Euphemistic
Language The term "euphemism",
derived from the Greek EW (well) and Phanai (to speak), originally
meant "to use words of good omen." The definition of euphemism
as we know it today is similar; it is the substitution of a
mild or inoffensive expression for one that may offend or suggest
something unpleasant. With respect to dentistry, the use of
euphemisms
is particularly
indicated in place of:
-
fear-provoking or threatening words, and
-
technical terms
The use of threatening and technical
language is a frequent barrier to communication between doctors and
patients. It either creates apprehension and confusion or
intensifies them if already existent. In order to prevent
potential problems that can result from the use of
emotionally-charged language (with which dentistry is richly
endowed) or technical jargon, the doctor must develop alternative
methods of
communicating potentially
threatening information to patients.
Euphemistic language should be used with all
patients. Since it tends to minimize anxiety, it is an
integral part of iatrosedation. An example of its use may be
seen in the communications used above for the atraumatic
injection. Although these preparatory and explanatory
communications are very brief and quite simple, thought has been
given to substituting low threat words for threatening ones and
non-technical for technical ones. For example, few lay people
know what a topical anesthetic is, hence it is referred to as
a surface anesthetic. Instead of saying "This won't
hurt," the phrase used was, "I don't expect you to feel
this." "I will be injecting slowly" is replaced
with "I'll be doing it slowly." since some people may have
disturbing imagery stimulated by the word "injecting", particularly
if the
injection is
the primary fear problem.
These simple euphemistic substitutions are
not earth-shaking. Most dentists seem to be aware of the many
threatening words and terms with which the dental vocabulary is
laden: drill, needle, shot, cut, clamp etc. What is
consequential is the decision to avoid these words, to replace them
with euphemisms and to develop the constant, ongoing vigilance
required to avoid falling into the trap of being verbally
threatening. When one considers the dilemma of describing, in
non-threatening terms, a pulp tester and its use to an anxious
patient, one realizes how
euphemistically agile
the dentist must be!
It is necessary to maintain the
iatrosedative posture in all phases of involvement with your
patient. Another communication principle for reducing threat
in what might be a threatening situation is
the use
of a Preparatory Interview.
Preparatory
Interview
The preparatory interview is a
brief interview conducted with the patient prior to performing a
treatment or diagnostic procedure for the first time with a patient
which could be threatening to him. The
objective is
to learn 2 things:
- Has the patient ever experienced this
specific procedure before (eg endodontics, injection, periodontal
probing, periodontal surgery etc.)
- How
does the
patient feel about it?
The general principle of knowing how it
is
with the patient before taking him into an area of potential threat
seems irrefutably sensible and sensitive. Preparing to use
potentially fearsome instruments or procedures with no knowledge of
the person's experience with
and feelings
about them seems illogical.
Let us assume that Mrs. X has successfully
shed her fear of injections. However, in the course of
continuing dental treatment it becomes apparent that endodontics is
required. Following the examination, the need for it had been
discussed briefly. How should Mrs. X be approached? If
the roentgenograms indicate that endodontics had been performed
should you assume that no problem would be encountered, tell her of
the need and proceed to refer her to an endodontist or set up an
appointment to treat her? Or should you learn something of her
feelings about having endodontic treatment? The obvious
answer to
an obvious question: yes.
Doctor: "Mrs. X if you
recall I had mentioned that you would need to have a root canal
treatment. The X-rays indicate that you have had this kind of
treatment. How did it go?"
Mrs. X: "Well,
(hesitantly) I really had a bad time with
it."
Doctor: "A bad time?"
Mrs.
X: "Yes, the tooth was very painful, it ached badly and
although the doctor gave me several shots, all of which scared me,
when he took the nerve out I almost died, it hurt so
much."
Doctor: "I can see that you did have a
bad time of it and I can appreciate how you must feel about
considering root canal treatment again. Fortunately, however,
we have a different situation now. You see, when the tooth is
very inflamed such as yours was last time, it is very difficult to
get good anesthesia. This is not the case with the tooth
now. As a matter of fact, no anesthesia
is needed
at all because ..."
The remainder of the discussion need not be
pursued here. The example is used to point out the wisdom of
exploring potentially threatening procedures
with the
patient before starting treatment.
Nonverbal Empathic
Strategy It was stated that the
iatrosedative interview
technique is
composed of 2 strategies:
-
a verbal fact-finding interpretive
strategy
-
a nonverbal empathic strategy
It was further stated that these were
separated for the purpose of discussion but the separation is
artificial, since verbal and nonverbal communications are in reality
inseparable. The crucial function of nonverbal communication
is the transmission of feelings. The major feelings to be
communicated to the
fearful patient
by the doctor are:
-
attentiveness and concern
- acceptance of the patient and his problem
-
supportiveness
-
involvement with
the intent to help
These feelings and nonverbal statements are
created through the process of listening, "hearing" what you
are listening to, then responding empathetically. Listening is
the act of turning your attention to another person and permitting
him to speak. "Hearing" is understanding what he is
saying. Although these are nonverbal behaviors, they were
discussed as part of the verbal fact-finding strategy because the
"hearing" is a prerequisite for responding by facilitating the
telling of the story, offering support and commitment.
