What To Do When Your Patient Cries

Author: Michael A. Harvey, Ph.D., A.B.P.P.

One day my patient, a physician, began our psychotherapy session with the following question: “Did you know that emotional tears have high levels of prolactin, adrenocorticotropic hormones and leucine –enkephalin that are produced by the anterior pituitary gland?”

“Gee, I had no idea,” came my admission. “But why are you asking me that?” He then recounted that his patient “broke down in tears without warning right in front of me in my office and I didn’t have any idea what to do.” His anxiety was palpable. He was obviously much more comfortable with organic chemistry.

Like physicians, many audiologists have no requisite training for what to do when their patients cry. But for many patients, a hearing evaluation triggers a slew of raw emotions associated with years of feeling short changed personally and at work, missing words and conversations, anxiety and fear about inadequacies, loneliness, etc. The resulting affective eruption in the office typically blindsides both the patient and audiologist. Consider the reports on the right from audiologists about their internal reactions to their patients crying:
What Not To Do
Patients with hearing loss often tell me, as their psychologist, about how their audiologist responded to their crying during an office visit. The following patient reports exemplify general guidelines for what not to do:
  • “Ya know what Dr. Smith did when I became tearful after he told me about my son’s hearing loss? He told me to see a shrink!”
  • “He put his arm around me and made me feel very uncomfortable.”
  • “She immediately listed all the positives a nd made ME feel like a baby.”
  • “She had the bloody nerve to tell me, ‘I know how you feel.’ How the hell does she know?”
  • “She told me to stop crying.”
  • “I felt guilty because he started to squirm in his seat.”
  • “He had the nerve to tell me not to be anxious or depressed.”
Note that these are general guidelines and, as such, cannot be applied universally. For example, it may sometimes be helpful and appropriate to suggest therapy even when a patient first cries, to put your arm around a patient, to list positives, etc. Individual judgement and timing are critical. But the default goal should not be to prevent or curtail crying. Although our natural instinct may be to do something that will stop patients from crying, to relieve their suffering, not only is that often impossible, it is not necessarily what patients need. As New York Times reporter Benedict Carey put it,“After a good cry, I always feel cleansed, like my heart and mind just rubbed each other’s backs in a warm bath.”

What To Do
The following patient reports exemplify general guidelines for what to do when a patient cries:

“She didn’t rush me out of the office.”
When patients are emotionally dysregulated, it is particularly important not to impose stringent time constraints. Naturally, this caveat must be balanced with managing your appointment schedule. One technique is to use bounded open-ended questions. For example,“This is hard stuff, I know, but can you give me at least a glimpse of how you’re feeling in the few minutes we have together?” Delicately introducing the limited time factor also helps ensure against unbounded, affective flooding – aka opening up a can of worms.

“When I told her in between sobs about my son’s hearing loss, that doctor really wanted to hear my story.”
Many health care professionals minimize the transformative power of “just listening” and sitting with patients as they painfully share their stories of loss. Many years ago, a group of journalists went to Haiti to do a report about the AIDS epidemic. When they exited the helicopter, they were swarmed by hundreds of natives who were infected with the AIDS virus. The natives knew the reporters had no medical authority, no cures — only the power to hear their story. In times of crises, we humans have a need for another caring person to hear – to bear witness to – our story. In some ways, it’s that simple.

“When I teared up, he asked me what I was feeling without making assumptions.”
It is important not to assume you know what a patient is feeling even when it seems obvious. For example, at first glance, saying to a patient, “I can see from your tears that you are sad” seems like a safe assumption in service of rapport–building. However, it may be fallacious, as fear, anger, and shock all produce tears. I recall saying to a patient who was screaming at his wife: “You look angry,” to which he indignantly replied, “No, I’m pissed off!” Moreover, ironically, even if you correctly discern a patient’s feelings, s/he may be experience a boundary violation. One patient complained, for example, that “It’s my right to tell him how I feel!” Perhaps had I asked the screaming man whether he was angry, he wouldn’t have felt the need to scowl at me and counter my observation.

“He assured me that crying is a normal and a healthy part of grieving a loss.”
Validation is important. It is the recognition and acceptance of another person’s thoughts, feelings, sensations, and behaviors as understandable. Humor can also be helpful. I once remarked to a patient who was embarrassed about crying over her terminally ill husband, “Hey, it’s not like you’re crying about the Red Sox losing last night. It makes sense that you’re crying.”

