Difficult Conversations: Talking About Stigma

Kris English, PhD

Professor Emeritus

The University of Akron

Audiologists observe the impact of stigma on hearing loss (HL stigma) on a regular basis, and yet we haven’t addressed it much as a counseling issue.  HL stigma can be a complicated experience: for many patients, developing hearing loss can itself be stigmatic (associated with negative stereotypes of aging). And as we know, the added prospect of hearing aids can compound the stigma further. Recent research (David et al. 2018) supports this long-standing observation: that hearing aids can be “central to the stigmatic experience,” which is why we need to attend to “the importance of these devices for psychological wellbeing” (p. 133).

From a counseling perspective, we have to acknowledge that HL stigma has negative power and should be addressed. Stigma has been consistently found to impede help-seeking (e.g., Gagné et al., 2011; Heijnders & van der Meij, 2006; Wallhagen, 2009), so our challenge is to address it openly and therapeutically. This article will provide a basic background regarding the development of stigma, and suggestions on how to address stigma in clinic.

Stigma Develops in Stages

Corrigan et al. (2006) describe stigma development as a socially-constructed three-stage process:

1st stage: Stereotype Awareness, wherein we are aware of society’s negative beliefs about a health condition or disability: My grandmother says all of her friends are losing their hearing. She says they always seem confused, and she doesn’t enjoy their company anymore.

2nd stage: Stereotype Agreement, wherein we concur and endorse these negative beliefs, developing our own prejudice: When I visited my grandmother, I could see why she doesn’t enjoy her friends these days. They are in their own world and have no idea what anyone else is talking about.

3rd stage: Self-Congruence or Self-Stigma, wherein we internalize society’s negative attitudes and apply them to ourselves, risking adverse effects on self-concept and personhood: I am having the same hearing problem my grandmother used to complain about.  It’s so humiliating.

The final stage – self-stigma – includes self-rejection, a belief in a diminished self, and shame, wherein an individual feels “disqualified from full social acceptance” (Goffman, 1963, p. 9). Weiss et al. (2006) describes self-stigma as a “hidden burden” – our challenge is to help patients discuss that burden and perhaps free oneself from it.

Rosenstock, 1974

Our take-away: as described above, stigma is a belief, which in itself presents a challenge. Because of our scientific base, audiologists don’t pay much attention to beliefs, but we should. After all, common objections to hearing devices – the impact on self-image and self-identity, cosmetic sensitivity, the certainty of social rejection – are beliefs, not facts.  We may be familiar with The Health Belief Model (Rosenstock, 1974), created as a means to predict health-promoting behaviors (e.g., Saunders et al., 2013), but it has yet to impact clinical practices.

Preparing Ourselves

Before we respond to a patient’s perception of stigma, we must be comfortable talking about it. For instance, we may worry about the “elephant in the room” phenomenon: should we “go there?”  We may think that talking about it will increase a patient’s self-stigma, yet if we don’t talk about it, we can be fairly sure it will not resolve on its own.

As applied to audiologic counseling, we aim to help patients consider changing their negative beliefs about hearing loss and hearing help (Clark & English, 2019). Consider the following dialogue: how did the audiologist help the patient transcend stigma and move forward?

A Self-Stigma Conversation

Audiologist:   Mr. Petry, now that we’ve compared your initial concerns to your test results, we can shift gears and talk about next steps. You mentioned upfront that you just wanted information but had no interest in hearing aids – could you expand on that?

Mr. Petry: Wait, are you saying I need hearing aids?  I really don’t want to!

Audiologist:  Because ….?

Mr. Petry: (getting agitated) Because … hearing aid users are feeble and old. I don’t want to be that kind of person.

Audiologist: Are you thinking of someone in particular – someone you know? (Patient nods.) What might it seem like from his/her point of view?

Mr. Petry: Sure, there’s my old pal Jim. He doesn’t seem to mind how his hearing aids look – but I do.  Why advertise your problems like that?  No one wants to look weak.

Audiologist: OK. It sounds like he doesn’t see it that way, though. If you asked him, how might he describe hearing aid use?

Mr. Petry: I know him pretty well; I think he’d say he doesn’t care about what other people think.

Audiologist: Have you ever wondered how you developed your reaction to hearing aids?

Mr. Petry: Just from what people say, I guess.

Audiologist: Other people really can influence us, and often we don’t even notice it. My concern is this: your thoughts on amplification are keeping you from improving the problems you initially mentioned. Is there another way you could think about amplification that would make you feel strong instead of weak?

Mr. Petry: Well, I normally face my problems head on – like Jim, actually. It probably wasn’t easy for him to become a hearing aid user but he did it anyway. If he can do it, so can I.

Audiologist: Then we’ll tap into your past history of successful problem-solving. You might experience mixed feelings along the way, but we’ll keep talking about it. I agree, it’s not easy.

A Breakthrough in Self-Stigma

What Happened Here?

The audiologist attempted to:

  1. Accept the negative beliefs without judgment.
  2. Shift from “stereotype agreement” (“that kind of person”) to a specific relationship (Jim) and asked the patient to imagine a different perspective.
  3. Validate that different perspective (“sounds like he doesn’t see it that way”) and encouraged the patient to again consider his friend’s situation.
  4. Ask the patient to consider the source of his stigmatic belief.
  5. Ask the patient to reframe his belief (“Is there another way you could think about” hearing aids, like your friend does?)
  6. Validate his past history of successful efforts.

These steps helped the patient examine unquestioned negative beliefs about hearing aids and consider alternative points of view and choices.

Three Things Didn’t Happen

The audiologist took pains not to:

  1. Discount or overrule expressed self-stigma (“you shouldn’t feel that way/you shouldn’t let that belief hold you back”). Once a patient verbalizes a position, it’s hard to back down (Gardner, 2004).
  2. “Upshift,” as described by Goulston (2010): “Most people upshift when they want to get through to other people. They persuade. They encourage. They argue. They push. And in the process, they create [even more] resistance” (p. 4)
  3. Use the words stigma, stereotype, or beliefs, to avoid putting the patient on the defensive.

