The "Third Ear" and the
Interview The above interview is a
reconstruction of a relatively uncomplicated exchange. It
seems simple, merely a matter of "common sense." However it is
technically highly structured, proceeding in an arrow-like
projection straight to the target.
More complicated histories require additional
skills. The ability to be effective will depend upon how well
one "hears" what is being said. One may listen but may not
"hear." "Hearing" relates to the picking up of obscure cues;
words and phrases that contain the clue to the fear being expressed,
cues less obvious than "pain", "drill" and "needle." Hence
they may go "unheard." Success will depend on the doctor's
knowledge of these cues and the development of his "third ear" which
permits him to "hear" the subtle and less obvious statements of
fear.
What follows is an example of an interview in
which some obscure cues are put forth by the patient. She is
not aware of their meaning, yet without knowing the significance of
these cues, the patient is compelled to give them. The
interview was performed by a relatively inexperienced third year
dental student as part of a course on Iatrosedation. He did
quite well up to a point, but his "third ear" was not developed
sufficiently to enable him to pick up the more obscure cues.
Student: "Are you
having any difficulties?"
Patient: "Yes, I
have a tooth that has been aching and I need to have it fixed ...
but I can't take novocaine ... and the whole idea makes me
nervous."
Student: "Is there some reason why you
cannot have a local anesthetic?"
Patient: "My
doctor said I am allergic to all of the 'caine' family and therefore
I must have a general anesthetic to get my work
done."
Student: "How did your doctor come to the
conclusion that you are allergic? What
happened?"
Patient: "Well, I had to have a tooth
pulled that was in my palate, an eye tooth. The dentist gave
me several shots and then left while it took effect. All of a
sudden I couldn't breathe. It felt like something terribly
heavy on me. My heart started palpitating, pounding and I was
choking and having a terrible problem. The dentist came back,
was upset and said that I had to have an EKG immediately ... he
wouldn't work on me ... so I went to see the doctor he called.
There was nothing wrong with my heart ... he said I can't take local
anesthetics."
Student: "Have you had dental work
since then? What did you do?"
Patient: "I
had all my work done without a local ... even the rebuilding of a
tooth with spikes in it ... I so dread it ... it's worse than having
a baby which I also had without a
local."
Student: "How did you feel when you did
get injections?"
Patient: "There's a little
tenseness ... but not bad. The needle doesn't bother me ...
but I'm kind of scared ... I think most people are anxious, don't
you? It has nothing to do with the dentist as a person ... I
don't know ... there's just something about it ... it's a sort of a
frightening experience ... you don't know if you're going to choke
or something. It's more a matter of being able to control the
situation."
This interview had been videotaped as part of
the course on Iatrosedation. A teacher reviewed the tape with
the student and pointed out that the patient had repeated a cue
three times to which he had not responded. She had said,
" ...I couldn't breathe ... I was choking .... you don't know
if you're going to choke or something..." and then added,
"It's more a loss of being able to control the situation."
Generally speaking, when a patient reacts to
a dental situation with a sensation of not being able to
breathe, or feeling like he/she is choking, the cue suggests
some previous experience that was a threat to breathing. The
student was advised to resume the interview with the patient,
stating that during the review of the tape it was noticed that she
mentioned having had difficulty with breathing and choking. He
was to ask the patient if she had ever had an experience that was a
threat to her breathing. Her response was, "Yes, now that I
think of it, when I was a young girl I almost drowned." So
indeed, she had suffered the harrowing experience of suffocation and
the assumption can be made that any sensation which suggests
interference with the airway may trigger the feeling of panic that
accompanies suffocation. The suffocating experience was
generalized to the dental scene.
The probable sequence of events was
reconstructed in order to offer the patient an interpretation of the
origin and cause of her fear. Working with such an
interpretation is helpful to the patient in diminishing the fear and
permits the doctor to plan for the clinical phase of the
iatrosedative process.
