From the Desk of Gus Mueller
Most of you do not remember, or have never heard the name Morris Albert. I’m betting, however, that you can sing a few bars of his popular 1975 hit tune, which just happens to the be topic this month at 20Q.
In the old days, many future audiologists started their training in communication disorders, which had a heavy emphasis on speech-language pathology. After receiving our bachelor’s degrees, it was common for most of the class to continue on in speech, but a few of us veered to the left, to obtain a degree in audiology. While there was no secret club (that I know of), during the senior year it became pretty obvious what students were heading down the audiology road—they were a little “different” than the others.
Most of us who made this decision viewed audiology as a world of diagnostics, and this was very attractive, as it was much more black and white than the shades of gray we had experienced in speech pathology. We used our knowledge of anatomy, physiology, math and science to make objective decisions. There was a sense of exactness—the patient’s threshold was 50 dB, not 45 dB, not 55 dB, but 50. And, rather than interacting face-to-face with the patient for 30 minutes or more, week after week, which is typical in speech therapy sessions, we spent 90% of the encounter time in a different room than the patient!
This month’s 20Q is about counseling. Experts have stated that a good counselor should have passion, empathy, patience, compassion, genuineness, self-awareness and . . . feelings. Certainly all admirable traits, but one could argue, maybe not consistent with those of a professional who chose to spend most of his or her clinical time physically separated from the patient. To discuss this topic, we’ve brought in a counseling guru, David Citron, III, Ph.D.
Dr. Citron certainly has had the opportunity to hone his counseling skills, as for over 30 years he operated his own private practice, South Shore Hearing Center, south of Boston, MA. Today he is the CEO of David Citron and Associates, an audiology practice management firm.
Over the years, David also has been very active in professional organizations. He was one of the original 32 founders of the American Academy of Audiology, and has served on many task forces and committees for this organization. He was the president of the Academy of Doctors of Audiology, and it was during his tenure that the implementation for the Doctor of Audiology (AuD) was developed.
In his excellent 20Q article, Dr. Citron points out that audiologists are pretty good at content counseling, where we deal with technical aspects that are information-based. He adds, however, that often we are not very good at managing the patient’s affect, or feelings. Feelings are the major factor that make patients sense that they are connected to us. That’s right, what Morris Albert wrote about in 1975, “Feelings.” Dave provides a road map of how we can improve in this area, to become more effective counselors, which will then naturally lead to better overall patient care.
Gus Mueller, PhD
Browse the complete collection of 20Q with Gus Mueller CEU articles at www.audiologyonline.com/20Q
20Q: Effective Counseling = Information + Feelings
After this course, readers will be able to:
- Define counseling as it applies to hearing care practices.
- Explain typical psychological barriers an audiology patient may manifest and how those barriers may impact the management program recommended by the audiologist.
- Describe principles and microskills of motivational interviewing and how they may apply to hearing care.
- Identify when patients may be moving toward change and respond using techniques of motivational interviewing that support and facilitate that change.
1. Counseling seems to be “battered around” as it applies to audiology. What is your take on this?
A common mistake made by audiologists is to define counseling as providing information as part of the hearing/balance evaluation or hearing aid orientation process (Citron, 2008). This misconception is not unusual, as many dictionaries provide the same ambiguity in defining counseling and orientation. The American Heritage Dictionary of the English Language (1992) and Webster’s New Twentieth Century Dictionary (1996) define counseling as “advice or guidance, especially as solicited from a knowledgeable person.” Orientation is defined as “an adjustment or adaptation to a new environment, situation, custom or set of ideas; introductory instruction concerning a new situation.” Merriam-Webster’s Collegiate Dictionary (1993) defines counseling as “professional guidance of the individual by utilizing psychological methods, esp. in collecting case history data, using various techniques of the personal interview, and testing interests and aptitudes,” whereas orientation is defined as “to set right by adjusting to facts or principles; to acquaint with existing situation or environment.”
2. Those definitions sound reasonable to me. How can we better define counseling? What’s missing?
The “psychological” component. We are very good with “content counseling” (Clark & English, 2004) where we deal with technical aspects of care that are information-based. Examples include explaining outer hair cell damage, providing the nuts and bolts of candidacy for bone anchored hearing aids, and orienting patients on the use of their telecoils or streaming features. The mistake audiologists make in most situations is that they see their task as just supplying information—hard, cold facts and descriptions. They want to be Dr. Informative. However, we often are not comfortable managing patient affect or feeling statements.