Not a One-Time Conversation

Developing stigma is a process; transcending it will also be a process. We should remind ourselves to continue the conversation in subsequent appointments regarding changes in perception, beliefs, acceptance.  Why? Because change is hard! “Stigma is powerfully reinforced by culture and its effects are not easily overcome by the coping actions of individuals” (Heijinders & van der Meij, 2006, p. 356).

Also: Invite the Conversation

Doherty (2016) reminds us. “Our patients will likely be sensitive to potential stigma, even if they do not mention it.”  As a matter of course, we can routinely bring it up ourselves: “Sometimes patients worry about [appearance, societal reactions, etc.]. What are your thoughts? Any qualms?”

Conclusion

Talking about stigma certainly qualifies as a difficult conversation!  Our skill in doing so could make the difference in patient decisions, but we have had virtually no guidance.  We need to develop our own guidance, and share our work with the profession.


7.5 Tier 1 CEUs in Counseling Available Here!

 

 


References

Clark & English (2019). Counseling-infused audiologic care. Inkus Press/Amazon.com

Corrigan, P. W., Watson, A. C., & Barr, L. (2006). The self-stigma of mental illness: Implications for self-esteem and self-efficacy. Journal of Social and Clinical Psychology, 25(8), 875–884.

David, D., Zoizner, G. & Werner, P. (2018). Self-stigma and age-related hearing loss: A qualitative study of stigma formation and dimensions. American Journal of Audiology, 27, 126-136.

Doherty J. (2016).  New thoughts on hearing loss and stigma.

Gagné J-P, Southall K, & Jennings MB. (2011). Stigma and self-stigma associated with acquired hearing loss in adults. Hearing Review, 18(8), 16-22.

Gardner, H. (2004). Changing minds: The art and science of changing our own and other peoples’ minds. Boston: Harvard Business School Press.  

Goffman, E. (1963). Stigma: Notes on the management of spoiled identity. NY: Simon & Schuster.

Goulston, M. (2010). Just listen: Discover the secret to getting through to absolutely anyone. New York: AMACOM.

Heijnders, M., & van der Meij. (2006). The fight against stigma: An overview of stigma-reduction strategies and interventions. Psychology, Health & Medicine, 11(3), 353-363.

Rosenstock, I. (1974). Historical origins of the Health Belief Model. Health Education and Behavior, 2(4), 328-335.

Saunder, G., Frederick, M.T., Silverman, S. & Papesh, M. (2013). Application of the health belief model: Development of the hearing beliefs questionnaire (HBQ) and its associations with hearing health behaviors. International Journal of Audiology, 52(8), 558-567.

Wallhagen, M. (2009). The stigma of hearing loss. The Gerontologist, 50(1), 66-75.

Weiss, M., et al. (2006). Health-related stigma: Rethinking concepts and interventions. Psychology, Health & Medicine, 11(3), 277-287.

Difficult Conversations: Screening for Bullying Problems

Kris English, PhD

Professor Emeritus

The University of Akron

We all know that childhood bullying is nothing new.  However, we now also know a great deal about the long-lasting effects of bullying victimization. Longitudinal cohort studies indicate that children with a history of being bullied are at increased risk for overall mental and physical health problems, anxiety, depression, and self-harm — toxic stress responses that extend far into adulthood (Copeland et al., 2013; Lereya et al., 2015).

The U.S. Department of Education (2011) has identified bullying as a public health/public safety issue, and Takizawa et al. (2014) have framed it in the clearest possible language: “Victimization by bullies is increasingly considered alongside maltreatment and neglect as a form of childhood abuse” (p. 777).  Excuses such as “kids will be kids” and “bullying is just a rite of passage” can no longer be tolerated.

As part of a child’s support system, we must understand that children who are being bullied might hesitate to ask for help, for a variety of reasons: embarrassment, fear of retribution, or worry that adults will make the situation worse. They may not even be sure of the difference between “tattling” (which they’ve been taught they should not do) and telling an adult about being bullied. Bauman and Pero (2010) unsurprisingly found that children with hearing loss were just as likely as other children to “not tell.”

Rather than wait for a child to disclose a problem, the American Academy of Pediatrics (AAP) (2009, 2017) adopted a policy to routinely screen for bullying concerns as a standard of care. Squires and colleagues (2013) have advocated for audiologists to assume the same responsibility. But how to broach this sensitive subject?

First, Do Our Homework

We should not screen for bullying until we have some basic information:

⇒ Review StopBullying.Gov for important information on “red flags,” at-risk children, cyberbullying, a child’s legal rights to a safe environment at school (Norlin, 2015), and bullying concerns outside of school.

⇒ Learn local laws and policies re: anti-bullying programs in the child’s school, and communicate with school administration when possible.

⇒ Develop a support team at your setting, and ensure you are ready for “next steps” should a child disclose a concern, including self-harm.  We should not screen until we are comfortable with the unpredictable nature of the subsequent conversation.

A Screening Conversation

The following bullets and flowchart can be used to frame the screening conversation (Clark & English, 2019). The approach starts from a safe and general context, shifting to a child’s social circle, and eventually to the child him/herself:

  • Here in our clinic, we now have a question we ask every child these days, and I hope you will help me with it. I understand all schools have a bullying prevention program; can you tell me about yours?
    • (If little information is shared, some follow-up questions include: is there a safety officer?  Posters around school about being safe? What do you think about the program?)
    • (If the audiologist is working in a school, the opening question would address the on-site program: We have a program here, but we always want to check to see what children think about it.  Do you think it works, etc?)
  • Do any of your friends have problems with a bully?
  • If it happens, do your friends know what to do/who to talk to?
  • How about you: do you know any bullies? Do they bother you…?

As We Screen:

Children may hesitate to describe a situation as bullying. We are listening for:

  • An imbalance of power
  • Ongoing recurrences
  • Intentional rather than accidental behavior
  • Behaviors that cause mental, social, emotional, or physical harm
  • Any sign of distress

Our follow-up steps:

  • Let the child know we will help
  • Communicate concerns with parent/caregiver (who may need help bringing the concern to school officials)
  • Share information on strengthening the child’s IEP (see Hands&Voices.org)
  • Monitor the child’s well being and school responses
  • Keep referral systems up-to-date: a child could be in a crisis situation and considering harm to self or others.
  • Document
    • Note: If working in a medical setting, the AAP recommends adding a screening query to the electronic medical records system, not only to document but also establish the process as a standard of care.

