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Some audiology patients experience a doctor visit as a trigger for past trauma, causing panic. A joint effort from their audiologist and a psychologist could help them to shift their mindset to obtain the care they need. By Michael A. Harvey, PhD I met 66-year-old Susan* a year after she was in a serious bicycle accident. Previously, she had been an accomplished IT consultant with a master’s degree. However, the accident resulted in traumatic brain injury (TBI), mild hearing loss, headaches, vertigo, left sided hemiparesis, vision problems, tinnitus, and hyperacusis. She was referred by her audiologist, Dr Smith*, who was treating her hyperacusis. The reasons for referral were to help Susan with stress reduction, and to help Dr Smith understand Susan’s psychological makeup so she could provide better audiologic treatment. Reportedly, Susan had been doing well with the protocols up until recently when she began making a lot of excuses about why she could not continue the second phase. Susan’s Story What was first apparent upon meeting Susan was her disheveled appearance. Immediately, she complained of being “exhausted” because of so many doctors’ appointments: her PCP, otolaryngologist, ophthalmologist, neurologist, psychiatrist, sleep specialist, rehabilitation doctor, physical therapist, audiologist, and “Now a psychologist!” (I felt overwhelmed just hearing her list.). Most of her appointments necessitated traveling (we met virtually) which, in turn, necessitated making travel arrangements with agencies which routinely “screwed up.” In her words, “My rides cancel at the last minute or are late and then the doctor cannot see me, and often they go to the wrong address, and the doctors complain when I’m not there and threaten to stop seeing me.” As Susan summarized, “All that in addition to my TBI is too much for me to handle!” I asked Susan about her visits with her audiologist and offered to talk with her to coordinate care. She readily agreed. “Dr Smith is very nice and said she’s confident she can help me,” she said. “So then why haven’t you continued with her?” I asked. I took care to smile to lessen the interrogation-like tone of my question. She didn’t smile back but shook her head repeatedly. “Dr Smith told me to watch movies as a next step in the hyperacusis protocol, but the movie plots are too complicated and it’s too much for me.” She covered her eyes and ears, as if to protect herself. She continued chronicling the endless number of tasks and obligations that she was juggling: “I can’t control anything!” Included in her list was “All my husband does is play sports and he expects me to go to all of his games!” Further reading: Aging with Dignity with Assistance from an Audiologist Later, when Susan was calm and more lucid, she confirmed that Dr Smith had only suggested that she choose a few suitable, easy-to-follow movies, but then returned to “Everything is too hard.” And then parenthetically, she reported that “My concussion doctor told me to do something different than Dr Smith did.” On my next session with Susan, I used a cognitive behavior approach for stress reduction and inquired about a common cognitive distortion of “All or Nothing Thinking” with reference to what she could and could not control. “You can’t control anything?” I asked. “Must you go to all of your husband’s games?” Although she was not yet able to control many aspects of herself and her environment, I elicited some important things she could control - e.g., she enjoyed cooking different recipes, she meditated, chose when to rest. I also reminded her that, most recently, she asserted her control over whether she followed the hyperacusis treatment protocol. Susan nodded. Although there were brief moments in our session when Susan seemed calm and grounded, she would quickly revert to panic. Ultimately, she was not yet able to step away from her worldview in which there were hidden landmines at every corner. In addition to the neurologic and audiologic sequelae of the accident, she had recurring traumatic flashbacks and nightmares, difficulty concentrating, and she was depressed. She often “zoned out” by forcing herself to think of nothing. Her world was spinning out of control. We had met three times and set up a fourth appointment. However, she canceled it, saying, “I’ll get back to you.” We haven’t met since. She also put Dr Smith’s visits on hold. Discussion This case is complex and multi-layered, but the treatment considerations are not atypical. Collaboration of Audiologist and Psychotherapist You have expertise in diagnosing and treating hearing loss. I know little about the audiology part (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 landmines that hinder effective care. What if we team up? During the time I was seeing Susan and with her permission and endorsement, I routinely shared her progress with Dr Smith, particularly how it related to her audiologic care. I explained the effects of “traumatic transference” (explained below) to Dr Smith. Briefly, traumatic transference is a psychological phenomenon that causes patients to feel traumatized by a helping professional’s compassionate advice because they interpret it as abusive. I also discussed with Dr. Smith the dysfunctional effects of some of Susan’s doctors possibly giving confusing or conflicting advice (also explained below). Recommendations for hearing healthcare professionals: Two heads are better than one. Collaboration is often helpful for patient satisfaction and adherence to treatment recommendations. In my experience, most patients welcome it. There are different models, such as telephone/electronic communication (as Dr Smith and I did) or including the providers and patient in sessions, as needed. Traumatic