Reflecting and reacting to the patient's feelings and story by face,
voice and body is
responding nonverbally
to what one "hears."
The principal factor in listening is being
attentive. This requires concentration, discipline and the
intentional use of your behavior.
Attentiveness is
communicated in 2 ways:
- Through your physical presence (physical
demeanor and posture)
- Through your psychological presence
("hearing" the total communication of
the patient,
both verbal and nonverbal.)
Physical Attending
Skills The skilled use of one's face,
voice, and body will result in a posture of involvement. This
is the medium that will communicate whether you really are or are
not involved with your patient. The nonverbal signals you send
out will either verify your words of
concern and
support or belie them.
Man's richest sign system is his head and
face. The voice and body have almost as much value as the face
in the the wordless communication that plays such a powerful role in
the creation of an empathic climate in which the doctor and patient
will interact. There are many components of nonverbal
communication. Some of
the significant
ones considered here are:
-
Eye contact
-
Facial expression
-
Vocal characteristics
-
Body orientation
-
Trunk lean
-
Proximity (distance)
Haase and Teffer carried out research on the
nonverbal components of empathic communication. The intent of
the study was to explore the relative contribution of verbal and
nonverbal behaviors to the
communication of
empathy. Their findings were:
- A verbal message of medium empathic value
can be altered favorably by maintaining good eye contact, forward
trunk lean, good body orientation, and good distance.
- Conversely, high levels of verbal empathy
can be reduced to unempathic messages when the communicator utters
the message without eye contact, in a backward trunk lean, rotated
away from the
addressee, and
from a far distance.
These findings add to the existing knowledge
of the power of nonverbal communication,
colloquially alluded
to as "body language."
Eye
contact Eye contact is a
crucial key in the communication system. It is virtually
impossible to create a sense of attentiveness and interest in a
person if you are not looking at him. "Looking
at him"
means making eye contact!
This mutual looking tends to increase when
the participants like each other and when they are involved in their
interaction. It lessens when touchy subjects come up or
unpleasantness develops between the interactants. A
"noncollision course" is taken, a lowering of the
eyes, a
"dimming of the lights."
Good eye contact does not mean staring or
constant eye contact. This is very disconcerting. It
should be varied. You should permit your eyes to drift to an
object not too far away and then return to the patient. As in
all nonverbal behaviors, this should be done naturally, in a
relaxed, comfortable manner. The eyes contribute to the facial
expression in many ways. For example, in smiling, they can
either lend warmth or put a chill on the smile. If when the
mouth expresses a smile and there is no expression around the eyes,
the smile
tends to be "icy".
Facial
Expressions The face can be the
best expression of emotions but it can also be a superb mask.
However, it is the most difficult of our nonverbal behaviors to
monitor. We are aware of what our eyes are doing, how our
voice sounds, what movements we make, but the face is the one
expressor from which we get no feedback. Hence, it is the most
vulnerable area of our behavior. Many doctors avoid facial
risks by wearing a noncommittal mask, a sort of professional "poker
face." Generally, unless one has learned to pay attention to
his nonverbal communications, he is almost totally ignorant of his
facial behavior. Consequently he may be sending signals
facially that he doesn't intend to, or may be inadequately
expressing
what he
would prefer to say.
Facial expressiveness in skilled attending
is used in 2 basic ways: (1) to send messages and (2) to respond
appropriately to messages being received. When the doctor
turns his attention to his patient at their first meeting, the
facial signals most people would like to see are warmth, interest
and alert intention of being involved. Facial responsiveness
should mirror the feelings of the patient to varying degrees;
that is, concern should be reflected by concern and not by apathy, a
faint smile or exaggerated interest. The face is an instrument
of wide range from broad to very subtle communication, some almost
imperceptible. It is wise to remember the admonition, "Be
careful what you say with your face when talking with your
mouth!"
Vocal
Characteristics The voice can
be used like a musical instrument. It alters the meaning of
words, either giving the lie to them or making them ring true.
In our culture, we ascribe certain characteristics to voice
sounds. The voice of authority generally is characterized as
being low in pitch, resonant and used with measured tempo. A
fast, high-pitched, squeaky
voice is
often associated with immaturity.
In attending, it is desirable to speak at an even
tempo with moderate volume, at as low a pitch and with as much resonance
is consistent with your voice. There should be variations
of these qualities to reflect and support the meaning of the
words. Above all, one must be on guard to avoid mixed messages
wherein the voice and the face are saying something different
than the words. One of the most common examples of a
mixed message is that conveyed by the doctor who, hoping to assure
the patient, ways with disinterest in his voice and looking away,
"Don't
worry, everything
will be all right!"