3. Why is affect so important?
Affect or feelings are the major factor that makes patients feel connected to us. With any health care provider, patients respond positively to having their feelings acknowledged and validated. It is the most critical skill in clinical care because it reflects the patient’s affective experience in relation to their worlds. Patients are looking for the meaning behind the information (Carkhuff, 2014). They want more than just the facts. And you need to create the right situation to allow that to happen.
4. Situation? Are you referring to the office environment?
Yes, patients must have freedom and safety to share their feelings and thoughts. Front office staff must be welcoming and patient friendly. Physical attending is an important building block and involves undivided attentiveness. This involves making eye contact (more challenging now with electronic medical records), squaring by fully facing the patient, and leaning forward so our forearms can rest on our thighs. Cell phones must be silenced. Chairs need to be comfortable and have arms. Examination rooms must be neat and respect privacy.
5. Are patients always open to this type of counseling?
Not always. Denial is a common initial reaction if one is faced with a threat to their physical or emotional health. It is a means to “stall for time” to build up the necessary emotional energy to come to grips with their problem. The slow progressive nature of hearing loss can make denial an easy alternative because the change in hearing sensitivity is so gradual that it is frequently not noticed by the patient. Denial is not limited to hearing loss.
Most studies find that about 50% of the people with serious mental illness do not take their medications (Amador, 2012). The most common reason is poor insight into illness. They are not aware that they are ill. Amador and colleagues (1994) studied over 400 patients with psychotic disorders all over the United States. They found that nearly 60% of patients with schizophrenia, about 25% of those with schizoaffective disorder, and nearly 50% of subjects with manic depression, were unaware of being ill. This is more than just poor insight. Amador (2012) found another critical factor at play in this population; many of these patients with serious mental illness manifest a condition called anosognosia, where they are unaware of deficits, symptoms or signs of illness. Often, these patients stop taking their medications, as the medications cause them to “feel fine”, and they perceive they are “cured.”
Projection is another avoidance action and involves shifting the focus of the hearing loss to another person or condition. A common example of this is the patient who states “I hear fine, people mumble, especially my wife and daughter.” They may also blame the room acoustics or TV speakers for not being able to comprehend speech on television. This defense mechanism is similar to denial in that the erroneous lack of awareness of the slow, progressive nature of hearing loss can lead to projection. The underlying psychological behavior is that nothing is better than a good scapegoat to avoid solving a problem.
Ambivalence is quite common in a myriad of health conditions such as obesity, need for exercise, diabetes compliance, alcohol use, smoking cessation and hearing loss (Rollnick, Miller, & Butler, 2008). People typically feel ambivalent about change, especially for change that is positive for them in some fashion. Ambivalence is a normal process of thinking about the pros and cons of making a change. Most patients want good health and want to act positively in the interest of their health. On the other hand, most people are very content with their regular habits and there are downsides to change. These can be the significant side effects of some treatments, the pain of physical therapy following surgery, or the perceived stigma of wearing hearing aids. The result is that patients feel “stuck” in that they want or do not want change, or they want incompatible things at the same time. It is normal to have this conflict. Most patients are aware of the positive reasons for the behavior change we have in mind (using amplification/assistive technology). It is also likely that patients also enjoy the status quo (turning up the TV; asking to have things repeated).
6. What are some examples of ambivalent statements that people with hearing loss might use?
- I know I need hearing aids, but I just can’t seem to do it.
- I want to hear better, but my cousin’s hearing aids whistle all the time.
- I want to try hearing aids, but I hate the thought of people noticing them.
The easy indicator of ambivalence is the “but” in the middle. It is as if the internal disputes on either side of the “but” cancel each other out so that nothing changes.
7. Where is a good place to start in managing patient denial, projection and ambivalence?
As these behaviors are quite common in health care, a broad variety of management and treatment strategies exist, with most coming from our partners in psychology (Rollnick, Miller & Butler, 2008; Amador, 2012; Carkhuff, 2014). Rollnick, Miller and Butler (2008) describe Motivational Interviewing (MI), a comprehensive guiding style to behavior change as opposed to direct persuasion.