The evidence was pieced together in the
following manner. The dentist had given several injections to
produce palatal anesthesia. This undoubtedly extended to the
soft palate producing a numbness and a feeling of largeness that so
many patients report with a posterior palatal injection. This
feeling of intrusion on the airway triggered off a feeling of panic,
resulting in the acute anxiety the dentist faced on his return to
the operating room.
The student was advised to have the patient
tested for tolerance to one of the local anesthetics. Results
of the testing indicated that she was not allergic. Armed with this
information and the reconstruction of the past events, he proceeded
to explain and interpret what he thought was the origin of her
anxiety, suggesting that she could unlearn the feeling involved and
learn a new way to respond to the situation. He suggested that
by starting with treatment where no palatal anesthesia was involved
she would undoubtedly tolerate it very well. This is indeed
what happened. The treatment phase started with the use of
infiltration injections for anesthesia. The patient tolerated
this very well and the relearning process expanded as treatment
continued, to the point where palatal injections did not set off a
high anxiety response.
Another indirect cue that must be "heard" and
understood is the word "gag" or "gagger." Gagging frequently
is a panic response, related to a feeling that some threat to
breathing or swallowing is about to occur. This feeling has
its roots in the past, similar to the cue discussed in the previous
history, due to an experience of actual or anticipated suffocation,
a traumatic surgical experience involving the threat or a choking
incident.
In the following iatrosedative interview,
this type of cue arises. The "what" questions are used to track down
the specificity and origin of the fears, but in addition, the cues
are facilitated by the use of reflection .
"Reflection" is a major method of
facilitating cues. The word or phrase is reflected or
repeated, either exactly as stated or in a similar form. This
echoing or repeating the patient's word or words acts as an
invitation to continue talking about that subject. It is the
most economical and productive facilitating tactic in the
repertoire.
In the exchange that follows, the key words
(cues) are underlined as are the reflective responses of the
doctor. In addition, the "what" questions are underlined.
Doctor: "Good morning,
Mrs. Caswell. How are you?"
Mrs. C: "Good
morning, Doctor. I'm fine, thank
you."
Doctor: "Tell me, are you having any
difficulties?"
Mrs. C: "Well, yes. I'm a
terrible coward about anything to do with my
teeth."
Doctor: "You are? In what
way are you a coward?"
Mrs. C: "I'm
terrified. I guess that sums it up. I really get
very jittery."
Doctor: "Have you had any idea
what happened to terrify you?"
Mrs.
C: "Yes, well, I ... when I was a little girl I had
very bad baby teeth I guess, and the dentist I went to see was kind
of mean. ... and also ... I"m a gagger ... those two
things ... when I was 18, I made about 3 appointments, showed up and
then ran out."
Reflecting the words "coward" and "terrified"
accomplished several objectives swiftly. The doctor
communicated his recognition of the patient's fear and invited her
to tell him more about it. Simultaneously, he moved from the
general statement of fear toward the specific fear. The past
doctor's behavior was stated in a general way ("he was mean") and an
indirect cue was sprung ("gagger"). The doctor then combined a
"what" question with the reflected word "mean" to continue the
facilitation.
Doctor: "In what way
was he mean?"
Mrs. C.: "I have a horrible
memory of the nurse grabbing me and holding me while the doctor
worked on me ... and not being able to get my breath .
The vivid image of the behaviors of the
doctor and his assistant, though briefly stated, expresses the
patient's feelings about that behavior. In addition, an
important indirect clue is uncovered: the "not being able to get my
breath." Gagging is the physical expression of panic; in this case,
the panic associated with "not being able to get my breath." This is
the specific fear. If the interviewing doctor did not "hear"
the cues "not being able to get my breath" and "gagger", and if he
did not know that there was an important relationship between them,
he probably would have gone off on a time-consuming and unproductive
tangent. Instead, he moved straight to the target of
determining the origin.
Doctor: "Did you ever have
an experience where you were not able to get your
breath?"
