It’s not uncommon to come across patients who genuinely need psychological counseling as a result of their hearing loss by itself or in combination with a personal loss, depression, or other reasons. Here are some tips on how to refer these people to a mental health professional—without alienating them.
It is wishful thinking to assume that simply suggesting to patients that they get mental health counseling typically results in follow-through. The process of a dispensing professional referring successfully to mental health professionals is psychologically complicated and—unless the referral is made in a careful and compassionate manner—it will likely result in nonadherence by patients and may damage your professional relationship with them.
It may seem self-serving for me, as a psychologist, to write about the process of referring successfully to mental health professionals. But it’s a “win-win-win” situation. The patient learns more adaptive psychological ways to cope with hearing loss and amplification; the hearing care professional is gratified by patient adherence to recommendations and a lower return rate; and the psychotherapist becomes involved in a rewarding collaboration. Beyond this, the mental health professionals gain a better understanding of hearing loss and its potential impact on mental health, and may even end up referring patients suspected of having a hearing loss.
Although the guidelines in this article are to assist the hearing care professional in setting the stage for making mental health referrals, it is perhaps more accurate to note that, in some ways, the stage is already set by the patient. The frequent need for initiating mental health referrals is due to at least two factors. First, there is a higher prevalence of depression and anxiety with persons who have acquired hearing loss.1,2 Second, in earlier publications, I described how an audiologic consult may trigger painful and intense grieving reactions for patients, including anxiety, depression, despair, and anger.3-6 As one hearing-impaired patient said half-jokingly, “Every time my audiologist talks about my hearing loss, I start to cry. Why can’t he talk about anything else?” Alternatively, whereas some patients may become overtly emotional during an appointment, others may exude a persona of composure—only later to become acutely destabilized.
Compile a list of patient-specific qualified professionals. The first step to initiating a mental health referral is to have maintained a listing of psychotherapists who have specific competencies in evaluating and treating persons who have hearing loss. Professionals without such expertise may do significant psychological harm by falsely minimizing and/or maximizing the effects of hearing impairment.
In addition to “word of mouth,” a directory of appropriately trained psychotherapists may be obtained from the State Commission for the Deaf and Hard-of-hearing. A caveat: it is important to inquire about the goodness of fit between a patient’s identity with respect to hearing loss and the prospective therapist who works with “deaf and hard-of hearing persons.” For example, if patients with acquired hearing loss define themselves as “hearing-impaired” and favor oral communication, therapists who have expertise only with culturally Deaf persons and American Sign Language would be inappropriate.
Approaches. The next step is to discuss the need for a referral with a patient. Consider the following common responses of audiologists to patients who exhibit psychological distress:
- “Emotional issues are beyond my area of expertise, so I would like to refer you to a psychotherapist.”
- “I’m sorry, we can’t get into emotional stuff here as our appointment is only for a set amount of time. A therapist can help you.”
- “Given the pain that you feel, you can benefit from therapy.”
- “You have to think positive about the hearing you still do have!”
At first glance, these responses may seem appropriate, compassionate, and/or direct. However, in my opinion, they are not typically helpful. These approaches would likely decrease the probability of a successful mental health referral and possibly disrupt your alliance with the patient. The patient would likely feel stigmatized, defensive, or rejected.
In one patient’s words, “Dr Smith doesn’t care about how I feel and just wants to get rid of me.”
Guidelines for a Successful Referral
Validate and contain the patient’s feelings. As noted above, patients may express significant and debilitating emotional pain regarding their hearing loss, in reaction either to being questioned or to the context of the audiologic visit. This sets the stage for initiating a mental health referral.
The first task is to validate a patient’s feelings by indicating that their feelings are normal—not crazy. Do not make the common mistake of saying, “I understand how you feel.” It is impossible to truly “put yourself in another person’s shoes,” and patients are typically put off by this well-intentioned phrase.