8. What are the main principles of motivational interviewing?
Rollnick, Miller and Butler (2008) use the acronym R.U.L.E. R=Resist the Righting Reflex; U=Understand Your Patient’s Motivations; L=Listen to Your Patient; E=Empower Your Patient.
R=Resist the Righting Reflex. As audiologists, we are wired with a strong desire to help people and make a difference. When patients are headed in the wrong direction, we have an almost automatic reflexive motivation/impulse response to try to intervene and steer a patient into a better course. “You have a significant sensorineural hearing loss. Hearing aids will really help. Let me put these demos in your ears so you can hear the difference.” This is a praiseworthy motivation; it is part of the call to make a difference and do what is best for the patient.
The problem is that this response can often produce a “pulling back” behavior. It is not because of any major flaw on the part of the patient. There can be a natural tendency to resist persuasion, particularly for those who are ambivalent about something. Many patients know they have a hearing loss, but do not see themselves as “broken.” They will often pull back and say “It is not that bad and I am doing fine.” Our tendency in these situations is to argue more forcefully and pump up the volume. The patient’s reaction to this is typically negative and predictable. In MI, the patient should be the one voicing the arguments for change.
U=Understand Your Patient’s Motivations. We DO NOT motivate the patient. Motivation comes from within the patient. This involves being interested in the patient’s motivations, concerns and values. In MI, one explores the patient’s perceptions of their present situations and their own motivations for change. A common complaint is that this process is too time consuming, but it can be done well within the timeframe of the typical consultation session. The key factor in limited consultation time is to seek information about goals, aspirations and beliefs. Then explore how these relate to their present circumstances, followed by directing the patient toward the discrepancies between what they want and their present circumstances.
L=Listen to Your Patient. MI is geared toward spending just as much time listening as informing. The typical consultation involves expectations that the audiologist has the answers and will supply them to the patient. Frequently, we do have the answers and patients seek us out for our expertise. Behavior change is a very different story where the answers lie within the patient and finding them involves good attending as well as a safe and free listening environment.
Good listening is a multifaceted clinical skill that requires much more than just asking questions and remaining quiet to hear the patient’s reply. Empathy and interest are critical in understanding the patient and making summaries about meaning. Look at it through the patient’s eyes. A good statement can be: “That makes sense - I can see why you view it that way.” This involves acceptance, but it is not agreement or approval.
E=Empower Your Patient. Outcomes become better when patients are committed to taking an active interest in their health. We know that exercise is important, but having the patient strategize building it into their daily life is the key. An example in tinnitus management is empowering the patient to integrate all the items in their tinnitus management “toolbox” when they are having a bad day. Patients become your consultants on their own lives and how to accomplish behavior change.
9. I understand the concept, but it seems like this style requires some microskills.
It does, and they are best described by the acronym O.A.R.S. (Rollnick, Miller, & Butler, 2008). “O” stands for open-ended questions. These are designed to encourage a full, meaningful answer from a patient using their own knowledge and/or feelings. This is an invitation to talk. It is the opposite of a closed-ended question that encourages a one-word or short response.
10. What are some good examples of open-ended invitations to talk?
“What brings you in today?” “What’s on your mind?” “How can I be of service to you?” “What would you like to talk about today?” “How would you like to begin?”
11. What about closed-ended questions - aren’t they important?
Certainly. Closed-ended questions are important to gather important case history information (tinnitus, vertigo, familial loss, middle ear disease, acoustic trauma, etc.). The problem is that one-word/very short answers slow down the process and make it harder to keep the session momentum going. The best idea is to mix the open and closed-ended questions and build in a much greater proportion of open-ended questions.
12. What types of open-ended questions can follow the invitation to talk?
“What do you already know about hearing aids?” “What listening situations are most challenging?” “What kind of things do you do now for relaxation?” “What are your hobbies/favorite activities?” “How has your hearing loss affected your life?” “Describe for me your typical day/week.”
These types of questions leave plenty of room for your patient to talk about what is on his/her mind, and puts the responsibility for moving the conversation along on your patient’s shoulders rather than on yours. The answers to open questions often reveal details of a problem or direction to go that you might not have thought about, and help to keep the session momentum flowing.