Mrs. C: "That's a very interesting question,
Doctor. I'll tell you why. When I was a child I had
diphtheria. I remember fighting trying to get my breath, and the
memory of a band of fire around my throat. ... and faces coming very
close to me. I remember my breath, you know ... they were
trying to decide whether or not to give me a tracheotomy ... my
grandmother told me. They didn't, but I do remember all those
faces and even now, if anyone gets too close to my face, I feel like
my breath is being cut off. It's the memory of that fear and
the distrust of my first dentist.
The specific fear apparently stems from this
experience it's generalized so that any doctor coming close in a
therapeutic situation triggers the associated feeling of
panic. This presumably, is what occurred with her first
dentist. Using this as a basis for initiating a relearning
process, reducing the anxiety and offering support, the doctor at
this point switches from gathering information to giving information
he interprets and explains past events and suggests change can
follow. Doctor: "Yes, the heads
coming close to your face became associated in your mind with the
choking and the panic you felt when you were gasping for air.
When your first dentist approached you, you panicked. He
ignored this, had you held down and intensified your fear. But
this can be changed. What we have to cope with is the
present."
Mrs. C : "You sound very
psychologically oriented."
The doctor accepts this recognition of
expertise and uses it to expand on his interpretation of suggestion,
finally leading to commitment:
Doctor: "I am,
and for an important reason. What we have to deal with here,
the dominant issue, is your fear, not the condition of your
teeth. If I cannot assure you that I will take care of you as
a person, then you'll run away from me in the same way you did
from other dentists. And you'll not get what you want and
need."
Mrs. C: "Yes, that's right ... and as you
pointed out, I would not really be reacting to the fear here ... the
reality of the situation ... but rather to the earlier fear rooted
in my childhood."
Doctor: "Exactly. Just
as your mind can record and retain a vivid image of something that
happened thirty years ago, so it has the capacity to relearn.
And that's what we're going to talk about now. You are not that
child, you do not have diphtheria, you are not going to choke.
I will keep you informed in advance at all times what I plan to do
and what you may expect in the way of discomfort or lack of
it. I will ask for feedback from you as to how you feel about
it. In short, you will have a great deal of control over the
situation. I believe that my approaching you will not set off
the panic button and we will be able to accomplish what you
want. Just remember, I will keep in mind at all times how you
feel."
Mrs. C: "All right. Thank you,
Doctor, I do feel better now."
This statement by the patient
infers that
she feels less anxious. It remains for the clinical
iatrosedative encounter to determine this and to continue
the fear reduction process.
The concept of determining the specific
fear, its origin, interpretation, explanation, suggestion and
commitment is a general one. It is used here in a particular
manner. Each
individual will use it in a way peculiar to
himself. The principles are sound. The manner of
implementing them is individualistic.
A common thread seems to weave through most histories
of fearful patients. It is an unholy quartet
of feelings consisting of:
-
The specific fear (needle, pain, drill
etc.) invariably combined with:
-
distrust
-
an intensified fear of helplessness and
dependency
-
an intensified fear of the unknown; a
sense of being unsafe and unprotected from the
perceived threat or danger
The variations on this theme seem
endless. The following history is quite typical. It is
not as obscure as the last two, but more complicated than the report
preceding them.
Doctor: "Good morning, Mrs.
Brown."
Mrs. B: "Good morning,
Doctor."
Doctor: "Are you having any
difficulties?" Open-ended question.
Mrs. B:
"Yes, my gums bleed and I think I have
pyorrhea."
Doctor: "You think you have
pyorrhea?" Facilitation by reflection
Mrs. B:
"Yes, I've heard that bleeding gums is the beginning of
pyorrhea and can cause teeth to loosen and they have to be
pulled. And this makes me very nervous."
It is best not to take for granted what "makes me very
nervous" means, therefore facilitate the cue.
Doctor:
"What is it that makes you nervous?"
The "what" question is combined with reflecting "makes me
nervous".
Mrs. B: "Well, the idea that I might lose my
teeth and the kind of treatment I might need."
The
"what" question yields a new clue ... closer to the specific fear we
want to uncover.
Doctor: "What kind of treatment
are you referring to?"
Mrs. B: "Surgery
... that some cutting might have to be done."
This seems to be the dominant problem and more specific.
