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	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. Click here to view part 4 (of 4) of this paper Suzanne Boswell Presentations -  12108 Amoretto Way, Raleigh, NC  27613  USA Phone: 919-845-4189   -    Fax: 919-845-4188  Email : Suzanne@BoswellPresentations.com Website: www.BoswellPresentations.com