While validating a patient’s feelings, it is also important to gently set limits (or contain) their affect so the issue doesn’t consume the session or get out of control. Without limit-setting, an audiologic visit may become more like a psychotherapy session. For example, a dispensing professional may say:
- “It sounds like you have a lot of painful feelings. I can appreciate that, as I’ve heard many many people with hearing loss talk about this a lot. We don’t have more than a few minutes, but I’d really appreciate it if you could give me a glimpse of your pain.”
- “What you’re telling me about your feelings certainly make sense. Thank you for telling me, as it helps me understand where you’re coming from. Would it be okay for me to finish explaining your audiogram and we can set another appointment?”
- “I cannot completely understand your pain since I’m not you, so I won’t insult you by saying, ‘I understand.’ But of course you feel depressed, scared, anxious having lost your hearing! Frankly, if you didn’t have those feelings, I’d be concerned, as your feelings are quite normal. Later, we can talk about all that more, but can we finish doing …?”
Normalize (de-stigmatize) the referral. When first referencing the patient’s emotional pain, do not use loaded words such as “therapist,” “mental health,” “psychologist,” “psychiatrist,” “counselor,” or “psychotherapy.” Although well intentioned and accurate, these words may be experienced by patients as assaults to their self-esteem and integrity. Instead, it is important to support a patient’s self-esteem while initiating a referral:
- “Many people with hearing loss feel it’s helpful to really talk about the emotional stuff that you just mentioned. I know someone …”
- “I have found that people benefit more from hearing amplification if they talk about the emotional adjustment issues.”
- “There is a set of psychological skills that people with hearing loss learn to use. Would you be interesting in meeting with …?”
- “You know, 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.”
Emphasize that optimal treatment of hearing loss necessitates a team approach. The audiologist can make reference to the mind-body connection or use terms such as “holistic” or “multi-disciplinary approach” that are recognized and accepted in today’s culture. Such references can include an explanation of the mind-body or holistic perspective of hearing and understanding communication; they depend on both appropriate amplification and environmental modifications, as well as stress management and realistic expectations. The team can be framed as a partnership between audiology and psychology. For example, a clinician may say:
- “I’m happy and proud to tell you that we have a kind of ‘dream team’ to help people …”
- “I’ve found it more successful to use a holistic, team approach to help people benefit from hearing aids.”
- “I can take care of your ears, and another person can take of your emotions; we’ll cover all bases.”
Humanize 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. Anticipatory anxiety will be reduced. Most patients assume adequate professional competence and training, so this is typically not a major source of anxiety. However, a prospective professional’s personality and warmth—human qualities—typically are deemed most important. For example, an audiologist may say, “I’ve known Dr Smith for over 20 years. She’s nice, maybe about 50 years old, been practicing psychology for over 30 years. I think she also collects antiques. She has a dry sense of humor. I think you’d like her.”
Ask permission to telephone the mental health professional in front of the patient. As a second option, ask permission to make that contact soon afterward, and inform the patient immediately afterward that you had made the call. The goal is to decrease the psychological space between the audiologist-patient and the therapist.
For example, an audiologist may ask:
“Is it okay if I call Dr Jones now to give her a heads-up that you’ll be calling?”
Ask the patient about the status of the referral appointment. Inquiring about whether the patient has made contact with the therapist is a way of keeping the referral “on the front burner” and conveys the message that the patient-audiologist-therapist team is important. The tone of this inquiry should be one of support, as opposed to undue pressure. Despite the best implemented referral, the patient making and keeping that first therapy appointment provokes anxiety and possibly avoidance.
If a patient did not follow through on contacting the therapist, an audiologist may ask:
- “Hey, this is not the kind of thing that points are taken off of your final grade. But would you help me understand what you were thinking or feeling that may have made you not make the call?”
- “You know, this is easy for me to suggest. I have the easy part. Tell me how it feels for you?”
- “Is there any information or assurances about Dr Shlomo that I can give you that would be helpful?”
A Fictitious Example
The following scenario between an audiologist and patient may have a familiar “ring” to it. This hypothetical dialogue also illustrates the guidelines for making referrals, as outlined above.