Doctor: "What is there about the surgery that
disturbs you?" The "what " is an attempt to learn the
specific fear.
Mrs. B: "The whole idea ... I was
told to have a gall bladder removed 3 years ago and I refused to do
it." What is behind "the whole idea?"
Doctor:
"Is there some reason why you feel this way about
surgery?" An "on target" question designed to uncover
the specific fear or fears surrounding the surgery. It may
elicit information of its origin as well.
Mrs. B: "Yes
there is. When I was about 5 or 6 years old I had my tonsils
removed. Although I do not remember anything specific about
it, I was not prepared for this and the experience left me
fearful. (The origin begins to unfold as does an
important element of the fear - the unknown) When I was 8
years old I went to an orthodontist who looked at my teeth but
nothing was done. A few months later my mother said she was
going to take me to a party the orthodontist was giving for all of
his patients. I put on my party clothes and we went.
(Distrust of the mother ... authority ... based on
deceit) When we arrived I was immediately grabbed,
forced into the dentist's chair, held down and given gas. I
was terrified. When I came to, I found that I had wet myself
and was crying bitterly. (Distrust of the dentist,
exaggerated fear of helplessness and dependency, and fear of the
unknown probably are intensified.)
Fear of surgery is not the totality of the
problem. It may be viewed as a vehicle carrying the powerful
feelings of distrust, helplessness and the unknown with it.
For this reason the maxim, "Fear is soluble in trust"
seems credible. The promises, therefore, made in
the commitment are important since they tend to initiate a feeling
of trust and security with an attendant drop in the fear
level. It remains for the iatrosedative encounter to fulfill
the promises made and the hopes raised.
Iatrosedative Clinical
Behavior The clinical encounter
begins the moment you pick up an instrument, whether it be a mirror
or a probe. An important commitment should be made at this
time, to wit: the quality of your tactile behavior. How
delicately or roughly you use your instrument tells the patient
something of your involvement with him; your awareness, concern and
skill. The more threatening an instrument is, the more
significant is your manner of wielding it and the more important are
the verbal communications made in conjunction with its use.
What you are about to do with it and what you anticipate the effects
on the patient will be are two important happenings that should be
shared with him/her. In short, you should communicate in a way
that will
prepare your patient for what is about to occur.
Skill in the use of such preparatory communications
is essential in iatrosedation.
Preparatory
Communication Let us consider Preparatory
Communications in relation to the "normal" patient first. The
non-fearful patient is subject to normal anxiety which is an
anticipatory state of expecting threat or danger and preparing for
it. We all tend to be apprehensive when dependent on another
whose actions hold the threat of pain and /or body damage. We
have no control and are helpless. The unknown is disturbing:
that disquieting sense of not knowing what the other person is going
to do, the threatening silence when the "needle" or other
potentially painful or cutting instrument is picked up. All of
these feelings are exaggerated when the person in
control gives us no information with which to brace
ourselves psychologically, no assurance that he is aware
or concerned about us.
Preparatory communications are brief
communications made to the patient prior to using an instrument or
performing an action which could be perceived as threatening.
The communication is intended to prepare the patient for what is
about to happen or may be experienced; such as discomfort, pain,
noise, pressure, etc. Such preparatory communications tend to
dispel the fear of the unknown and the sense of helplessness through
the
simple act of foretelling. The patient receives an additional
sense of control over his situation because he
knows what to expect.
Control through knowing (cognitive control)
tends to increase with the use of preparatory communications.
When the
Danger Control and Protective Authority shares knowledge with the
patient, it tends to reduce anxiety significantly. Egbert's
studies clearly demonstrate this.
Egbert and his
colleagues demonstrated the effects of preparatory communications on
the anxiety level of patients scheduled for major surgery.
A number of clinical experiments were performed by his group of
anesthesiologists to determine the effects of the doctor's behavior
and communication on the anxiety level of surgical patients.