A Matter of Urgency

If the reader has any concerns or questions about this topic, please do not hesitate to contact the author.


7.5 Tier 1 CEUs in Counseling Available Here!

 

 


References

American Academy of Pediatrics. (2009). Policy statement – Role of the pediatrician in youth violence protection.

American Academy of Pediatrics. (2017). Protecting youth from bullying: The role of the pediatrician.

Bauman S. & Pero H. (2011). Bullying and cyberbullying among deaf students and their hearing peers: An exploratory study. Journal of Deaf Studies and Deaf Education, 16(2), 236-253.

Clark JG. & English KE. (2019). Counseling-infused audioloigc care. Cincinnati: Inkus Press/amazon.com.

Copeland W. et al. (2013). Adult psychiatric outcomes of bullying and being bullied by peers in childhood and adolescence. JAMA Psychiatry, 70(4), 419-426.

Hands&Voices.org. (n.d.) Silence is NOT an option: A parent driven plan to keep our children safe at home and at school”

Lereya S et al. (2015). Adult mental health consequences of peer bullying and maltreatment in childhood: Two cohorts in two countries.  The Lancet Psychiatry, 2(6), 524-531.

Norlin JW. (2015). Disability-based bullying and harassment in the schools: Legal requirements for identifying, investigating, and responding.

Squires, M., Spangler, C., Johnson, C., & English, K. (2013).Bullying is a safety and health issue: How pediatric audiologists can help. Audiology Today, 25(5),18-26.

Takizawa R et al. (2014). Health adult outcomes of childhood bullying victimization: Evidence from a five-decade longitudinal British birth cohort. American Journal of Psychiatry, 171(7), 777-784.

U.S. Department of Education. (2011). President and First Lady call for united effort to address bullying.

Difficult Conversations: Screening for Dementia

John Greer Clark, PhD

Professor, University of Cincinnati, OH

Audiologists must always be prepared to view their patients in a context wider than the immediate condition for which they may be seen. One of the seven primary components of person-centered care in audiologic practice is that of a holistic outlook for patients which dictates “a continued vigil for the safety and well-being of those served both within the clinic and within the patient’s broader life context” (Clark & English, 2019, p. 5).  Both hearing loss and dementia can have negative impacts on patients’ emotional well-being, psychological status, and societal and family interactions.  The incidence of dementia increases with advancing age, as does presbycusis, presenting significant challenges to the audiologist when these conditions coexist (Cacace, 2007).

Hearing loss is one of the noted modifiable risk factors for dementia (Livingston et al., 2017), and if identified and treated early, its impact on dementia may be lessened (Beck et al., 2018).  Similarly, early detection of dementia has the potential to lessen the negative impact of hearing loss on one’s quality of life.

Broaching the Subject

One means of broaching the subject of possible cognitive decline with patients is to include inquiry of concern within the case history (Amero et al., 2017).  The following scenario depicts how to segue into a discussion about screening.

While reviewing case history information with Mr. Baxter and his wife, Dr. Collier says, “I see that you answered ‘Yes’ to the question ‘Do you or any members of your family have any concerns about memory challenges or confusion that you appear to have?’ Can you tell me a bit about your concerns?”

Mr. Baxter looks over at his wife hoping that she might respond to this topic that he tries his best not to think about.  After a brief pause, Mrs. Baxter responds, “Well we aren’t sure if it is anything really, but we have noticed that Jim seems to lose things a lot.  His glasses… keys… his watch the other day.  We all lose things, but this just seems to be so much more frequent than before. And last week he called me from the grocery parking lot.  He said he wasn’t sure if home was to the left or the right from the store.  We downsized four years ago and it used to be a right turn out of the lot, but now it’s a left turn.  We haven’t really talked to anyone about this.  Not yet, anyway.”

“Well, you are correct,”Dr. Collier says.  “We all do forget things and lose things, even lose our direction sometimes.  But what you are saying does seem to make one pause.” Turning to Mr. Baxter, she continues,“Would you be willing to have me give you a brief screening to see if we should be concerned?  If the results of the screening suggest that further exploration on this would be in order, I know a wonderful doctor I could recommend for you.”

(From: Clark & English, 2019, with permission)

 

And Then What?

As noted by Beck and colleagues, the very act of completing a cognitive screening, or even suggesting such, can serve as a post-traumatic trigger for the memories, sometimes all too recent, of the many unwanted changes (of all kinds) that frequently accompany aging.  As such, these authors suggest empowering patients at this juncture by relinquishing the lead and asking if they would like information on how the results of the screening may be beneficial.

Subsequent conversation should emphasize that no screening is definitive and that poor performance (that is, not failure) can be related to prescription medications, vitamin deficiencies, or depression.  It should be stated that the audiologist’s goal is to ensure that patients remain as socially active as possible and that further evaluation is recommended to help achieve that goal.  At this juncture, and in keeping with the audiologists’ code of ethics, audiologists should have well established referral networks. Conversely, when the patient performs well on a cognitive screening, discussion should include mention of the fact that screenings are imperfect, and if the family’s present concerns continue or increase they should discuss them with the patient’s physician.

And What If?

Patient-centered ethics dictates that a patient’s desire to decline professional recommendations take precedence over the professional’s desire to provide treatment (Clark, 2007).  Even so, when a patient initially selects to decline recommendations, explorations of underlying reasons through practices of motivational engagement are often successful in helping a patient find the internal motivation and resources to engage with recommendations (Clark & English, 2019).  But in the end, accepting the supremacy of patients’ decisions on the direction of their care should never be viewed as a case of failed intervention.

And Now What?

A support system can help us increase confidence and reduce discomfort with difficult conversations

Each of us must examine our comfort level in discussing issues of cognitive decline with our patients and providing screenings when indicated.  When we feel uncomfortable with providing services our patients may need, we are ethically bound to research the area of discomfort, discuss it with colleagues and prepare ourselves to provide the best care possible.  When screening patients for dementia, two useful cognitive screening tools are the Mini-Cog Screener (Borson et al., 2003) and the Saint Louis University Mental Status Examination (see video for more info: http://bit.ly/2ofDNBf).


