Kris English, PhD
The University of Akron/NOAC
Recently, a friend described how her grown son currently chooses to be homeless. She doesn’t know how to find him, and doesn’t know how he manages. Needless to say, she is worried sick. Looking back, she now recognizes the early signs of mental health problems during his teen years, but at the time, she didn’t recognize them as such. After all, it’s not unusual for teens to be rebellious, non-communicative, disorganized, or moody. As any parent would, she applied what she knew in general about adolescence to make sense of her son’s decisions and actions; only when her explanations no longer made sense (this is not how teens typically act) did she feel ready to consider broader, more complicated explanations and seek help. The diagnosis of mental health problems was a first step toward making sense of a profoundly unfamiliar situation.
Most adults approach life’s uncertainties in the same way: we experience something we don’t fully understand and start by working through “what we know.” Our car makes a funny noise so we look under the hood. We notice a new ache or pain, and make changes in our diet or environment (maybe more exercise?). Our computer freezes so we turn it off, count to ten, and turn it back on. In doing so, we are applying the sensemaking process, which helps us understand a change or shift in our world. If that process fails us, we consider taking the next step of asking someone for help.
Although much of audiologic counseling focuses on emotional and psychological reactions to hearing loss, our patients of course are also decision-making individuals whose minds seek logic, facts, and answers that make sense. Here we will consider how the sensemaking process applies to our patients as they ask for our help.
It Might Look Like Denial
Sensemaking in health literature is often applied to the diagnosis of a life-altering disease or disability (e.g., Pakenham, 2008), as in “why is this happening to me?” and “what will become of me?” Acquired hearing loss is certainly a life-altering condition, and both patients and audiologists attempt to make sense of it. We understand our role: in our initial encounter with a new patient, we begin with the query, “What brings you here today?” to help us understand the patient’s concerns, and then we test. However, we may not understand that the patient is also striving to make sense of this appointment. For many patients, a gradual hearing loss does not yet make sense, as reflected in these remarks:
- My family says I can’t hear them – but that can’t be true because I definitely hear them complain!
- People speak too fast these days.
- It’s not my hearing, it’s the background music on TV that’s the problem.
- How can anyone be expected to hear in such noisy restaurants? They used to be quieter.
Gill et al. (2010) describe these types of comments as “candidate explanations,” offered to convey a patient’s efforts to make sense of the situation. However, we may be inclined to interpret these comments as denial (or stubborness, embarrassment, suspicion) instead of reasonable efforts to understand a problem based on what the patient currently knows: that one’s hearing seems to be generally adequate.
What patients don’t yet know is their actual hearing status. How we go about informing them can support the sensemaking process.
Do We Inadvertently Impede the Sensemaking Process?
Knowing that many patients are trying to make sense of our time together, we have to ask ourselves if we help or hinder that process. Consider the information that we collect but do not share with patients until our testing is done:
- During pure tone tests, patients have no idea of the intensity required to define their thresholds. Whether it was 20 or 70dB, as far as they know, it was soft and therefore assumed to be “good” hearing.
- During word recognition tests, patients receive no feedback about the words they misheard, and are often shocked to be told they missed any at all.
- During speech-in-noise tests, patients recognize at some point that the noise is a problem, but they don’t know that their abilities may be far from normal.
Their hearing concerns now make sense to us, but so far the patient has been kept in the dark. When we do convey test results, we must understand why some patients will still be skeptical, challenging, or confused. Our summary can be quite inconsistent with what makes sense to them (that they can hear fairly well). Can we do better?
Sensemaking as a Social Process
Manojlovich (2013) describes sensemaking as a “process arising from dialogue when 2 or more people share their unique perspectives … to build consensus” (p. 295). Recall the mother mentioned above and her journey toward her son’s diagnosis: she started with her knowledge base but ultimately she also needed to learn what an expert knew (via their dialogue) in order to make sense of her son’s mental health. In our dialogues with patients, to help them make more sense of the appointment, we can provide advanced notice about the “unknowns,” for intance:
- You’ll be hearing a series of tones, and we’ll find out how soft you can hear them. I may have to increase the output to some extent for you to hear them, but you won’t be able to tell during the test. I will definitely explain that afterwards.
- You’ll be repeating back several words, many of them sounding very similar to other words. I will keep track and let you know how many words you heard correctly and also how many words you thought you heard but actually missed. It will be helpful information to have.
- You’ll be hearing sentences to repeat while background conversation goes on. Everyone has trouble at some point; when we’re done I’ll review the kind of trouble you experience.
Giving patients a “head’s up” can help them make more sense of the testing as it transpires, and also better understand the subsequent debriefing: “I mentioned that you may not be able to tell if you missed some of the words. You did misunderstand several, about 20% of them — does that make sense, now that you’ve gone through this process? I can explain further if not …” And so on. Asking “does this make sense?” or “does this information enhance what you already know?” helps us know if our dialogue is supporting the necessary shift toward recognition and acceptance of hearing loss.
Sensemaking Can Help Patients Move Forward
Many patients leave an audiology appointment without addressing their hearing problem. There are many reasons why, and one reason may be that the process they just experienced did not make enough sense to them, and so they decide to do nothing. We have the ongoing challenge to understand every patient’s mental and emotional state, realizing that “how we think affects how we feel and act.” If our appointments and patient education efforts make sense to patients, they will have more confidence in our recommendations and consider those next steps toward, for them, a profoundly unfamiliar situation.
Gill, V.T., Pomerantz, A., & Denvir, P. (2010). Pre-emptive resistance: Patients’ participation in diagnostic sense-making activities. Sociology of Health & Illness, 32(1), 1-20.
Manojlovich, M. (2013). Reframing communication with physicians as sensemaking: Moving the conversation along. Journal of Nursing Care Quality, 28(4), 295-303.