One such study measured the effect of the anesthesiologist's
pre-operative
visit with his patients in producing calmness versus the
effect of pentobarbital for pre-anesthetic medication. They summarized
their findings this way:
"Patients who
had received a visit by an anesthetist before the operation were
not drowsy but were more likely to be calm on the day of the
operation. Patients receiving pentobarbital one hour before
an operation became drowsy but it could not be shown that they
became calm. If the purpose
of pre-anesthetic medication is to allay anxiety, our data
suggest that pentobarbital, causing drowsiness does not achieve
the desired result alone."
Their data also
suggested that the
psychological impact of the pre-operative visit made the effects
of the pentobarbital seem inconsequential. In their comment,
Egbert et all stated:
"At first sight
it would seem surprising that an anesthetist, in a 5-10 minute
interview, would be able to exert a psychologic effect
demonstrable the following day. The patient's interest in
knowing about anesthesia would not seem to be an adequate
explanation. A better explanation is provided by
Janis. He found that persons facing a frightening situation
became anxious and looked for emotional support ... an authority
supposedly able to modify the
dangers, becomes invested with strong emotional significance. The statements
made by this authority assume greater importance than
would ordinarily be expected."
Iatrosedation on the "Firing
Line" The patient whose iatrosedative
interview revealed she feared painful injections is now on the
"firing line" - the first clinical encounter in which the injection
will be given.
Doctor: "How are you feeling this
morning?"
Patient: Fine, thank you ... I'm a lot
less nervous about the shot than I was before we talked, but I'm
still somewhat nervous."
Doctor: "Well, I would
expect that ... but I think you will learn today to be a lot less
nervous than you are now. As I told you I am confident that I
can give you an anesthetic with very little, if
any, pain. Should you feel anything I think it will be
something you will be able to handle very well. I will keep
you informed as we go along as to what you can expect ... I will be
responding to you and between us I feel sure you will develop a new
set of feelings. Okay?"
Patient:
"Okay."
Doctor
: "Is there anything else you would
like to talk about?"
A combination of
manual and communicative techniques are involved in order to carry
out, as succinctly as possible, the promise of an atraumatic
experience with this injection. Although we are using the
injection as a model, this
concept should be carried out in all aspects of
clinical treatment. Each doctor must develop his own
style of iatrosedative behavior.
The
Manual Component (Infiltration) The
syringe is prepared beforehand with a needle that has been tested
for sharpness and a warm cartridge. It is kept out of sight
behind the patient, to be passed over the shoulder below the line
of vision. The objective of penetrating the tissue noiselessly
and painlessly (or with the minimum amount of
pain) is achieved by:
-
painting a topical at the
site of penetration (in this case the reflection
of the alveolar mucosa);
-
making the mucosa as
taut as possible by pulling the lip or
cheek out without discomfort;
-
establishing
a firm finger
or hand rest to provide maximum stability and
control of the syringe;
-
delicately penetrating the taut mucosa, the
bevel toward the tissue, to the depth of
the bevel (1-2mm) only
-
very slowly
injecting a drop or two of anesthetic. After a few
moments, penetrate 1-2mm and deposit a few more drops.
Move slowly into an anesthetized area until the
target area is reached.
This manual technique is combined with preparatory communication
in the following manner:
"I am going to put a surface anesthetic
on your gum to numb it so that you will be more comfortable."
This is said as you approach with the topical. The
mucosa is pulled taut with syringe poised to penetrate.
"I don't expect you to feel this."
The needle is inserted to the depth of the bevel,
stopped and a few drops injected. "Do you feel
it?" If the patient indicates that he does not,
the doctor answers: "Good, I will be injecting
very slowly ... it may take longer than usual. I won't be
using any more than the normal amount, but it will be easier for
you. Do you feel anything?" If the patient
indicates "No", reply: "Good."
If the patient indicates in any way that she does
feel something it is wise to respond by saying,
"I'm sorry, but I don't think you will feel
anything from now on. I will be going very slowly."
This is not said defensively, but merely to let the
patient know that you care.
These simple preparatory communications carry much more weight
for the patient than one would suspect. An interpretation
of what they may mean follows:
- Using a topical anesthetic communicates
the concern of the doctor and the wish to minimize pain.