Transference As with many people who incur trauma, many of Susan’s interpersonal experiences were altered by so-called “traumatic transference.” This is an unconscious dynamic that happens when people have been traumatized and are later in a situation that reminds them of that trauma. One transfers the emotions that were associated with an earlier traumatic situation onto people who are reminiscent of the trauma. As an example, I once co-taught a seminar for medical students with a Deaf** colleague. Unexpectedly, he began with (and I’ll never forget his exact wording): “So you future doctors think you’re so damn smart! You don’t know a damn thing about Deaf people.” And he went on from there, berating the poor med students for crimes they hadn’t committed: “You don’t give a sh*t about our rights”; “You care only about power”; and “Who the hell do you think you are anyway?” Later, I apologized to the students on behalf of my colleague and offered an explanation that he had authorized me to share. His wife had experienced a life-threatening miscarriage, and he couldn’t understand the doctors because the hospital refused to provide an interpreter. He transferred his rage at the hospital onto the innocent med students. Further reading: Grieving that Hearing Aids Have Improved Our Lives Let’s return to Susan. On many occasions during our brief treatment, she became agitated and reported feeling blindsided by her audiologist, only to later acknowledge that “she is nice and tries to help me.” It appeared to me that Susan transferred her experience of being blindsided by the accident and its sequelae onto Dr Smith. In other words, the audiology treatment regimen triggered Susan’s post-trauma reactions. I discussed this with Dr Smith and suggested that she slow down the pace of treatment and take care to emphasize that Susan was in the “driver’s seat.” Soon afterward, I received an email from Susan: “Thank you for talking to my audiologist about my being overwhelmed. Her solution to step away for a little while was really appreciated. I find it interesting that the places overwhelming me the most are the places that don’t wanna hear my suggestions.” Although there are ways to psychologically lessen traumatic transference, some manifestations of this reaction are often inevitable. It 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. “Now hold on,” the reader may interject. “Susan said that Dr Smith was very nice. Doesn’t Susan’s positive impressions of Dr Smith contradict her ‘trauma,’ as you put it, about being blindsided by her?” Indeed, it does. Often a person feeling “blindsided” and even victimized has nothing to do with the likability of the professional. For we humans, our reality is often contradictory and irrational. I offer this analogy. A kid was learning how to become a baseball umpire. Three umpires gave their advice. The first umpire said, “I call them as they are.” The second umpire said, “I call them as I see them.” The third umpire said, “They are as I see them.” We are all, including Susan, the “third umpire.” To use another metaphor, patients like Susan are apt to perceive helping professionals through a trauma lens. Note that Susan interpreted Dr Smith’s suggestion to watch easy-to-follow movies as a demand to watch many complicated movies. For many patients, audiologic treatment should be conceptualized as trauma-informed audiologic care. This is also a recent movement in the human service field. Trauma-informed care is an approach that acknowledges the pervasive presence of trauma symptoms and the role trauma may play in an individual’s life. It teaches us that traumatized patients often hold on to control for dear life, even to refuse treatment that would benefit them. Recommendations for hearing healthcare professionals: Affirm the patient’s locus of control. Take a one-down position. For example: “I believe these can help you, but it’s your call when, how, or if.” “When would you like to talk via phone so we can discuss our next steps together?” Lessen your perceived power. Be the opposite of intimidating. For example: “I know about hearing loss, but I need you to teach me about you.” “If I were in your place, I might feel very overwhelmed and intimidated. Do you feel that?” Acknowledge the “elephant in the room”: your stature and the patient’s intimidation and ambivalence. For example: “Hey, I bet you’d rather be in 1,000 places except in my office, right?” “May I ask you how you feel being here?” Countertransference Healthcare providers, including audiologists, are human. Accordingly, we are allowed to have human reactions to patients—what psychologists call “countertransference. Moreover, inevitably, we have such reactions, whether we are allowed to or not! When providers deny having any human reaction to a difficult patient, I give them a polite version of “Liar, Liar, Pants on Fire.” One’s negative countertransference is “unprofessional” only if they are indiscriminately shared with the patient. The ethical caveat with countertransference is we share it with a colleague or consultant, away from the patient, so it does not impede treatment. And this is also a benefit of collaboration. We not only share diagnostic and treatment ideas, but we share how the treatment is emotionally affecting us. We “detoxify” our countertransference by giving it a voice. My countertransference to Susan was frustration as she kept postponing our appointments. Additionally, I became a bit anxious when she discontinued her audiologic treatment, particularly since her audiologist had referred her to me. As much as I enjoy the camaraderie of working with another helper, there is a bit of “stage anxiety”: If Susan terminates her treatment with Dr Smith, what will Dr Smith think about me? I also noticed that Dr Smith was, at