Where There’s a Will, There’s an Aid Use of motivational interviewing can help keep hearing devices on your clients … and out of the kitchen drawer. Features
Features  |   March 01, 2014
Where There’s a Will, There’s an Aid
Author Notes
  • Cathy Kooser, MSW
    is a licensed independent social worker at Southwest Ohio ENT Specialists and Hillcrest Hearing & Balance Center in Dayton, Ohio. She developed and teaches a counseling-based rehabilitation program, “The Kooser Program: The Hidden Impact of Hearing Loss.” ■ckooser@soents.com
Article Information
Hearing Disorders / Hearing Aids, Cochlear Implants & Assistive Technology / Features
Features   |   March 01, 2014
Where There’s a Will, There’s an Aid
The ASHA Leader, March 2014, Vol. 19, 48-54. doi:10.1044/leader.FTR2.19032014.48
The ASHA Leader, March 2014, Vol. 19, 48-54. doi:10.1044/leader.FTR2.19032014.48
On May 17, 1984, my life changed. That was the day my audiologist told me I needed hearing aids. As a child, I had been diagnosed with sensorineural hearing loss that had continued to progress. My great-great-grandparents had been deaf, and I had scarlet fever, measles and the mumps—any of which may have caused my hearing loss.
Yet, I was stunned. You’ve got to be kidding me, I said to myself. No way! Only old people wear hearing aids. At 24, being told I needed hearing devices was not something I was ready to hear. “Surely there is some surgery or medication,” I pleaded, “Something—anything—other than having to wear hearing aids!”
Of course, no such option existed in 1984. So in spite of my shock, I went through the fitting process, as the audiologist recommended. I took my new devices home and promptly put them in a drawer … never to come out again. Over a 16-year span, I actually put three pairs in the drawer before finally starting to wear them at age 40.
So what was the problem? Obviously, I wanted help or I wouldn’t have returned three times for new hearing aids. And obviously hearing devices help us to hear better, so we should not only want them, we should actually wear them! But in reality, it’s not quite that simple. I was not psychologically ready to use hearing devices. Really, it wasn’t technological help I was after; I needed help to deal with my grief and ambivalence.
And I’m not alone. According to the National Institute on Deafness and Other Communication Disorders, 80 percent of us with difficulty hearing go undiagnosed and untreated. We ignore help that is readily available, or we reluctantly purchase hearing devices and put them in a drawer.
Deep-seated, outdated attitudes tend to accompany hearing loss and technology use, which contribute to many people’s ambivalence about wearing devices. To further complicate matters, the client often needs to experience two psychological processes—grief and accepting change—to ensure success. These processes require not only a change in self-identity—from a person with normal hearing to one with hearing loss—but also behavior changes. Those of us with hearing loss must initiate the new behavior of wearing devices, modify our communication strategies and techniques, and cease certain behaviors—such as bluffing, dominating the conversation and withdrawing from social situations.
Some resilient people handle change with grace … but the vast majority of us do not! For a client to use hearing devices successfully, motivation must come from within. It’s not enough for the clinician or a family member to want change. The client must take ownership of the problem. So how do we help those who are not yet ready, and determine their progress toward ownership? That’s where support counseling and motivational interviewing come into play.
In the early 1970s, William Miller and Stephen Rollnick—clinical psychologists who work with people with addictions, specifically alcoholism—developed motivational interviewing. Today many health care specialists, including audiologists, use the technique successfully. In their 2013 book, “Motivational Interviewing: Helping People Change,” Miller and Rollnick define the process as “a person-centered counseling style for addressing the common problem of ambivalence about change.” In short, it’s a conversation about change between the hearing care professional and the client. In the audiology profession, it makes use of three simple yet effective tools: the circle, the line and the box.
The circle
The circle identifies and describes the seven stages of change (see diagram on p. 51). Knowing these stages—in combination with the results of the line and the box—helps the professional determine how far the client has progressed through the change process. It’s important to determine the client’s progress prior to fitting, because each stage suggests a specific treatment approach (and counseling time may be reduced as the professional applies stage-appropriate treatment).
Here are the stages of change—developed in the late 1970s by James Prochaska and Carlo DiClemente—each with treatment recommendations to best assist the client. Although I’m not directly involved in the hearing device consultation process in our practice, as a mental health professional I find this information to be extremely beneficial when I provide counseling-based rehabilitation.
  • Precontemplation. Unaware there is a hearing problem, the client sees no need to change. Listen to the client and provide clear and accurate information. Don’t persuade or discuss hearing devices yet.

  • Contemplation. The client is aware of the hearing difficulty, yet is ambivalent about change. Listen to the client and talk about the problems he or she is experiencing and also about any ambivalence. Help raise awareness of personal costs and the benefits of better hearing. Don’t persuade or discuss hearing devices yet.