13. Back to OARS—What about the “A”?
“A” stands for affirmations. These statements are anything positive that is noticed about a patient. They serve to develop a sense of self-confidence and are very helpful at building the counseling relationship. They can include awards, attempts, prior successes, accomplishments and achievements. Some examples are: “Thank you for coming in today and choosing us as your audiologist.” “You have tried hearing aids in the past. Thank you for your continued commitment to improving your life.” “It’s a real plus that you have worn hearing aids in the past.” “I see from your history that you were in the marines. Thank you for your service.”
14. And the “R?”
It is reflective listening. This is the most important skill in MI and any type of personal adjustment counseling. It involves understanding what the patient is thinking and feeling, and then saying it back to the patient. It can be mixed with questions! They are statements made to the patient that mirror, give back, repeat, rephrase, paraphrase, or otherwise make manifest what you hear the patient saying or see the patient doing, such as smiling or looking sad, for example. That’s why skilled attending involves paying attending to facial expressions and body language.
Reflections are really guesses or hypotheses about what is going on in the patient’s mind and heart, so you are reflecting what you think the patient means by what he or she says and what you think your patient feels emotionally as well. Delivered confidently as statements with your voice inflection going down rather than up at the end. And they stand alone and don’t need to be followed by a question. The key to respond to feelings (the hardest part) is to ask yourself “If I were the patient, how would I feel?”
15. Do you have an example of how this might go?
Patient: “I love going to Rotary and my movie club. It irritates me that I have trouble hearing the program and discussion. People laugh at the punchline at the movies and I feel left out.”
Response: “Rotary and movie clubs are important activities for you. You feel frustrated and detached because it’s hard for you to understand the discussion and dialogue.”
Patient: “I hate the thought of wearing hearing aids. Everybody will notice them. Plus, my brother’s hearing aids whistle all the time.”
Response: “You are not happy with the idea of wearing hearing aids. You are distressed that people will notice them and treat you differently. Hearing them whistle is embarrassing.”
This conversation is a perfect example of ambivalence. Wanting and not wanting to make a change. The responses are good in that they reinforce the patient’s feelings.
Patient: “I don’t think I have a hearing loss.”
Response: “You are not sure about your diagnosis of hearing loss.”
Patient: “I don’t like my wife’s frustration of having the TV up.”
Response: “Having the TV up and your wife’s frustration are things you’d like to change. Tell me more.”
In this example, the audiologist reflects and then senses an opening to change based on the patient’s statement of dealing with his wife’s frustration.
16. What next?
Using the patient’s statements to tailor your response style. If a patient is in a highly emotional state, MI employs a following style. In following, listening is the dominating factor. It gives full attention to understanding the patient’s experience. There is no directing or instructing, agreeing or disagreeing, warning or analyzing. The purpose is to “follow” the patient’s lead with a reflective response. It is seeing and understanding the world through the patient’s eyes. This strategy is best employed with a mother who is in tears having just learned her infant has a severe hearing loss or a high priority tinnitus patient with extreme anxiety.
A guiding style in MI (the crux of its focus) is similar to a tour guide in that it helps you find your way. The guide does not have the power to decide what you want to see or do. You decide where to go, and the guide or travel agent assists to get you there. In managing behavior change, the guiding style says, “I can help you solve this for yourself.” Synonyms to describe guiding include “encourage,” “motivate,” “support” and “elicit.” This is a common style among audiologists, as we listen carefully to the needs of the patient, asks which options he/she is considering, and develop a treatment strategy. As is the case with a following style, guiding uses reflective listening. Some examples: (Listening): “You are feeling concerned about your hearing, and you are not sure where to go from here.” (Asking): “What kind of change makes sense to you?” (Informing): “Advanced technology hearing aids would make sense, but how does that feel for you?” A good guide is skilled at using listening, asking and informing interchangeably with a use of reflective attending.