 

7.5 Tier 1 CEUs in Counseling Available Here!

 


References

Armero O, Crosson S, Kasten A, Martin V. &, Spandau C. (2017).  Cognitive screening model expands health care delivery. Hearing Journal, 70(6), 12-13.

Beck DL, Weinstein BE, & Harvey MA. (2018). Dementia screening: A role for audiologists. Hearing Review, 25(7), 36-39.

Borson S, Scanlan JM, Chen P, & Ganguli M. (2003). The Mini-Cog as a screen for dementia: Validation in a population-based sample. Journal of the American Gerontological Society, 51(10), 1451-1454.

Cacace AT. (2007). Aging, Alzheimer’s disease, and hearing impairment: Highlighting relevant issues of additional research, Editorial. American Journal of Audiology, 16, 2-3.

Clark JG. (2007). Patient-centered practice: Aligning professional ethics with patient goals. Seminars in Hearing, 28(3), 163-170.

Clark JG. & English KE. (2019). Counseling-infused audioloigc care. Cincinnati: Inkus Press/amazon.com.

Livingston G, Sommerlad A, Orgeta V, et al. (2017). Dementia prevention, intervention, and care. The Lancet, 39, 2673-2734.


Resources

Alzheimer’s Association and Centers for Disease Control and Prevention. (2013). The Healthy Brain Initiative: The Public Health Road Map for State and National Partnerships, 2013–2018.

Centers for Disease Control and Prevention. (2011). The CDC Healthy Brain Initiative.

National Institute on Aging. (2017). Basics of Alzheimer’s Disease and Dementia.

Prince, M., Bryce, R., Albanese, E., Wimo, A., Ribeiro, W., & Ferri, C. P. (2013). The global prevalence of dementia: A systematic review and meta analysis. Alzheimer’s Dementia, 9(1), 63-75.

Teaching Empathy: Evaluating Skills and Habits (Part 3/3)

 

Kris English, PhD

The University of Akron/NOAC

In Part 1 of this series, we considered empathy as an act of “sharing space” with another’s experience and emotional state. In Part 2, we highlighted the importance of actively checking our impressions of another’s experience and state, to avoid the disconnect of “rejected empathy.”

Taking this learning process to its logical conclusion, as educators we are charged to evaluate the development of these interpersonal skills. However, to date very little has been written in audiology as to how to go about it.  Fortunately, there are several valid and reliable assessment tools (Batt-Rawden et al., 2013), including the Four Habits Coding Scheme, described and referenced below.  Before testing out the Four Habits, though, let’s consider one habit not included on this rubric, a habit that we may need to break: a tendency to try to “make things better” by saying “at least.”

“At least” … Creating Distance, Not Sharing Space

Such a seemingly innocuous phrase! And yet, consider the following comments and their impact on empathy:

  • At least we can improve your hearing problems with modern technology.
  • At least we identified your child’s hearing loss early.
  • Lots of people have hearing loss far worse than you do (“at least” is not spoken but implied).

On the surface, our intention is commendable: to help a patient or parent feel better (Lundberg & Lundberg, 1997). However, ironically, to say or imply “at least” only makes the speaker feel better, and at the same time diminishes the patient’s experience. By offering impersonal reassurances, we inadvertently distance ourselves from our patient.  We convey access to some special knowledge, that we know more about the situation than the person experiencing it. Such distance-creating signals are inconsistent with what Carl Rogers (1979) called “the subordination of self.” Discuss!

Applications to Audiology

Learning Objective #1: Catch/break the habit of saying “at least.”

Learning activity:  View this 3-minute animated segment of a popular TED talk:
Brené Brown on Empathy.

  1. Give three examples of how an audiologist might be inclined to “empathize” with an “at least” response.
  2. Name three emotional reactions a patient or parent might experience when presented with an “at least” response.

 

Learning Objective #2: Evaluate empathy skills with a valid, reliable rubric.

Learning Activity: Ask students to self-evaluate their present ability to communicate empathy using one section of the “4 Habits Coding Scheme” (Jensen et al., 2010; Krupat et al., 2006), summarized in the table below.  Conduct your own evaluation of each student and then compare notes. What seems to be your next step to improve empathy skills?

Coding Scheme: Code each item below using categories 1, 3 or 5. If you feel strongly that the behavior being coded is directly between these categories, use the values 2 or 4.

5 = Exemplary

  1. Clearly accepts/validates patient’s feelings (e.g., I’d feel the same way… I can see how that would worry you…)
  2. Makes clear attempt to explore patient’s feelings by labeling them (e.g., It seems to me you are feeling quite anxious about ….)
  3. Displays nonverbal behaviors that express great interest, concern, and connection (eye contact, tone of voice, body orientation) throughout appointment

3 = Acceptable

  1. Briefly acknowledges patient’s feelings but makes no effort to accept/validate.
  2. Makes brief references to patient’s feelings but does little to explore or label them.
  3. Nonverbal behaviors show neither great interest or disinterest (or behaviors over course of appointment are inconsistent)

1 = Poor

  1. Makes no attempt to respond to/validate the patient’s feelings, possibly belittling them (e.g., It’s ridiculous to be so concerned about …)
  2. Makes no attempt to identify patient’s feelings
  3. Nonverbal behavior displays lack of connection (e.g., little or no eye contact, body orientation or use of space inappropriate, bored voice)

(Sources:Jensen et al., 2010; Krupat et al.,2006; Lundeby et al., 2015)

A Final Thought (For Now)

When it comes to teaching empathy, Batt-Rawden et al. (2013) suggest we think about “walking the walk:”

Bayne (2011) highlighted the importance of role models and the reciprocal nature of empathy development in training, suggesting that “Indeed, perhaps students need to receive more empathy from faculty… before they can truly understand how to establish empathic connections.” Thus, educators should consider using the practice of relationship-centered care as the fundamental building block for their educational interventions to teach empathy” (p. 1175).


References

Batt-Rawden, S., Chisholm, M., Anton, B. & Flickinger, T.  (2013).  Teaching empathy to medical students: An updated, systematic review. Academic Medicine, 88(8), 1171-1177.

Bayne, H. (2011). Training medical students in empathic communication. The Journal for Specialists in Group Work, 36, 316-329.