  • Preparation. The client may still be ambivalent, but recognizes the need to take action. Give advice and ideas about how to improve communication, including discussion of devices. Focus on the benefits of better hearing.

  • Action. The client takes steps to initiate change. Focus on how changing behavior is helpful and continue providing encouragement and support. Don’t assume the client has successfully implemented the change at this point.

  • Maintenance. The client has sustained change successfully for six months or longer. Continue with support and encouragement.

  • Relapse. The client returns to “old” behavior—denying the hearing problem, for example, and not wearing hearing aids. Many clients never experience this stage. Support and encourage the client to verbalize the problem and solve it while focusing on the benefits of improved hearing.

  • Permanent exit. The client is comfortable wearing devices and experienced at solving problems related to hearing difficulty. Provide continuing support as needed.

Ideally, the client permanently exits this process … although it may take a few attempts to do so. Please “hear” me—the client is not yet psychologically ready to discuss hearing devices in the precontemplation or contemplation stages. Discussing devices during these stages may cause ambivalence, device abandonment or refusal to seek future help.
The line
The line—Miller and Rollnick refer to it as the “importance ruler”—is a quick and simple tool to get clients’ answers to the following questions:
  • How important is it for you to improve your hearing?

  • How ready are you to improve your hearing?

  • How do you rate your ability to improve your hearing?

The hearing care professional gives the client a worksheet with a line numbered 0–10. Then the professional asks one, two or all of the three questions above—as well as any others of interest to the clinician or client. The client puts an X on the number (0–10) that most closely represents his or her current thoughts and feelings—zero meaning not at all ready and 10 being highly ready.
The professional’s responses are important, as different approaches can elicit ambivalence or reinforce positive talk about change. For example, if the client marks a four and the clinician asks, “Why did you choose a four and not a six?” then the focus is placed on the client’s ambivalence. To instead elicit “change talk”—positive talk about change—the audiologist could instead ask, “Why did you choose a three instead of one?” This response places the focus on the benefits of change.
Of course, professionals may be tempted to discuss only the benefits and ignore concerns. But this is counterproductive and may cause harm. It’s very important to address the client’s ambivalence—do not ignore or avoid it. Some may fear that discussing ambivalence can encourage a client’s inaction. In fact, the opposite is true. Identifying and emphasizing only the benefits may encourage the client to argue for the status quo—which reinforces inaction.

Looking for more?

The following ASHA resources may be helpful to clinicians who provide counseling to people with hearing loss and their families.

  • “Guidelines for Audiologists Providing Informational and Adjustment Counseling to Families of Infants and Young Children With Hearing Loss Birth to 5 Years of Age” ?(on.asha.org/counseling-families).

  • The results of a joint American Association of Retired Persons and ASHA survey, which outline the “state of hearing” among the 50-plus generation (on.asha.org/hearing-health-poll).

  • A library of hearing survey data collected over 25 years by Sergei Kochkin (bit.ly/hearing-trends).

The box
The box helps to identify the client’s perceived pros and cons of hearing loss and device usage. Divide a sheet of paper into four squares, and give each square a label:
  1. Benefits of Status Quo

  2. Costs of Status Quo

  3. Potential Costs of Change

  4. Potential Benefits of Change

“Status quo” means taking no action to improve hearing, and “change” refers to taking steps to improve hearing. This tool is used together with the line to help the client and professional understand positive and negative thoughts and concerns regarding hearing loss and devices.
Have the client fill out each box with brief phrases in numerical order, and follow up with a discussion. For example, under “Benefits of Status Quo” the patient may say, “I don’t have to wear or purchase hearing devices.” Or under “Potential Benefits of Change” a response might be, “I will be able to understand my grandchildren better.” The client’s answers in boxes one and three clearly identify ambivalence. Boxes two and four reflect change talk. As with the line, it’s important to discuss both benefits and concerns with the client.
The client, not the clinicians, should physically complete the line and the box—a patient-centered approach—at the beginning of the consultation process. However, the tools can also be used with the client and his or her communication partners throughout treatment. It’s important for the clinician and client to have follow-up discussions throughout treatment to explore the client’s evolving responses and associated feelings.
Incorporating these motivational interviewing tools in the counseling process helps professionals assess a client’s emotional reactions and readiness levels. Using them provides a win-win for professional and client by empowering and assisting the client through the change process. At times, I pause to consider how my hearing loss journey might have been different had my audiologist used these counseling tools with me. I’m inclined to believe I would have begun using my hearing devices at a younger age.
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March 2014
Volume 19, Issue 3