Matt Macho arrived 10 minutes late for his second appointment with his audiologist. He had incurred a severe-to-profound bilateral hearing loss 1 year prior, and Dr Smith was examining his new hearing aids. The meeting was going smoothly until the patient suddenly burst into tears and screamed, “I’ve had it!” His tears soon became uncontrollable sobbing. Dr Smith put down the hearing aids and handed Matt some Kleenex.
After a moment, Dr Smith said, “Don’t worry, I don’t charge for Kleenex.”
Matt laughed and muttered, “Thanks.”
“You know,” Dr Smith said, “there’s more to this hearing loss stuff than just hearing aids.”
“I’m sorry I got emotional,” Matt responded.
“Hey, we weren’t talking about taxes. Of course you’re emotional! Figuring out the emotional stuff with hearing loss goes with figuring out how to use hearing aids, do lip-reading, etc. You know, some people actually feel embarrassed about getting help with how to deal with the emotional stuff, particularly men!” Dr Smith smiled at Matt and raised his eyebrows.
“You mean me? Not me!” Matt responded with a smirk.
“I meant other men, of course, not you,” Dr Smith responded. “Do you remember when OJ Simpson was on trial?”
“Yeah.” Matt looked confused.
“Remember the dream team, the defense for OJ?”
“Yeah,” Matt answered. “That’s why he got off as innocent!”
“So I have good news and I have more good news,” Dr Smith continued. “Which would you like to hear first?”
“The good news,” Matt smiled.
“Okay, the good news is we also have a dream team. The other good news is, unlike for OJ, the fee is much less than $4 million.”
“Who’s on this dream team?” Matt asked.
“I work with this guy down the street, about 2 miles from here. He specializes in teaching people psychological skills to manage their hearing loss.”
“Don’t you do that?” Matt asked.
“I do the diagnostic and hearing amplification piece. Dr Shlomo is a psychologist and he does the psychological piece. You know, mind-body, psychologist-audiologist. I’ve been working with him for …”
“Hold on, doc, are you telling me I need a shrink?” Matt quipped with irritation and defensiveness.
“No, I’m not, Matt. I’m saying that people that I’ve worked with adjust much better to hearing loss and hearing amplification when they learn various psychological skills as well as lip-reading, as well as environmental modification, and so on. It’s a holistic approach!”
“Who is this Dr Shlomo?” Matt asked.
“He’s a nice guy, a big Red Sox fan—so he was thrilled last year when they won the World Series. I didn’t think they’d win, so I ended up losing 10 bucks to him. One of his specialties is working with folks with hearing loss. He’s been part of the team for geez, maybe 15 years.”
“Sure, why not,” Matt responded.
“OK, here’s his number. Let me call him and tell him to expect your call, okay?”
“Sure,” Matt acquiesced.
Dr Smith made the call, and scheduled another appointment with Matt. Matt appeared at Dr Shlomo’s office only 5 minutes late.
This is a successful outcome, obviously because it’s my fantasy and, as such, I had the final say on how it ended. Dr Shlomo met with Matt and he lived happily ever after. Often reality isn’t so simple. However, I have been impressed with how a positive audiologist-patient relationship and careful, step-by-step initiation of a mental health referral frequently results in a “win-win-win” for the professionals and patients.
- Carmen RE. Hearing loss and depression in adults. Hearing Review. 2001;8(3):74-78.
- Carmen R, Uram S. Hearing loss and anxiety in adults. Hear Jour. 2002;55(4):48-53.
- Harvey MA. The transformative power of an audiology visit. ADA Feedback. 1999;10(9):13-21.
- Harvey MA. Mourning my mother, welcoming my family. Hear Jour. 2001;52(1):57-59.
- Harvey MA. Sharing the wisdom of old age. ADA Feedback. 2000;11(2):15-21.
- Harvey MA. Presbycusis, mortality and Brussels sprouts: a family’s struggle with hearing loss and growing old. Hearing Loss. 1998;19(4):17-21.
Correspondence can be addressed to [email protected] or Michael Harvey, PhD, at.