Krupat, E., Frankel, R., Stein, T., & Irish, J. (2006). The Four Habits Coding Scheme: Validation of an instrument to assess clinicians’ communication behavior. Patient Education and Counseling, 62, 38-45.

Jensen, B., Gulbrandsen, P., Benth, J., Dahul., Krupat, E., & Finset, A. (2010). Interrater reliability for the Four Habits Coding Scheme as a part of a randomized controlled trial. Patient Education and Counseling, 80, 405-409.

Lundberg, G., & Lundberg, J. (1997).  “I don’t have to make everything all better”: Six practical principles that empower others to solve their own problems while enriching your relationship. New York: Penguin Books.

Lundeby, T., Gulbrandsen, P., & Finset, A. (2015). The Expanded Four Habits Model – A teachable consultation model for encounters with patients in emotional distress. Patient Education and Counseling, 98, 598-603.

Rogers, C. (1979). Foundations of the person–centered approach. Education, 100(2), 98-107.

Teaching Empathy Skills: “Checking” (Part 2/3)

Kris English, PhD

The University of Akron/NOAC

In Part 1, a vignette depicts a patient informing her physician that her spouse had recently passed away. Unfortunately, the physician assumed too much about the patient’s life and experience, and expressed empathy for a situation that didn’t exist. The patient decided to correct the physician’s assumptions, an awkward counter-response that Frankel (2017) calls “rejected empathy.” Although hypothetical, we should spend a moment imagining the rest of this scenario: once the first exchange went off the rails, the physician would hopefully apologize, clarify, and try again — still appreciated by the patient but not an optimal outcome (Derksen et al., 2017).

An Avoidable Misstep

We would never intentionally cause hurt or harm by offering empathy that a patient will need to reject, but we may find ourselves taking similar missteps. Perhaps we still think of empathy as Barrett-Lennard (1981) did when he described an “empathy cycle” consisting of three phases:

  • Phase 1: the inner process of empathetic listening to another who is personally expressive in some way
  • Phase 2: the attempt to convey empathetic understanding of the other person’s experience
  • Phase 3: the other person’s reception or awareness of this communication

In light of Frankel’s vignette, it seems fair to say that this “empathy cycle” is incomplete. All three phases were involved, and yet the outcome was ineffective. Perhaps Barret-Lennard suspected as much, since he does point out, “There is room for considerable slippage” (p. 91).

Teaching “Checking”

When we take on the task of teaching empathy skills, we should base our instruction on the most complete definition possible.  Like Frankel, Mercer and Reynolds (2002) include the aspect of “checking for accuracy”:

  1. Understand the patient’s situation, perspective, and feelings (and their attached meanings)
  2. Communicate that understanding and check its accuracy (emphasis added)
  3. Act on that understanding with the patient in a helpful (therapeutic) way (p. S9)

In other words, regarding #2 above, “If you don’t get that confirmation, you aren’t done” (Coulehan et al, 2001, p. 225).

Applications to Audiology

Our time with patients and family is usually limited, and we certainly don’t want to spend time repairing rejected empathy if we can help it. Ideally, we keep the encounter on track by assuming nothing and inviting/waiting for relevant details that we can respond to with accuracy, or as Brené Brown describes it, “climbing down into the hole” (described in Part 3).  For example:

Learning objective #1: Identify “checking for accuracy” skills.

Learning activity: View this 2.5 minute segment from the animated movie Inside Out. Find an example of a listener who did not check for the accuracy of another’s feelings. What was the result? Find an example of a listener empathizing with another’s feelings who did check for accuracy of her perceptions. What was the result?

Learning objective #2: Demonstrate “checking for accuracy” skills.

Learning activity: With a partner, write an alternative dialogue for this video segment with an intentional “rejected empathy” exchange, plus a second version that checked for accuracy. Present your script to classmates. On a 0-10 scale, (0= easy, 10=very difficult), how challenging is it to listen to another’s story without assumptions or solutions?  How difficult is it to check for accuracy?

Conclusion

Improving our empathy skills requires consistent reflection of empathic opportunities and how we respond to them. Just by trying to empathize, we are bound to make mistakes occasionally. But as students of the process, we must ask ourselves: Why did the physician in Frankel’s scenario assume incorrectly? How do we avoid assuming too much? What do we routinely assume about our patients, and are we right in doing so? How do we know we are right?

And what skills will serve us best?  Every article and book on empathy offers the same answer: genuine listening.  But how do we describe and evaluate empathic listening? The final entry in this series will focus on the relationship between listening and empathy, and also breaking the habit of saying “at least.”


References

Barret-Lennard GT. (1981). The empathy cycle: Refinement of a nuclear concept.  Journal of Counseling Psychology, 28(2), 91-100.

Coulehan JL, Platt FW, Egener B, et al. (2001). ‘Let me see if I have this right…’: Words that build empathy. Annals of Internal Medicine,135(3), 221-226.

Derksen, F., et al. (2017). Consequences of the presence and absence of empathy during consultations in primary care: A focus group study with patients. Patient Education and Counseling, 100, 987-993. 

Frankel, R. (2017). The evolution of empathy research: Models, muddles, and mechanisms. Patient Education and Counseling, 100, 2128-2130.

Mercer, S., & Reynolds, W. (2002). Empathy and the quality of care. British Journal of General Practice (Suppl.), S9-12.

Teaching Empathy Skills: Sharing Space (Part 1/3)

Kris English, PhD

The University of Akron/NOAC

The concept of empathy is a foundational aspect of audiologic care – foundational but elusive. Students and instructors generally know how to define it, for example, “the ability to understand the patient’s situation, perspective and feelings, and to communicate that understanding to the patient” (emphasis added) (Coulehan et al., 2001, p. 221).

However, as is often said in counseling texts, “knowing is not enough.” Knowing a definition does not mean a skill has been acquired. How can instructors bring the concept of empathy to life, and actively support the develop of empathy through course content and clinical training?