times, irritated with Susan. She found it troubling and irksome that Susan was both requesting help but resisting it. A familiar refrain among helping professionals. Recommendations for hearing healthcare professionals: This is difficult work, often replete with patients who are grieving, angry, tearful, etc. Find someone to talk to about what all this does to you emotionally to minimize its fallout. Know that there are also benefits to bearing witness to a patient’s pain. In the words of one audiologist, “Our patients teach us the things we might have learned from grandparents, wise elders. Sharing joy and sorrow, laughter and pain, wisdom and ideas with another person is at the heart of what it means to be human.” A Plethora of Doctors An old saying: With five doctors, you have six opinions. As patients get older, they have more doctors, and for patients with multifaceted injuries, the number of doctors for different parts of their bodies is multiplied. Note Susan’s first utterance to me when we met. “I’m exhausted because of so many doctors’ appointments.” She was being treated by a total of 10 doctors! Adding to her own stress is a stressed healthcare system, rushed appointments, more paperwork, less time for coordinated care, etc. Susan’s succinct description in an email to me: “I am stopping going to doctors because they are like directors… it takes about four steps to get to the person that can do the help. Example: the rehab doctor sends me to the sleep specialist and I wait a half a year to see him and then he sends me to three more doctors. I can’t even remember who else at this point. And this happens with everyone I go see.” Moreover, frequently the plethora of doctors give conflicting advice to a patient. Again, to continue with Susan: “The problem with my audiologist is that her suggestions at this point in the program conflict with my concussion doctor but I had no idea that would happen as I had no idea what the next steps were in the program I signed up for up front.” Recommendations for hearing healthcare professionals: Inquire about the other providers in your patient’s so-called “relevant system” and inquire about their recommendations, particularly which ones, if any, contradict yours. It may be useful for these professionals to coordinate care, perhaps even inviting them to a session with your patient. Thanks to today’s prevalence of telehealth, the logistics of this are easier than before. Concluding Thoughts The reasons for referral were to help Susan with stress reduction, and to help Dr Smith understand Susan’s psychological makeup so she could provide better audiologic treatment. How do we evaluate the outcome of our collaboration? Unfortunately, Susan prematurely bolted from her treatment with both of us and continues to suffer from anxiety and hyperacusis. Not a positive outcome! My conjecture is we failed to sufficiently address the inherent destabilizing effects of so many doctors in her life who also may have been giving her conflicting medical advice. However, Dr Smith made a profound psychotherapeutic intervention without practicing psychotherapy. Whereas Susan had initially felt blindsided and disempowered by Dr Smith, because of perceiving her as authoritarian and demanding, Susan learned that she herself had the power to pace her audiologic treatment regimen. This wasn’t inconsequential. Her burgeoning experience of empowerment came in marked contrast to feeling traumatized by her world spinning out of control. Stated in psychological lingo, she no longer perceived Dr Smith via her traumatic transference. This was a reparative experience, one important step to repairing her pervasive feelings of helplessness. And then there is my own countertransference. How did I feel when Susan bolted from treatment? Not good feelings, I assure you. There is a Buddhist saying: When the student is ready, the teacher will come. We can and should continue to help motivate our patients to improve the quality of their lives. But sometimes, we are ready for our patients to change, but they aren’t. Maybe Susan’s “bolting” was premature for me, but not for her. However, the resolution of her traumatic transference toward Dr Smith makes it more likely that Susan will be ready to return. ' Michael A. Harvey, PhD, is a clinical psychologist who practices in Framingham, Mass. His most recent books are Odyssey of Hearing Loss: Tales of Triumph and Listen with the Heart: Relationships and Hearing Loss, both published by DawnSignPress. Feedback is welcome at mharvey2000@comcast.net. Photo: Dreamstime * Susan is a fictitious name and details have been omitted or modified to preserve confidentiality. Dr Smith is also a fictitious name. ** Deaf with a capital D indicates one who is culturally Deaf whose primary language is American Sign Language and who typically cannot speech read well. Original citation for this article: Harvey MA, Managing Patients’ Traumatic Transference Through Collaboration Hearing Review. 2024;31(9):26-29. References: Harvey MA. What your patients may not tell you: combating deep metaphors and the rationale for audiological-psychological collaboration. Hearing Review. 2010;17(3):12-19. Harvey MA. Alabama Office of Deaf Services enewsletter Signs of Mental Health. Standing up to bricks and filth. 2019;16(3):12-14. Van der Kolk B. The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma. New York, NY: Penguin Random House; 2015. Harvey MA. The changer and the changed: the perils and benefits of empathizing with your patients. Hearing Review. 2021;28(8):18-20. Harvey M. BJGP Life. The psychosocial effects of a chronic, undiagnosed Illness. Sept. 25, 2023. Available at: https://bjgplife.com/the-psychosocial-effects-of-a-chronic-undiagnosed-illness/

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