I have a good friend whose wife has a severe hearing loss. Other members of her immediate family are affected as well. Her severe loss is one of those that we would expect to benefit greatly from amplification, but she has a very poor success rate with hearing aids.

Much of the problem has to do with the nature of the hearing loss. She has poor word recognition in

Dennis Van Vliet, AuD, has been a prominent clinician, columnist, educator, and leader in the hearing healthcare field for nearly 40 years, and his professional experience includes working as an educational audiologist, a private-practice owner, and VP of audiology for a large dispensing network. He currently serves as the senior director of professional relations for Starkey Technologies, Eden Prairie, Minn.

noise and intolerance for louder sounds, which necessitates the use of higher compression ratios that undoubtedly further distort speech. The other element is that she suffers from what appears to be an anxiety disorder of some type. I’m not making a mental health status diagnosis, but instead make a general observation about her behavior, which can become obstructive to the hearing aid selection, fitting, and adaptation process.

Another patient I am working with has an unusually configured hearing loss with very poor word recognition. Her face-to-face communication skills are impressive, and she reports appreciating benefit from hearing aids, but has a wide range of reasons for not wearing the aids consistently. The last time I saw her, we went through the specifics of what could be done to improve the comfort and ease of insertion of the hearing aids. During our visit, her comments went beyond the specifics about the hearing aids and revealed that she also is troubled by anxiety.

So…What Now?

In the course of our interactions with patients, we see a cross section of the population who may have a variety of issues in addition to hearing or balance problems. Because of the long-term nature of the relationships we develop, we get to know them personally, and are likely to be engaged in a conversation about health or other personal matters that go beyond our practice and responsibilities.

In these two cases, there appear to be mental health issues that impact the management of their treatment. Both individuals are likely candidates for cochlear implantation. It is certainly within my scope of practice and my responsibility to have frank discussions with these women about the options available and the next steps for each of them. Initially, hearing aids are a reasonable option to explore because it is a typical requirement in the path to cochlear implantation. The mental health issues are obstacles that may never be completely resolved, but must be addressed to continue the course of treatment.

You might next be expecting a narrative on how I applied clever professional skills to resolve the referral issues. Well, that hasn’t happened yet, and I’m not quite sure what is next. Both are out there like an unfinished project that I feel a responsibility to finish. For both women, the next step is very likely counseling to address their anxiety. In both cases, the referrals for treatment came to me from their husbands. I have had face-to-face and email conversations with both men, but mostly regarding scheduling and financial matters. Do I violate their privacy by contacting the husbands and reinforcing the referrals I made in discussion with the patients? I do not have written permission from either patient to contact others, so I have to assume that there would be a violation of their privacy.

In the case of the wife of my friend, he occasionally asks for advice, and I can likely direct him to help her through the process without discussing details that would be a violation of her privacy. The consequences for her are primarily delays in appropriate treatment.

The second patient is more complicated. She recently made statements to me that suggested that she might have thoughts about harming herself. I wasn’t formally trained in suicide prevention in graduate school, nor have I been in continuing education, but there is enough reporting in the media that I am generally aware of our responsibilities. In this patient’s case, since the reference was vague, it didn’t seem that there was an immediate threat. We had a conversation about how important it was for her to talk to her physician about getting a referral for help specific to her anxiety. Had she been more specific, I would have handed her off to a suicide prevention hotline immediately.

For more on this topic, see Michael Harvey’s HR article on referring patients to mental health professionals.

Following the encounter, I wondered about responsibilities within state law about what mandatory reporting might be required when faced with a patient who may be suicidal. A search of California state regulations specific to audiology and dispensing revealed no requirements, but suicide prevention links quickly came up. Common sense is often better than legislative mandates.

The Final Word? Counseling is the cornerstone of the rehabilitative care we provide. It only goes so far, however. Providing hearing care to patients who may have a variety of other health conditions may put us in a position of having to make judgments and referrals that are outside our comfort zone and expertise. If you are part of a hospital system or larger group, you undoubtedly have policies and procedures to guide your actions when someone indicates that they may cause harm to themselves. Independent practitioners may not have such guidance.

Fortunately, there are resources easily accessible online including: www.sprc.org or www.afsp.org.

Correspondence can be addressed to HR or: [email protected]