Guidance is available in related fields. For instance, Batt-Rawden et al. (2013) provide a systematic review of methods designed to teach empathy to medical students. These methods include a range of educational interventions that effectively maintain and enhance students’ personal capacity for empathy, such as:

  • Patient narratives
  • Reflective essays
  • Communication skills training
  • Problem-based learning
  • Interpersonal skills training (role-playing, standardized patients)

Applications to Audiology

For our purposes, we can start with two simple exercises on the process of “sharing space” with another. Here is a combination of reflective essay and communication skills training, for both students and instructors:

Learning objective #1: Develop “empathic understanding” (Mercer & Reynolds, 2002), or more specifically, “the passive emotional response of one individual to the emotions of another” (Batt-Rawden et al, 2013, p. 1171).

Learning activity: View this popular 4-minute video developed by the Cleveland Clinic: Empathy: The Human Connection to Patient Care.   Then, write down at least four specific scenarios that made an impact on you, and describe what the persons in those scenarios were experiencing. Include adjectives that describe emotional states. Repeat the exercise one month later; do any scenarios have a different impact than before? Again, write down your perceptions of patient and family experiences.

Learning objective #2: Demonstrate “empathetic communication” (Mercer & Reynolds, 2002); described as “an active skill that can be acquired and is amenable to nurturing” (Batt-Rawden et al.,2013, p. 1171) and “a visible communication behavior that is enacted when a clinician recognizes and responds to another person’s suffering” (emphasis added) ( Frankel, 2017, p. 2129).

Learning activity: Ask a friend or family member to view the same video, then ask for their reactions and listen carefully. Listen but do not insert your own reactions into the dialogue. Find ways to express that you are trying to understand. Provide some prompts: what else caught your attention?  Other scenarios you’d describe as important or memorable? Later, evaluate your skills: did you refrain from interrupting? Was it difficult or comfortable to “just listen”? Did you understand the other’s experiences and actively communicate that understanding at least once?

Caution: “Empathic Communication” Could Go Awry

Empathic communication can be difficult at times. It can also be unintentionally inaccurate. Frankel (2017) offers this example:

Patient     My husband of 67 years passed away last week.

Doctor     Oh my goodness. I am so sorry. This must be awful for you have been married for such a long time.

Patient    Well, actually, he had dementia for the last 15 years and it was hard work tending to his needs at home because his insurance ran out. It was actually kind of a relief when he passed (p. 2103).

Frankel describes the doctor’s effort as “rejected empathy.” Lacking relevant information, the doctor assumed too much, and the patient had to correct the assumption. Her need to do so neutralized the empathy the doctor was trying to provide. Because of this risk of “empathy breakdown,” Frankel suggests we keep in mind all four of these components to empathic communication:

  •          Recognizing emotions
  •          Sorting (assigning meaning to patient input)
  •          Responding
  •          Listening for evidence of response accuracy 

Conclusion

Part 1 of this short series introduces a simple strategy for teaching empathy skills to audiology students. In Part 2, we will consider how not listening for evidence of accuracy per Frankel can cause a breakdown in the “empathy cycle” (Barret-Lennard, 1981).


References

Barret-Lennard GT. (1981). The empathy cycle: Refinement of a nuclear concept.  Journal of Counseling Psychology, 28(2), 91-100.

Batt-Rawden, S., Chisholm, M., Anton, B. & Flickinger, T.  (2013).  Teaching empathy to medical students: An updated, systematic review. Academic Medicine, 88(8), 1171-1177.

Coulehan JL, Platt FW, Egener B, et al. (2001). ‘Let me see if I have this right…’: Words that build empathy. Annals of Internal Medicine,135(3), 221-226.

Frankel, R. (2017). The evolution of empathy research: Models, muddles, and mechanisms. Patient Education and Counseling, 100, 2128-2130.

Mercer, S., & Reynolds, W. (2002). Empathy and the quality of care. British Journal of General Practice (Suppl.), S9-12.

Ask About Peer Support, and Parents Say YES

Kris English, PhD

The University of Akron/NOAC

Recently, a panel of pediatric audiologists asked parents for guidance in developing a Childhood Hearing Loss Question Prompt List (CHL QPL). QPLs are used in many specialties in health care, to help patients and families remember the questions they want ask, suggest questions they may not have thought about asking, and broach questions they’d like to ask but don’t know how. As a counseling tool, QPLs are very effective for patient education as well as for the open invitation to discuss important or difficult topics, and to equalize the power dynamic in a health care appointment.

One Question Stands Out

The CHL Question Prompt List underwent several stages of review, and the final version can be found here.  The report on this QPL does not include a breakdown of each question and degree of support, but one result is a stand-out and is worth highlighting here: of all the questions reviewed to keep or reject, the only question that was approved by 100% of parent reviewers (N = 122) was this one:

Any unanimous response is rare, but this one really should come as no surprise: research has long reported parents’ desire to connect with other parents for support. Parents in Mueller et al.’s (2009) study valued access to other parents as a source of information and emotional support, and a sense of being in a larger family. Other benefits include gaining new skills to deal with day-to-day issues, increasing a sense of power and belonging (Law et al. 2009), and reducing stress (Hastings & Beck, 2004). Parents of children with hearing loss have specifically identified their “predominant need” as meeting other parents (Luterman & Kurtzer-White, 1999), and the provision of these support services is described as a “state-of-the-art practice in family counseling” (Jerger, Roeser, & Tobey, 2001).

What to Do With This Information?

This web forum focuses on audiology counseling, but we must recognize our limitations. We cannot help parents the same way other parents can. In addition to providing every professional support possible, we can also:

  • Support a parent group in our community (provide space, communication mechanisms [newsletter, website], etc.)
  • Provide parents contact information about existing groups in our community and online (e.g., Hands&Voices)
  • Maintain and share a list of “veteran parents” who generously volunteer to provide one-on-one support, especially to those new to “the journey.”

Conclusion

Once again, parents have spoken. Will we act as well as listen? What can we do in our communities to meet this full-throated request for support?


References

Hastings, R., & Beck, A. (2004). Practitioner review: Stress intervention for parents of children with intellectual disabilities. Journal of Child Psychology and Psychiatry, 45(8), 1338-1349.

Jerger, S., Roeser, R., & Tobey, E. (2001). Management of hearing loss in infants: The UTD/Callier Center Position Statement. Journal of the American Academy of Audiology, 12(7), 329-336.