- "I don't expect you to feel this" states,
I am about to inject and will do all I can to do it without pain.
- "Did you feel it?" I have already
started injecting and I want to know how it is with
you. This is a continuing involvement and I want feedback
from you.
- "I will be injecting slowly, no more than usual ...
etc." I am keeping you informed, explaining in case
you get upset because you may think I am using too much
anesthetic, etc.
Communications of this kind should be used consistently with all
operative procedures. The above interpretation of the doctor's
preparatory communications is based on feedback from patients with
whom these kinds of exchanges have taken place. A patient who
had stated that she was no longer fearful was asked why she felt
this had occurred:
Doctor: "What is it that permitted you to
overcome your fear?"
Patient: "Well, I think
when you first saw me I had this tremendous fear built up because of
my past experiences. I'd heard so many stories about the
amount of pain I would suffer with your work ... but I have to have
it done. I've suffered so greatly with other dental work,
surely I'll have mountains of pain with this. By the time I came to
you and with my own frightening experiences, the thing that calmed
me was your ability to work psychologically with me.
(Expertise and Recognition) First, knowing
my tremendous fear. I had made just a couple of
comments, you know, about one dentist and how I should have been
here many years ago. ("Hearing" and responding to
critical cues during the interview.) The method you used to
tranquilize me by words (Interpretation,
explanation, suggestion and commitment) logically,
something for me to accept within my fear, so strong that I
automatically began to relate and listen to what you had to say
instead of closing my mind; logically you approached me and
tranquilized me...I don't know how else to explain it. In
other words, the very words that you used put me at ease enough to
say, 'listen, maybe he is telling the truth...' and I gained
more confidence as you talked to me ... as you
explained. (Trust developing) I felt very
confident; then when I came in for the surgery, I only had a slight
apprehension. (Iatrosedative interview dropped fear
level, but was still higher than normal) Yet I
figured I might suffer the tortures of the damned ... but I felt no
pain whatsoever."
Doctor: "Well, you were very apprehensive
predicated on past experiences. You say the words that I used
... what words?"
Patient: "You were willing to
go out on a limb in telling me what to expect from what
you were doing. (He made clinical preparatory
iatrosedation communications so that she would know what sensations
she may feel, thus minimizing the fear of helplessness and the
unknown.) You have a habit of saying in
advance "You may feel this, but it will not
be very much if anything, " "you will feel pressure but no
pain." This in itself, when the surgery began, is the
thing that puts your patients at ease ... because every time a
dentist picks up an instrument, just like everybody else, they want
to run away ... because he sees you picking up all kinds of
things. He doesn't know what you are going to do ... and
it's the not knowing that upsets the patient."
("Knowing" lessens the fear of the unknown.)
DOCTOR
STATEMENTS:
- "I can understand why you would be
afraid of injections ..." Support, respect,
empathy.
- "It seems to me that you
couldn't trust that doctor to protect you from pain. You
were depending on him but he didn't seem to want to help
you. These feelings still exist within you and you are still
feeling today the same terror and distress you felt as a
child." Interpretation and explanation of
why the patient is still fearful years after the original
events.
- "But you can unlearn and learn a new
set of feelings based on our relationship."
Suggestion and a promise of a new and different kind of
relationship.
- "Let me tell you how I think things
will go. First, I am confident that I can give you an
injection with very little, if any, pain. If there is some,
it will not be enough to be upsetting."
Beginning of the commitment. This offer is
based on the ability to give injections in that way. To
promise what you cannot deliver would be disastrous.
- "I will keep you informed at all times
..." This to dispel the fear of the
unknown.
- "If you feel any concern or discomfort
I will stop. I will not do any treatment until you are ready and
the area is numb." This to dispel the fear of
helplessness and dependency and to create some sense of control
for the patient ... as well as a sense of trust.
- "I know from past experiences that you
can learn not to be afraid." Suggestion that
the patient can learn not to be afraid is coupled with the
assurance of the doctor's knowledge and
expertise.
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