Directing in MI is a style where the practitioner “takes charge.” A director basically tells the patient what to do with the thought that he/she has the expertise, power and authority to do so without any rationale. As much as this style can lead to pushback (“Beware the Righting Response”), there are situations where this style is useful. A patient who depends on you and expects a decision and asks “what is the best solution for me?” As well, it can be necessary to save lives. However, it is often overused and it often the result of the changes in health care that is action-oriented, where there is a rush to check off boxes, reduce costs and conduct standardized assessments. Most problems are solved by using a combination and balance of following, guiding and directing. It is typically better to employ a mixture of styles where you follow and consider a bit to support and guide before shifting to a directing style.
17. What clues are there that patients are moving toward change?
Well, I have one more acronym for you: D.A.R.N. (Rollnick, Miller and Butler 2008).
Desire is the first theme of change talk. It includes verbs such as “wish”, “want”, a “like”. Some sample statements are: “I like the idea of having easier listening on TV.” “I wish I could understand my grandchildren when they call me from California.” “I want to enjoy the sermons at church.” These type of statements reveal either a patient’s desire to change or to maintain the status quo. Always be on the lookout for the “but” or similar clue of ambivalence.
Ability tells us what the patient recognizes as being within his/her ability. The key verb here is “can” as well as the conditional “could.” A few examples are: “I could try walking by the river as a relaxing activity for my tinnitus.” “I can see myself trying hearing aids.” “I might be able to try wearing hearing aids when I have court cases.” There are different levels of motivational energy. “Can” communicates much stronger desire than “could” or “might be able.”
Reason can be also expressed for change. There are no real verbs but it can be combined with the above-mentioned desire statements. Some additional samples: “My hearing loss keeps me from going to Lodge meetings.” “Trying hearing aids would help me hear in church.” “I want to hear my grandchildren as they grow up.”
Need involves imperative language such as “must”, “should”, “ought to”, “need”, “have to”, and “got to.” Some examples: “I need to communicate in court”, “I ought to get hearing aids so I can hear my golf partners”, “I must keep going to my Rotary meetings.”
Be wary of ambivalence that can intrude into any of the four above-mentioned motivational themes. Almost always, this can be easily recognized by the “but” that patients can use during change talk statements.
18. What’s missing from the D.A.R.N. change talk statements?
They lead in the direction of change, but do not trigger behavior change.
To say “I can” is not the same as “I will.” To say “I want to” is not to say “I intend to.” What’s needed is agreeing to change rather than just expressing reasons to do so.
Commitment is the 5th form of change talk. The key verb is will. These include strong statements such as: “I will”, “I intend to”, “I am ready to” and “I promise.” It is important not to miss lower levels of commitment such as “I plan to”, “I hope to”, “I’ll consider it”, and “I will try to.” These can signal some doubt about the ability to change. Careful listening, reflection and guiding are beneficial to reinforcing and encouraging change.
19. I don’t think we talked about the “S” in O.A.R.S.?
It is a summary. A long reflection of more than one patient statement. Uses opportunity for the practitioner to guide behavior change by selectively summarizing reasons for change. Here are patient and practitioner samples:
Patient summary (includes ambivalence):
“My wife complains I cannot understand her. My daughter too. I have to turn the TV way up. I hear the boys at the lodge just fine. I am thinking I may need a hearing aid, but most of my buddies keep them in the drawer. My cousin’s aids pop out of his ears and drive him nuts. I do want to understand my grandchildren when they visit.”
Audiologist summary with guiding response and recognizing need for change talk:
“If I understand you correctly, you’ve been thinking about getting hearing aids because you have trouble understanding your wife and daughters. The downside is that your friends and family have had problems with hearing aids and you feel hesitant. Thinking you’d be happier using hearing aids so understanding your grandchildren and enjoying television can happen.”
This can lead to goal setting and discussion of the “downsides.” All with the combination of listening, asking, guiding and directing styles.
20. Any final thoughts?
MI takes practice! Stick to the basics. Focus on listening to and reflecting the patient’s responses, especially using feeling statements. Develop a feeling vocabulary. Always keep in the back of your mind “If I were this patient, how would I feel?” Activate your ambivalence detector! Recognize and utilize change talk. Resist the righting reflex. Ask! Remember that motivation comes from within the patient.
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Citron, D. (2018, April). 20Q: Effective counseling = information + feelings. AudiologyOnline, Article 22476. Retrieved from www.audiologyonline.com