Law, M., King, S., Stewart, D., & King, G. (2002). The perceived effects of parent-led support groups for parents of children with disabilities. Physical and Occupational Therapy in Pediatrics, 22(2/3), 29-48

Luterman, D., & Kurtzer-White, E. (1999). Identifying hearing loss: Parents’ needs. American Journal of Audiology, 8(1), 13-18.

Mueller, T.G., Milian, M., & Lopez, M.I. (2009). Latina mothers’ views of a parent-to-parent support group in the special education system. Research and Practices for Persons with Severe Disabilities, 34(3/4), 113-122.

Is it Possible to Practise with Compassion and Empathy?

Paul Peryman, MA, Dipl Aud (Melb), MNZAS-CCC, Audiologist

Van Asch Deaf Education Centre 

Christchurch, New Zealand

I work as a paediatric audiologist at van Asch Deaf Education Centre in Christchurch, New Zealand. I have worked there for 30 years. During that time I have practised within a family-centred care model, in conjunction with the teams with whom I work in the Centre.

Part of my work includes meeting families with preschool and primary school aged children who are deaf/hard of hearing (DHH). These families are referred to our centre from around central and southern New Zealand and stay in residence for four days. During that time, they meet and work with a team which includes myself, a speech language therapist, a specialist literacy teacher, a specialist early intervention teacher, and a New Zealand Sign Language tutor. The families also meet other parents who bring their DHH children to our early intervention centre.

The objectives of our residential courses are to provide assessments of the children and guidance to the families. Immediate post-course ratings of each specialist area of assessment and support are received from families before their departure. In common with the approach of the Colorado Home Intervention Programme, evidence for modifying and continuing professional practice within the residential course teams has been based on both family and professional feedback (both internal and external), as well as international research within each team member’s professional speciality.

Some reasons why our residential courses work well

  • An intense focus is provided on early language, hearing, signing, speech, visual communication, social behaviour, and literacy.
  • Consistency exists for each family from across the team members.
  • Family and child-centred focus – parents find this refreshing.
  • Generous time frames and flexibility in courses, allowing the tailoring of courses to family needs and referrer priorities.
  • Opportunities to meet other families and share experiences – especially beneficial for isolated families.
  • Unique and relaxed environment – helps families focus on themselves and their DHH child’s needs.
  • Presence of other deaf adults and children on the site is perceived as a positive characteristic.
  • Family travel, accommodation and meal costs are supported.

Hearing family stories and experiences

Working with these parents and families involves hearing stories. The stories are invited and prove highly informative for the team. Hearing the stories and reflecting back to parents requires the display of empathy and compassion, as parents are often at the same time quite emotional. Some have not previously had the opportunity to tell their story, and it comes as a relief to do so and to be heard.  Some parents have also had experiences of rushed audiological appointments, leaving them with little time to share observations and to ask the questions they want of the professionals. Those parents were feeling removed from the audiological management of their child; not understanding what was happening and what to expect. In some cases, parents didn’t believe the diagnosis, which they admitted had affected their willingness to persevere with the battle of keeping hearing aids on an infant who appears to hear.

How to balance limited time?

It seems to me that this state of affairs comes about due to my hospital colleagues being so pressed for time that they have to reduce their service to one of meeting the required evidence-based clinical protocols, against which they are audited. While some try to resist this pressure, it is ever present. They are concerned that too much valuable clinical time might be used up once a conversation is entered, leaving them unable to complete the protocols. Colleagues have also said anecdotally that they feel ill prepared to engage in conversations that might become emotional or difficult. There is a feeling that stopping and allowing time for conversation will affect their appointment schedules and therefore cause them stress (Severn et al, 2012).

 

 

TWO QUESTIONS FOR THE PROFESSION:

1. Is altruism in clinical practice being lost?

The dominating effects of the need to conform to evidence based practice has been raised as an issue in nursing (Straughair, 2012): “…as the profession of nursing advanced to develop evidence-based practice, some of the ethos of the compassionate nursing character was seemingly lost in favour of technical skills. This is supported by evidence suggesting that nurses have a decreased affinity with the ethos of altruism. Recent reports have highlighted negative patient experiences which reflect a clear lack of compassionate nursing care. This has led to a variety of documents re-endorsing the concept of compassion as a core and fundamental nursing value.”

We need more research in this area amongst paediatric audiologists.

2. Can EBP, the desire to help, and having the space to show empathy and compassion co-exist in audiology?

Audiology is a helping profession“A helping profession is one that nurtures the growth of or addresses the problems of a person’s physical, psychological, intellectual, emotional or spiritual well-being, including medicine, nursing, psychotherapy, psychological counseling, social work, education, life coaching and ministry.”

Bearing in mind this definition while sharing my approach to paediatric practice with my colleagues, I believe that it is possible for us to listen to parents and have the conversations that they request and that I know are necessary to support their understanding. I know that this can be done in a compassionate and empathetic manner, while still completing clinical procedures. Being empathetic and compassionate, and talking about what is going on, does not add time to the appointment, nor prevent the professional requirements of an appointment from taking place. Rather, it can just be present in the manner of speaking during the conversations that occur. As Brill and Nahmani have said, the presence of compassion (and presumably showing empathy) is simply a means of taking a stance towards clients, and toward the clinical relationship with them (Brill & Nahmani, 2017).

In some cases, conversation with parents does become sensitive, for which some counselling skills are required. This is especially the case if it is noted that progress in managing a child’s or parent’s needs will not occur without helping parents to move forward, and if one knows that this is the best opportunity to begin these conversations for the benefit of the family.

Diana Harbor recently cited research in her article on this site showing that compassion and listening skills can be taught and measured in audiology students. It is time for audiologists in training to have a practical counselling component within the curriculum; and for them to be introduced to the concepts of mindfulness, compassion and empathy, and how they are woven into professional practice. One could go even further and state that training needs to embed compassion and empathy as core values of audiological practice. Effective role modelling in practice that demonstrates high-quality compassionate audiological care is also essential for newly trained audiologists.

In conclusion…

Families need a balance between audiologists getting the assessment and technical aspects right, and understanding what their child can and can’t hear and what audiologists are trying to achieve. They need this provided within a climate of compassionate and empathetic care. Families are the ones who live every day with their child with hearing loss. No family can be expected to run with our recommendations unless they trust their professionals, they feel listened to, they understand what is going on, and they are given appropriate emotional and practical support.