“She was impressed with my strengths; that, despite my emotional ups and downs, I’m getting treatment!”
It’s important to praise patients for their strengths and resilience, particularly if they feel weak for crying. When a patient is embarrassed about crying, I may recite Frank Perdue’s chicken slogan that “It takes a tough man to make a tender chicken.”

“He let me cry!”
It is easy to forget the inherent power imbalance in the audiologist–patient relationship in that patients feel dependent on the audiologist’s expertise. The phrase “He let me cry! [emphasis added]” implies that, on an emotional level, the patient felt grateful and beholden to the audiologist for permitting her to cry. This dynamic easily becomes entangled in a patient’s need to appear unemotional in order to impress the HCP. I recall one patient stating that “I wanted to burst out in tears in his office, but I couldn’t do that because he already thinks I’m a basket case.”

“He was supportive without being overbearing.”
The challenge here is to resist doing more. Just be there. In the words of Ram Dass, a spiritual teacher, “The quieter you become, the more you can hear.” One audiologist reported that when a patient cries,“Sometimes, patients don’t need words, they just need to know someone is there. I would just sit there and be quiet and ask if the patient would like to talk about it a bit. I let the patient lead me to what I should do, and I follow my heart about what’s right.”

“She asked me if I was ready to hear a treatment plan and assured me of her commitment to help.”
When patients become emotionally dysregulated, it is often important to use fewer words, particularly when discussing loaded topics, such as your diagnosis and treatment plan. It is often important to ask if a patient is ready to take in this information, as emotional dysregulation impairs concentration. Moreover, asking patients for their permission to discuss a topic gives them some control, in contrast to feeling barraged by loss that is uncontrollable.

This article suggests that there are therapeutic benefits for patients crying in the office, even though the audiologist is not conducting psychotherapy. It would be remiss not to add that there are also unintended, therapeutic benefits to the audiologist. In the words of one audiologist, “Our connections with persons coping with hearing loss through humor, love, and pain contribute enormously to our growth as individuals, add complexity to our lives, and increase our capacity for empathy and understanding. Sharing joy and sorrow, laughter and pain, wisdom and ideas with another person is at the heart of what it means to be human.”

Bottom Line
The proper management of crying promotes patient hearing care. A patient recalled when she first saw her audiogram: “I felt my tears welling up and immediately apologized. But then Dr. Smith said, ‘This can’t be easy.’ His four simple words were chock full of compassion. ‘No, it’s not easy,’ I responded between sobs. I shook my head and out came a torrent of tears.”

“How did that feel? Did that change your relationship? Maybe even how he could help you?” I was full of questions.    
Dr. Michael A. Harvey may be contacted at mharvey2000@comcast.net.
The First Interview
The first interview with a help-seeking patient is a little like a first date. Both parties – the clinician and the patient – know a little something about the other, but not enough to feel comfortable with each other. A primary task of the clinician during this uncertain opening moment of an appointment is to help everyone in the room feel comfortable enough with each other to continue the relationship.

The key to creating a trusting relationship between the professional and the patent (and their companion) rests with the clinician’s ability to communicate a genuine warmth and hospitality. The ability to communicate in this manner is determined largely by cultural norms. For example, there are differences in how you greet a patient in the Deep South compared to the upper Midwest. In the South, cultural norms warrant a stranger is greeted like a long lost friend, while that same avuncular greeting in the upper Midwest is likely to be perceived by the patient as cloying and insincere. Observing these unspoken cultural norms of your community helps put patients at ease because these behaviors introduce the familiar into what is usually for the patient an uncomfortable and anxiety-ridden situation.

At the same time, it is imperative for the clinician to maintain an aura of professionalism. After all, the patient will be relying on the clinician to guide them through the process of understanding their condition and treatment options. It is the clinician, not the patient, who is an expert on diagnosis and treatment. But, on the other hand, it is the patient who has been coping with the consequences of a “problem” for a period of time. In order to be effective, the clinician must keep a certain amount of emotional distance. This duality – being warm and hospitable, yet maintaining professional distance may be one of the most difficult challenges faced by clinicians.

Like the first few minutes of a blind date, both parties are uncertain and vulnerable. The first few moments of eye contact and banter are crucial. During those first few moments, there is no guarantee that the relationship between the patient and the clinician will develop. If the clinician, however, is cold and distant, or takes an approach that is perceived as too businesslike, the first few minutes will mean the reasons the patient sought help with a communication problem never get addressed. Genuine warmth and caring can be shaped and developed, but at its core these traits are innate.

Source: Basic Counseling Techniques: A Beginning Therapist’s Toolkit. By Wayne Perry