every decision is characterized by some level of ambivalence: “I wanna change, but I don’t wanna change.” There are reasons why people may wish to remain depressed, not go to the doctor, and not get hearing aids, etc.

If the health care professionals only advocate for change, the patient may feel defensive or disempowered, and therefore take the opposite position.4,5 With Susan, it was important to elicit and validate that, although her hearing loss hid her in the shadows, it sometimes protected her from unwanted “hustle and bustle.”

3) Eliciting Susan’s sentiments about the effects of the eternal eclipse shadow

MH: “Do you like, do you approve, of what the shadow takes away from your life?”

SP: “What do you think, Doc?” Susan retorted, obviously a bit miffed.

MH: “You’ve told me you don’t like it at all, that it makes you very depressed and lonely, but I want to make sure I don’t make assumptions.”

SP: “I hate it. It’s destroying any career possibilities. It’s causing other people to think of me as a snob, since they think I’m ignoring them.” She continued along these lines for several minutes.

An invitation to pause and reflect on the effects of the problem is often a novel experience for patients. Frequently, this sort of evaluation is undertaken by others: parents, doctors, therapists, etc. It is at this juncture that I often imagine a word counter in the office—and for every word I utter, the patient utters five! It is important for the patient to become the voice of the rationale for change.

4) Eliciting Susan’s justification for her sentiments about the effects of the eternal eclipse shadow

MH: “Susan, would you say more about why the shadow is a problem for you? Again, everyone is different in terms of the why, in terms of what values you cherish that are being threatened by the shadow? Do you have a story or something that can shed some light on this?”

SP: “Connecting with people is important to me.” And then, as if she were waiting for my question, she ruffled through some papers in her pocketbook and read her favorite quotation, one that she referred to as her “life mantra”:

“Oh, the comfort—the inexpressible comfort of feeling safe with a person—having neither to weigh thoughts nor measure words, but pouring them all right out, just as they are, chaff and grain together; certain that a faithful hand will take and sift them, keep what is worth keeping, and then with the breath of kindness blow the rest away.”6

I was impressed with her articulateness and depth, more so than when I had first met her. I believe our externalizing conversations (over 2 months) about the hearing loss (not her hearing loss) helped to delineate that she and the hearing loss were separate entities; that she had a relationship with it and was affected by it; that she didn’t like this effect; and that she valued relationships above everything else.

Moreover, the process of helping a patient to articulate an account of the tactics and strategies of power employed by the externalized problem has the effect of reducing its power.3 My hope was that as Susan continued to articulate the shifting ways she related to the hearing loss (shadow) and her own sentiment or evaluation of that relationship, in this way, the shadow would become less powerful.

Susan micromanaged her world. She adhered to a very rigid nutritional regimen: she ate her meals at exactly 8 am, 12 pm, and 6 pm; awoke and turned off the light at night at a precise time; prayed for a half-hour per day; exercised the same time and duration every day; took care to use a specific sequence of bathing lotions; and made almost weekly requests for the audiologist to adjust her hearing aids. Each week, Susan would complain that “they’re not quite right,” “the TV sounds wrong,” “sounds are too muffled,” and “I can’t stand hearing so much background noise.”

She had conflicting experiences with her hearing aids. She persisted in requesting hearing aid adjustments with the hope (as she put it) “of making everything sound right.” Yet she responded to each and every adjustment with acute anxiety and victimization, which, in turn, led to worsening tinnitus that robbed her of sleep. Psychologically, she experienced both the audiologist and hearing aids as traumatic agents. This is a common occurrence when someone has been traumatized (eg, with hearing loss), and is later in a situation that reminds him/her of that trauma, such as hearing aids or an audiologist.7 The audiologist and Susan were caught in an endless cycle that included her hopes and expectations morphing into trauma and despair. I asked Susan to describe this cycle.

SP: “Dr Smith has the power to change my whole world, to let me hear sounds—the old cash register at work, the chimes outside in the wind, to make the shadows disappear! I keep hoping, I keep going back, but it’s been brutal!”

MH: “I understand that you’re trying to rid yourself of the shadows by having your audiologist fine-tuning your hearing aid—and this obviously makes sense—but would you help me understand why the shadows are so terrifying for you, how they threaten to engulf you?”

SP: “It feels like they’ll take over and make me disappear.”

MH: “I wonder if we can find a way for you to not disappear; for you to accept the shadows, and even learn from them, while simultaneously trying your best to change them?”

Note the idealization of Dr Smith as omnipotent and as having “the power to change my world, to let me hear sounds.” I would address this later. I was intrigued with her palpable terror of the shadows and the vicious cycle that included her attempting to eradicate them via hearing aid adjustments, only for them to become more debilitating.

A paradox: In order to change yourself, you have to accept who you are. I wondered aloud with Susan what might happen if she left her hearing aid settings alone for at least a month, no matter how “wrong” she experienced sounds? The audiologist had repeatedly recommended this to her, with the explanation that it would allow her brain to adapt to the differing acoustic input.

We discussed this possibility in terms of purposely remaining in the shadows long enough to learn from them. I told her about a Jungian analyst, Jean Shinoda Bolen, who conducted spirituality workshops for women, leading them into underground caves, sitting in darkness and quiet for hours. Bolen described a resulting benefit called “endarkenment,” the profound wisdom one gains from darkness. It is complementary to the wisdom one gains from the light as in “enlightenment.”

How could Susan continue her attempts to make the shadows go away; simultaneously accept and even learn from them; and also experience “‘the inexpressible comfort of feeling safe with a person—having neither to weigh thoughts nor measure words”? I told Susan about Bolen sitting with women for hours in the total darkness and silence in a cave, and asked her if she thought anyone could actually benefit from this experience and gain so-called “endarkenment”?