References

American Speech-Language-Hearing Association. (2005). Position Statement.

Brill, M. & N. Nahmani (2017). “The presence of compassion in therapy.” Clinical Social Work Journal 45(1): 10-21.

Severn M. et al. (2011). “Occupational stress amongst audiologists: compassion satisfaction, compassion fatigue, and burnout.” Int J Audiol 51(1): 3-9.

Straughair, C. (2012). “Exploring compassion: implications for contemporary nursing. Part 1.” Br J Nurs 21(3): 160-164.

Kindness Begins at Home

Diana Harbor, BA

Audiological Scientist & Speech and Language Therapist

The Ear Foundation Nottingham England

This week yet again I have been reminded of the very powerful force of kindness and its power source…the listening ear. Yesterday I had the privilege of being with a group of teenagers all living with hearing loss, using different technology from cochlear implants to bone implanted devices with different personalities and experiences of the world, some who had never met each other before. We all took part in an exciting improv, drama workshop at the Ear Foundation. Much of the afternoon was spent in small groups creating wonderful stories and weaving a single idea into a feast of creativity that JK Rowlings would have drooled at. And the real magic happened as Loydie, a DJ from Capital radio, revealed to us very simple techniques for keeping ideas going, for turning problems into new ideas and for getting the best out of each other. The power of using the phrase “…yes and” and how to do this while listening and maintaining eye contact.

The reason I’m sharing it here is I will be using it in practice and it was a light bulb moment for me. Well maybe that’s a bit dramatic but definitely some sparks and embers that I’m going to ruminate over and feed with other new ideas on the subject. So if you are partial to a camp fire…feel free to bring along your marshmallow on a stick and sit with me for a bit as I share with you what I’ve learnt.

The Power of “Yes and…”

“Yes and…” Ideas start to fly; we feel accepted and heard

In the improv workshop we all put the idea of “yes and…” into practice as we started a story with “let’s go to…”. As one teenager started with a single idea (“Let’s go to the beach”), his team mates were asked to reply with “yes and…”

Wow!! This simple phrase encouraged a wave of ideas from “yes and we could build a sand castle”, “yes and we could build it so high it reached into space”, “yes and we could eat our picnic on the moon”, “yes and we could discover a new specifies of plant life that ends world hunger” or “yes and we can ride in a Lamborghini with the top down.”

At the heart of “yes and …” lay the principles of listening first, starting from what was shared, then accepting and acknowledging the value of the idea offered and then moving it forward by sharing ourselves. We were all amazed how quickly our ideas flowed, how quickly we got to exciting places in our minds because the people around us were listening and affirming our ideas. When it worked well, we bonded quickly with our groups and we were sad to leave them as we moved into different groups. It feels so good to be looked at, heard and our ideas enjoyed.

Compare to the Impact of “Yes, but …”

“Yes but…” usually means “we can’t”

Loydie then asked us to try the exact same activity, but this time when ideas were shared around the group instead of saying “yes and…. ” we had to say “yes but…” Not to overuse the campfire metaphor but this equally succinct phrase was like pouring cold water on the fire, as ideas fizzled into soggy piles of embarrassment and stray sparks leapt up in defensiveness. Now all our energies were going into planning our negative responses, usually judgmental.  “Let’s go to the beach…” “yes but it looks like it might rain”, “yes but we could take umbrellas”, “yes but it’s windy too they won’t work”….You get the idea now …. Whereas before our conversations and ideas flowed in a safe circle of sharing and equal power, now we found ourselves feeling dismissed, having to force our ideas into the circle — and the quieter members of the group withdrew completely.

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How To Create Moral Distress: Compromise Values and Professional Ethics by Not Practicing Patient-Centred Care

Jeanine Doherty, Au.D., M.Phil., M.B.S, B.Soc.Sci.(Hons.), 

Hearing Excellence 

Christchurch, New Zealand

Trying to live up to a philosophical ideal of increasing the social, psychological, cultural and ethical sensitivity of our human encounters requires our personal, deliberate effort in an ongoing process. The action requires reflection, experience, introspection and the development of emotional quotient (EQ). It is not possible to complete a course about Patient-Centered Care (PCC) and think “Hey I can write on ‘Linked in’ now that I am a PCC clinician,” nor is it something that clinic owners should believe is ‘ticked off’ by sending their staff to a course.

While PCC is not yet fully conceptualised within audiology (although some essays on the topic are available), as Stewart (2001) wrote, we do know that PCC is not technology centred, not practitioner centred, not clinic centred and not disease centred. I believe PCC has to be lived in like it is your 2nd skin – our “thermals” as we would wear in a chilly southern New Zealand winter. PCC has to be infused, like ethics awareness, into all aspects of student training, as well as within the modus operandi of any practice arena.

Ethics, Legality, Morality

As we know, ethics, legality and morality are each different, though related, constructs. Something can be legal, yet immoral to an individual, as our values lead to our personal morals. Moral distress arises when clinicians are unable to act according to their moral judgement and their Profession’s Ethical Code (Rodney, 2017). This distress is located not only within individuals when their actions mismatch their values, but also from within the broader healthcare structures of the clinician’s workplace. The socio-political structures that can create moral/ethical distress have been studied mostly within nursing, but the relevance of the concept to audiology should not be ignored. Moral distress also emerges from situations that are against all the principles of PCC.

Harris and Griffin (2015) write that some organisational policies can lead to diminished care quality and cynicism with lack of teamwork and lower morale amongst clinical staff. In such a work-place, increased competition and mistrust develops between staff, while middle management level finds itself stuck between demands from higher-up levels (e.g. profit/cost outcomes) and the lack of teamwork and lower morale of the clinicians who are in moral distress. The physiological and psychological effects caused by the existence of moral distress can lead to burn-out, and then the staff member becomes ill, finds another better workplace, or just gives in, morally disengages, and carries on in a manner that is opposed to their values/morals (Musto, Rodney & Vanderheide, 2015). Lachman’s (2016) list of symptoms of burnout includes fatigue, general illness, headaches, insomnia, disillusionment, anger, negative self-concept and a loss of concern for others.

Profit vs Patient Outcomes

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