One of the more penetrating studies
performed to determine which message is dominant when 2 incongruent
ones are sent was done by Mehrabian. He set up situations in
which the facial and vocal expressions were in conflict with the
verbal messages. His conclusions indicate that in the
communication of feelings, the words were responsible for only 7 %
of the impact, the vocal expressions produced 38% of the effect, and
the facial expressions 55%. Hence, if your face and voice do
not match your words, you would best say nothing! On the other
hand, the verbal promises of help and protection assume greater
significance if supported by empathic nonverbal communication.
In short, it is how something is said, not what is
said that
builds or destroys relationships.
Body
Orientation Facing patients
squarely tells them that you intend to pay attention. If you
sit with your body rotated away from the patient, you are "turning
away", thus creating an atmosphere of inattentiveness. This
inattentive orientation is intensified if your position is at a 90
degree angle or less. In addition, such a position makes
good eye
contact difficult and strained.
If the interview is taking place in the
dental treatment you should be in a position between 7 and 8
o'clock. Should you use your consultation room it would be
preferable not to sit behind a desk. Two armchairs can be used
in approximately the same position as above. In my opinion the
interviews would take place in the treatment room. If the
patient is fearful, the operatory may stimulate the expression of
anxiety in which case the issue is confronted. Sitting
comfortably in a consultation room, which tends to be a more relaxed
and social environment, provides
little provocation
to discuss one's fears.
Body Distance or
Proximity How close one sits in
a situation such as we are discussing influences the
communication. The degree of proximity engenders different
feelings in different cultures. Hall reports that most
Americans tend to deal
with space
in the following way:
- Intimate zone: ranging from contact to 18
inches. This is the zone for handling secrets and whispered
conferences.
- Casual-Personal zone: ranging from 1+1/2
to 4 feet. This is the region for normal personal
interaction.
- Social-Consultative zone: ranging from
4-12 feet. this is the area for handling impersonal
business.
- Public zone: ranging from 12 feet to the
limits of hearing. This is the region of
the public
speaker addressing an audience.
A distance between 3+1/2 to 6 feet is
appropriate when conducting the interview in the dental
operatory. The distance will vary depending on your comfort
with the patient with whom you are interacting. The more your
interest rises, the closer you will tend to be. As with eye
contact, facial expression and body orientation, there is the matter
of a dynamic process; that is, you should not be fixed and
rigid about any of these physical attendance components but
maintain a
moderate degree of fluidity.
Trunk
Lean A forward lean is a
powerful message of interest. Somehow it is difficult to be
indifferent while leaning forward and listening to another
person. The forward lean of the body is an eloquent statement
of attentiveness. The reverse of this, leaning backwards and
folding one's arms, is a statement of casual interest
at best
and inattentiveness at worst.
The trunk lean is an effective
facilitator. If a patient is speaking and pauses, merely
leaning forward slightly will act as a request to "tell me
more." Not only does it act as the body language of "tell me
more",
it also
indicates interest and empathy.
Another of the many components of "body
language" is tactile communication. During an interview,
support, concern, and empathy can be conveyed by touching the
forearm of the patient. This is the most acceptable and least
intimate area of the body for tactile communication. Needless
to say, in the clinical encounter tactile communication is
constant. The delicacy or roughness of one's "touch" conveys a
great deal of information to the patient about the doctor's presence
and, more significantly, the
doctor's awareness
of the patient's presence.
SUMMARY
Fear is a major
cause of avoidance of dental treatment for millions of people.
Some of the common dental fears and how they originate are
explored. What is presented here is a technique to treat fear
with interpersonal skills utilizing simple behavioral
principles. The goal is to either eliminate the fear, or to
reduce it to a level that permits the patient to
cope successfully
with the dental experience.
This technique has been termed,
"Iatrosedation" and is defined as the act of making calm by the
doctor's behavior. The
2 major
categories of iatrosedation are:
-
The Iatrosedative Interview
-
The Iatrosedative Clinical Encounter
The Iatrosedative interview is
designed to initiate fear reduction through a relearning
process. It is brief and economical, usually lasting no more
than 10 minutes. The clinical encounter continues the process,
thus dropping the fear level further.
-END-
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Post
Script from Suzanne Boswell:
I hope that you have found this paper insightful and
personally helpful. I can attest from our work interviewing
patients that all Dr. Friedman has written is so valid and
meaningful to patients. Having personally come from the
position of being a very fearful patient since childhood, I know the
power that thoughtful and caring practitioners have to positively
change the lives of their patients. And I thank those
exceptional practitioners who have so helped me overcome my own
dental fears!
On behalf of
the fortunate patients who have benefitted by being treated by
students of the Iatrosedative Process, I thank Dr. Nathan
Friedman. He and his work have touched thousands. And I
also thank him for his friendship, support and his willingness
to share this paper with online readers.
I can assure
you that your patients will value each step you take toward
increasing their confidence in accepting the treatment they
need. That in itself is fulfilling. You will also
benefit by a very loyal, responsive patient base who refer friends
and family to such a caring practitioner.