She gave me an odd look as if to say, “Are you nuts?” I returned her odd look as if to say, “I’m quite serious.” Perhaps Susan knew what was coming when I openly lamented that I didn’t know of any underground caves within a 100-mile radius of my office in Framingham, Mass, but that I have an idea on how to decrease her electric bill.

At first, I believe she followed through with my suggestion just to humor me, but she found herself spending more and more time sitting in her bedroom in pitch blackness. At first, it was seconds or a couple of minutes here and there, but it soon became a daily meditative ritual, often for periods of a half-hour, followed by writing her reflections in a journal. Initially, she incorporated this ritual into her overly micromanaged, compulsive daily regimen, but gradually these periods of meditation—she came to call them “shadow power”—took precedent over her micromanagement.

During the 6 months that we worked together, Susan continued to meet with the audiologist, although less frequently, with the hope of stepping out of the shadows as much as possible. And with me, Susan had come to appreciate the value of stepping into the shadows, rather than running away in terror. Regarding her life mantra of “‘the inexpressible comfort of feeling safe with a person,” she realized that the most important person that she needed to feel safe with was herself. In order to change herself, she had to accept who she was.

Toward the end of our work, I again asked Susan the question that I had first asked several months prior: “What cherished life values had been threatened by the shadow?” I will never forget her response:

SP: “You know the question you often hear at personal growth workshops: what would you want in your eulogy?”

I nodded my head and had an inkling of what was to come. Susan took a deep breath and shifted her eye gaze past me to the left, as if she was speaking to an audience:

SP: “I don’t quite know why I had to lose my hearing to learn this wisdom, but I did. I’ve come to know that there are real ways to live a productive life as a person with hearing loss, like getting support from my friends and family, and getting tools from my audiologist. But I also learned that what I call ‘the shadows’ will always be there in some form and trying to get rid of all of them is a waste of my precious time and effort. And I gotta say—I’m proud of myself for getting to know these shadows, particularly the ones that will always be there. I can both grieve and be grateful.”


Read past Michael A. Harvey, PhD, ABPP perspectives on audiology/patient psychology at HearingReview.com:

As audiologists, what are the benefits of externalizing conversations with patients, given that you typically do not have time and liberty to probe emotional issues the way I did with Susan?

Even in the context of time-limited appointments, this approach can effectively facilitate patients’ acceptance of hearing loss and adherence to your recommendations for amplification. As audiologist Megan Ford put it in a conversation with me: “When tweaking the hearing aids doesn’t do the trick, then this should be a red flag that we should step back and put on our ‘psychological helping hat.'”

The following are a list of questions and tools that hearing care professionals can use in a clinic setting for select patients:

  • “Would you draw a picture of the hearing loss?”
  • “Would you imagine that the hearing loss is located somewhere separate from you and imagine what it would be saying to you?”
  • “Would you help me understand your relationship with hearing loss and how it helps and hinders you?”
  • “How does the hearing loss get bigger or smaller with and without hearing aids in noisy situations, like a crowded restaurant?”
  • “Can you remember a time when you felt more or less separate from the hearing loss?”
  • “What would you like your relationship with the hearing loss to be?”
  • “Why do you want your relationship with hearing loss to change in that manner?”
  • “In the minute or two that we have left, would you give me a snapshot of what values that you hold for your life that are being threatened or helped by the hearing loss?”

Another common and valid concern from hearing care professionals is about going beyond your scope of practice by doing psychotherapy. As a psychologist, I cannot speak to the boundaries of audiologic practice, but I can speak to what is and is not therapy.

Being psychologically helpful is not practicing psychotherapy. Establishing rapport, eliciting patients’ personal metaphors for their hearing loss, creating an atmosphere of fun and play is not practicing psychotherapy. In particular, externalizing conversations is a way of separating the person from the problem so both of you can “step back” and learn how the hearing loss mucks up your patient’s life and how to make space for “de-mucking.” You are not diagnosing or treating a mental disorder.

However, two heads are often better than one. Collaboration between audiology and psychology “heads” often results in more effective treatment. An audiologist may refer a patient to a mental health clinician, as in the case of Susan, and/or may receive psychological consultation about ways of navigating around emotional land mines with patients. Likewise, an audiologist and a mental health professional may meet with the patient together and separately at select times. There are many possibilities. With coordination of care, we can more confidently expand our respective range of interventions.

Note that I proposed to Susan she decrease the frequency of her hearing aid adjustments. Had I not had an endorsement from Susan’s audiologist for this, I would have been acting unethically, beyond my scope of practice. Similarly, Dr Smith felt on surer ground when talking with Susan about eclipses, shadows, and endarkenment, knowing that we were working collaboratively. It made for both a more gratifying professional experience as well as optimal provision of care.

  1. Harvey MA. How to refer patients successfully to mental health professionals. Hearing Review. 2008;15(7):20-24. Available at:www.hearingreview.com/issues/articles/2008-07_02.asp
  2. Wright BA. Physical Disability: A Psychosocial Approach. 3rd ed. New York: Addison Wesley; 1983.
  3. White M. Maps of Narrative Practice. New York: WW Norton & Co; 2007.
  4. Beck DL, Harvey MA. Creating successful professional-patient relationships. Audiology. 2009;21(5):36-47.
  5. Harvey MA. Audiology and motivational interviewing: A psychologist’s perspective. Available at: www.audiologyonline.com.
  6. Craik D. A Life for a Life. Whitefish, Mont: Kessinger Publishing; 2004.
  7. Harvey MA. What your patients may not tell you. Hearing Review. 2010;17(3):12-19. Available at: www.hearingreview.com/issues/articles/2010-03_01.asp

Correspondence to HR or Dr Harvey at: