Health Care: Crisis and Change

. . . nothing will change unless or until those who control resources have the wisdom to venture off the beaten path of exclusive reliance on biomedicine as the only approach to health care.

—George L. Engel (1977a, p. 135)

The need to view counseling in audiology from a different perspective is understood best when examined in the context of changes occurring throughout health care. Historically, research and development, and the allocations of resources in health care, have been disproportionately focused on technological advances. At the same time, there have been glaring shortages in preventive and primary medical care, and woeful inadequacies in how chronic illness and disability are addressed, particularly in patient education and counseling. These shortages and inadequacies have led to unacceptably high rates of nonadherence to treatment recommendations creating a vicious cycle that includes:

■ treatment failures;

■ spurious results in outcome research;

■ deteriorations in health, functioning, and quality of life;

■ unnecessary medical tests and hospital readmissions;

■ increased demands on limited resources; and

■ escalations in health care costs.

In short, a health care system that has not focused adequately on chronic illness and disability has been drained by those very problems.

It is impossible for practitioners and patients to avoid reminders of the challenges and changes that health care is facing. The financial and political implications of these issues continue to be the subject of endless debate. What is abundantly clear, however, is the fact that chronic disease and disability cannot be addressed adequately by a system that is structured to address acute conditions. At the same time, the aging population and advances in acute care are contributing to an ever-increasing number of individuals with one or more chronic health conditions. The financial and human costs of these exigent circumstances, particularly the multiple comorbidities associated with increased longevity, have long demanded new approaches to health care. Collaborative/interprofessional health care teams, accountable care organizations, patient-centered medical homes, and increased emphasis on healthy lifestyles and prevention are but a few of the changes stemming from the obvious need to focus on chronic health conditions. Growing emphasis on person and patient-centered care offers hope that education and counseling to promote self-management of chronic disease and disabilities will become more prevalent throughout health care, particularly when patient satisfaction and the benefits of such interventions become more evident.

Why has health care been so ill prepared to address chronic illness and disability? The answer is literally centuries old. Medical science and practice have long been anchored in the biomedical model, a mechanistic product of dualism and reductionism. Dualism, in philosophy of mind, refers to the belief that mind and body are separate and independent entities. The church adamantly upheld this view through the 16th and 17th centuries because the mind was perceived to be soul-related and, therefore, strictly in God’s purview. The church, however, did permit study and dissection of the body. As a result, for centuries, the focus of medical science and practice in Western medicine has been on the human body. From the perspective of reductionism, all matter and phenomena are reduced to their parts, and those parts, in turn, are reduced to their parts. Hence, molecular biology has emerged as the science underlying modern medicine. Simply stated, the biomedical model has entailed assuming a detached perspective, finding the broken part, and fixing it.

The Biopsychosocial Model in Health Care Today

. . . the ongoing process of “becoming biopsychosocial” develops mental suppleness, diagnostic agility, thoughtful approaches to therapeutics, and a holistic vision; it provides a focus for finding meaning in clinical practice and pathways to strong relationships with patients

—Epstein and Borrell-Carrió (2005, p. 430)

George L. Engel (1913–1999), an internist and psychiatrist whose career at the University of Rochester Medical Center spanned five decades, argued passionately that health care has long outgrown the utility of the biomedical model. He faulted the scientific limitations of reductionism and dualism in understanding health and illness, and deplored the objectification and the disempowerment of the patient inherent in the biomedical approach. Engel also viewed the model as inherently flawed because it cannot account for individual differences in perceived “illness,” the subjective experience of disease. As Engel (1977a) repeatedly pointed out, illness cannot be understood without knowing why this particular patient is presenting in this particular way at this particular time. The issue of individual differences is critical when it comes to patients’ experience of disability; that is, the subjective experience of impairment and its associated limitations and restrictions. Research in audiology has demonstrated the effects of individual differences in a number of ways. For example, studies spanning a half-century have consistently shown that although audiometric measures and self-reported hearing problems are correlated, one cannot predict a patient’s communication and adjustment difficulties or quality of life from the audiogram (Brainerd & Frankel, 1985; Erdman & Demorest, 1998b; Gopinath et al., 2012; Hallberg, Hallberg, & Kramer, 2007; Hannula et al., 2011; Hawes & Niswander, 1985; Helvik et al., 2006; Hideki, Kyoko, & Eiji, 2004; High, Fairbanks, & Glorig, 1964; Hornsby & Kipp, 2016; Kielinen & Nerbonne, 1990; Kramer, Kapteyn, Festen, & Tobi, 1996; Rowland, Dirks, Dubno, & Bell, 1985; Speaks, Jerger, & Trammel, 1970; Weinstein & Ventry, 1983a, 1983b). Furthermore, the decision to seek audiologic services is correlated more strongly with self-reports of hearing problems than it is with the audiogram (Brink, Wit, Kempen, & Heuvelen, 1996; Laplante-Levesque, Hickson, & Worrall, 2012; Swan & Gatehouse, 1990). Indeed, the individual variability in difficulties experienced secondary to hearing impairment is one of audiology’s most well documented phenomena.

Of all the factors that affect the total life situation of a person with a disability, the disability itself is only one, and often its influence is relatively minor. This implies, in the final analysis, that the understanding of psychological reaction to physical disability requires the understanding of individual human beings in all of their complexity (p. 210).

The key aspects of the biopsychosocial approach as proposed by Engel (1977a, 1977b, 1980) include the following:

■ a view of the patient as a whole; a person whose fundamental nature is at once biological, psychological, and social;

■ a triadic process of observation, introspection, and dialogue through which the patient’s subjective experiences become scientific data;

■ a clinical interview in which the patient’s narrative is allowed to unfold without interruptions and with minimal prompting or interrogation;

■ a practitioner-patient relationship that fosters shared and complementary communication and responsibilities;

■ a mutual understanding of the patient’s narrative that ensures inclusion of his or her perceptions and experiences in the assessment and diagnostic process;

■ patient engagement in the treatment process and plans intended to alleviate or resolve perceived illness or disability; and

■ system theory rather than reductionism as the approach to analyzing and understanding health and illness.

The interdependencies and interactions among multiple systems that are implicated in pain, for example, cannot be examined or studied within the biomedical framework. Research has demonstrated that pain-related fear, hypervigilance, and catastrophizing play a significant role in the transition of acute and subacute pain to chronic pain (Crombez, Vlaeyen, Heuts, & Lysens; 1999; Goubert, Crombez, & van Damme, 2004; Peters, Vlaeyen, & Weber, 2005; Vlaeyen, Crombez, & Goubert, 2007; Vlaeyen & Morley, 2005). Indeed, comprehensive reviews confirm that emotions are primary factors in the conceptualization, assessment, and treatment of persistent pain (Gatchel, 2004; Gatchel & Turk, 2008; Lumley et al., 2011). Patients’ appraisals of their pain (i.e., the meaning they ascribe to their pain) and their capacity to manage fears of reinjury or exacerbation of pain contribute to the development of chronic pain (Turk & Okifuji, 2002; Vlaeyen, Crombez, & Linton, 2016). The more traditional biomedical approach to managing pain, prescription painkillers, has been blamed for contributing to addiction problems, which has added even more credence to the biopsychosocial approach to pain management (Bonnie, Schumacher, Clark, & Kesselheim, 2019; Gourlay, Heit, & Almahrezi, 2005; Passik & Kirsh, 2008). The benefits of applying a biopsychosocial approach to pain management following injury were made abundantly clear in a Colorado experiment in which the state mandated a “biopsychosocial law” to control worker’s compensation costs (Bruns, Mueller, & Warren, 2012). Briefly, the goal was to provide a biopsychosocial intervention that included rehabilitation and psychological intervention for the treatment of work-related injuries, especially when there were signs that the injury could become disabling. Colorado achieved a marked reduction in the inflation rate of medical and disability costs. Other states are incorporating aspects of this plan and it has become a fascinating case study for health care reform.

The increasing presence and influence of the biopsychosocial model can be seen throughout medicine and the allied health professions including those in the social and behavioral services (Wade & Halligan, 2017). Wampold, Ahn, and Coleman (2001) maintain that there is no empirical support for the biomedical model in the counseling professions because the person must be understood in relation to his or her particular circumstances. Sensitivity to individual and cultural differences is contingent upon a model that espouses a person in context approach. Suls and Rothman (2004) emphasize the particular relevance of the biopsychosocial model for health psychology and advocate emphasis on interprofessional collaboration and on efforts to expand research promoting the multilevel, multisystem, and multivariate nature of health. Anchin (2008), in a thought-provoking treatise on the pursuit of a unifying paradigm for psychotherapy, suggests that the biopsychosocial model “creates an organizing framework for systematically interrelating accumulating knowledge about biological, psychological, and social subsystems in relation to personality, psychopathology, and psychotherapy” (p. 328). Meyer and Melchert (2011) echo this point, stressing the importance of adhering to the biopsychosocial framework for mental health intake assessments to guide not only diagnosis but also treatment planning, implementation, and monitoring. On an even more fundamental level, it is impossible not to appreciate the relevance of the biopsychosocial framework and system theory in view of continuing developments in the neurosciences. Cognitive therapy, meditation, and even repeated practice of a skill are implicated in neuroplasticity and other observable changes in neuroanatomy (Garland & Howard, 2009). Ongoing and, at times, controversial research continues to delineate the possible role of mirror neurons in empathy, with potential implications for understanding social skills deficits in disorders such as autism and schizophrenia (Iacoboni, 2009; Pineda, 2010).

Patient-Centered Care: Hearing the Patient’s Story

The practice of listening to patients’ stories and responding sensitively to them provides an opportunity for more clinically effective, as well as more empathic, care.

—Garden (2010, p. 210)

Engel’s emphasis on the patient’s narrative is but one facet of the biopsychosocial approach that has had considerable influence on clinical routines. Engel believed passionately that the narrative, the patient’s experience, and the systems relevant to that experience should be heard and that patients’ stories are “naturally” disclosed. Seaburn (2005), who worked with Engel, has found that attentively listening to patients’ stories allows the elements of the biopsychosocial approach to emerge on their own. The key in allowing this to occur lies in truly listening. Many clinicians find it difficult to refrain from interrupting. In one study, the mean length of time before physicians interrupted patients was a mere 18 seconds (Beckman & Frankel, 1984); another study found a mean length of 23 seconds (Marvel, Epstein, Flowers, & Beckman, 1999). Some practitioners resist the narrative approach because they believe that a standardized intake form saves time. Studies have shown, however, that once one has developed skill with the biopsychosocial interview, consultations run less than a minute longer than the more traditional intake interview (Margalit, Glick, Benbassat, & Cohen, 2004; Stewart, Brown, & Weston, 1989). On the plus side, the investment of this additional time reportedly results in greater patient satisfaction (Charlton, Dearing, Berry, & Johnson, 2008; Epstein et al., 2003) as well as in the need for fewer referrals, prescriptions, and diagnostic tests (Margalit et al., 2004; Margalit & El-Ad, 2008; Soler & Okkes, 2012), all of which have implications for long-term cost containment. Regular intake forms tap standard symptoms; an individual’s narrative is more likely to reveal pertinent details and underlying factors—particularly affective, cognitive, and behavioral variables—that are implicated in his or her condition and situation. Insufficient specific information can impede or derail diagnoses, interfere with the patient’s ability to feel understood and, ultimately, have a negative impact on outcome. The IOM (2001) affirms that communication lapses and relationship obstacles can contribute to preventable harm and even death.

The emphasis on the patient’s story and perspective, and on the subsequent importance of practitioner’s communication and interpersonal skills, has also resulted in the development of numerous approaches to conducting clinical interviews. The following are among those that have had particularly widespread use.

■ Calgary-Cambridge Observation Guides (Kurtz & Silverman, 1996; Kurtz, Silverman, Benson, & Draper, 2003; Silverman, 2007; Simmenroth-Nayda, Heinemann, Nolte, Fischer, & Himmel, 2014)

■ Smith’s Patient-Centered Interviewing Method (Fortin, Dwamena, Frankel, Lepisto, & Smith, 2019; Smith, 1996)

■ Four Habits Model (Frankel & Stein, 1999; Gulbrandsen et al., 2008; Krupat, Frankel, Stein, & Irish, 2006; Lundeby, Gulbrandsen, & Finset, 2015; Stein, Frankel, & Krupat, 2005)

■ Kalamazoo Essential Elements Checklist (Duffy et al., 2004; Joyce, Steenbergh, & Scher, 2010; Makoul, 2001)

■ Patient-Centered Clinical Method (Stewart et al., 2013)

Patient-centered care has become somewhat of a generic term for many of the transformations occurring in health care; however, the need to definite it systematically has been addressed repeatedly. Mead and Bower (2000) cite five dimensions of patient-centered care:

■ a biopsychosocial perspective,

■ the “patient as person,”

■ sharing power and responsibility,

■ the therapeutic alliance, and

■ the “practitioner as person.”

The IOM (2001) defined patient-centered care as “respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions” (p. 6). Stewart (2001), in response to concerns that perhaps not all patients prefer a patient-centered approach, or need all aspects of such an approach, clarified that patient-centered clinical practice is “a holistic concept in which components unite and interact in a unique way in each practitioner-patient encounter” (p. 445). Since those descriptions, there have been continuing efforts to refine and expand the definition of patient-centered care. Epstein, Fiscella, Lesser, and Stange (2010), for example, point out six measurable aspects of patient-centered care:

■ fostering a healing relationship,

■ exchanging information,

■ responding to emotion,

■ managing uncertainty,

■ making decisions, and

■ enabling self-management.

Epstein and colleagues advocate a national health care policy that “helps health professionals acquire and maintain skills related to patient-centered care. It also should encourage organizations to move toward a culture of patient-centeredness. In turn, these organizations should support patients in self-management and shared decision-making” (p. 1494).

■ exploring the disease and the illness experience,

■ understanding the whole person,

■ finding common ground,

■ incorporating prevention and health promotion,

■ enhancing the patient-provider relationship, and

■ being realistic.

Hudon et al. (2012) suggest that validating the illness experience, acknowledging and capitalizing on patients’ expertise, and adding hope are other dimensions that should be included in patient-centered care, particularly when chronic conditions are involved.

The relationship-centered approach has also received considerable attention (Beach, Inui, & Relationship-Centered Care Research Network, 2006; Frankel, Eddins-Folensbee, & Inui, 2011; Frankel & Quill, 2005; Nundy & Oswald, 2014; Roter, 2000; Schoenthaler, Hassan, & Fiscella; 2019; Suchman, 2005; Tresolini & Pew-Fetzer, 1994; Williams, Frankel, Campbell, & Deci, 2000). According to Beach and colleagues (2006), relationship-centered care is founded upon four principles:

■ Relationships in health care should include the personhood of all participants.

■ Affect and emotion are important components of these relationships.

■ All health care relationships occur in the context of reciprocal influence.

■ Forming and maintaining genuine relationships in health care is morally valuable.

Relationship-centered care is viewed, to some extent, as an expansion of patient-centered care, but it is also a direct outgrowth of the biopsychosocial model (Smith, 2002; Suchman, 2006). Some proponents of a patient-centered approach suggest that the relationship-centered approach stresses the interaction rather than the goal of care (Brown, Stewart, Weston, & Freeman, 2003; Churchill, 1997). In their report on health professions education and relationship-centered care, however, Tresolini and the Pew-Fetzer Task Force (1994) emphasized the fact that the therapeutic relationship is among the most salient variables in health care:

This relationship is a medium for the exchange of all forms of information, feelings, and concerns, a factor in the success of therapeutic regimens, and an essential ingredient in the satisfaction of both patient and practitioner. For patients, the relationship with their provider is frequently the most therapeutic aspect of the health care encounter. (p. 9)

Without discounting any aspects of the patient-centered approach, Roter (2000) concurred with the Pew-Fetzer report acknowledging that mutuality and reciprocity, as hallmarks of the relationship-centered approach, are optimal throughout health care. Moreover, she contends, the emphasis on mutuality and interaction avoids the potential implications of paternalism and consumerism sometimes associated with the traditional biomedical model and the patient-centered approach respectively. The quality of practitioner-patient relationships reportedly influences patient satisfaction, adherence to treatment recommendations including medication use and behavioral change, and continued health care utilization (Williams et al., 2000). In the field of physical therapy, studies indicate that the therapeutic relationship is positively associated with: (a) treatment adherence in patients with brain injury, (b) depressive symptoms in patients with cardiac conditions and those with brain injury, (c) treatment satisfaction among patients with musculoskeletal problems, and (d) physical function in geriatric patients and those with chronic low back pain (Hall, Ferreira, Maher, Latimer, & Ferreira, 2010).

Proponents of relationship-centered care contend that it enhances patient-centered care as a result of the emphasis given to mindful practice and clinicians’ self-awareness (Dobie, 2007; Frankel, Eddins-Folensbee, & Inui, 2011; Frankel & Quill, 2005; Krasner et al., 2009; Smith, Dwamena, & Fortin, 2005). As Dobie (2007) observes, relationship-centered care “orients us to the importance of self-awareness and mutuality, which enrich us beyond our clinical practice” (p. 432). Of added significance, the relationship-centered approach encompasses relationships beyond the practitioner-patient dyad. Involvement of family members is clearly envisioned as critical, particularly those in caretaker roles or in positions to provide autonomy support (Williams et al., 2000). Additionally, clinician-clinician relationships are becoming increasingly important as the emphasis on interprofessional practice, collaboration, and teamwork becomes more widespread (D’Amour, Ferrada-Videla, San Martin Rodriguez, & Beaulieu, 2005; Dix, Steggles, Baptiste, & Risdon, 2008; Gaboury, Lapierre, Boon, & Moher, 2011; Gittell, Godfrey, & Thistlethwaite; 2013; Nester, 2016).

The biopsychosocial model, along with patient-, person-, family-, and relationship-centered care approaches, represent somewhat philosophical, theoretical albeit observable, even measurable ideals that are being promoted throughout health care. At the same time, related but more pragmatic changes are unfolding that will have a direct impact on the provision of health care services. These other changes, also aimed at improving health care, focus specifically on quality management and quality processes. The variable that will constitute the foundation of this wave of change is the patient-reported outcome (PRO). In short, PROs are becoming the mechanism for determining the effectiveness and the efficiency of treatments and providers. The IOM (2001) and the Patient Protection and Affordable Care Act (ACA) (2010) both call for patient-centered care and emphasize the importance of engaging patients in shared decision making to determine treatment goals and strategies and enhance care. Inherent in this process is the monitoring of progress and outcomes (Lavallee et al., 2016). The ACA mandated creation of the PCORI, which is testimony to the central role PROs now have in health care analyses. This broad-based utilization of PROs is necessary to ensure that care of individuals translates to populationwide improvements in health care quality and to long-term cost containment (Bobbit, Cate, Beardsley, Azocar, & McCulloch, 2012). The most commonly utilized PRO is patient satisfaction with provider care and treatment. Inasmuch as the literature indicates that the biopsychosocial approach, as manifested in patient-centered care is associated with patient satisfaction (Cvengros, Christensen, Cunningham, Hillis, & Kaboli, 2009; Margalit et al., 2004; Sherbourne, Hays, Ordway, DiMatteo, & Kravitz; 1992; Stewart et al., 2000) and, importantly, with cost containment (Bertakis & Azari; 2011; Bruns, Mueller, & Warren, 2012; Stewart et al., 2000; Stewart, Ryan, & Bodea, 2011), the rationale for implementing these approaches in all of health care is abundantly clear. Interestingly, Sherbourne and colleagues (1992) found that although patient satisfaction with the interpersonal aspects of care is predictive of adherence to treatment recommendations, satisfaction with the technical aspects of care is not. As mentioned earlier, the costs associated with nonadherence to treatment recommendations are staggering; hence, efforts to improve adherence are critical. Clearly, excellence in technical skills, albeit important, is not sufficient to ensure patient satisfaction, adherence to treatment recommendations, or reductions in health care costs. The fact that significant advances in technology have not given rise to comparable advances in the management of chronic health problems that call for patient self-management is testimony to this fact. Given the role that the interpersonal aspects of care have in patient satisfaction and long-term adherence to treatment regimens, it behooves all clinicians to maximize their interpersonal skills by incorporating those critical aspects of person- and relationship-centered care; in short, by adhering to a biopsychosocial rather than a biomedical approach to service provision.

The Need for a Paradigm Shift in Audiology

It is not that audiology ever explicitly abandoned A/R . . . We just do not do it very much or manage to get it rewarded very well . . . If we want to keep in touch with our roots, and have a future as an independent, self-supervised profession, evaluating and managing the communicative and psychosocial impact of hearing loss has to be our core purpose, our reason for being.

—Mark Ross (1997, p. 14)

Biomedical thinking is found in many aspects of audiology. Diagnostics rule. From the days of the tuning fork, our armamentarium of diagnostic technologies has come to include computerized and automated audiometers, tympanometers, ABR equipment, ENG equipment, OAE systems, real ear measurement and hearing aid test systems, computer administered self-assessments, and video-otoscopy and microscopy. Treatment-wise, the list is equally high-tech: remote-controlled hearing aids, in-the-ear hearing aids, behind-the-ear hearing aids, and CROS and BICROS hearing aids; various bone-conduction implantable devices with FM, infrared, Bluetooth, and wireless technologies; telehealth; video- and computer-administered training; and an ever-increasing array of assistive technologies. A true assembly line of technologies awaits the patient who comes to see an audiologist. The phrase “high tech, low touch” epitomizes much of audiologic practice.

The importance of patients’ perceptions of their hearing difficulties is not something to which audiologists have been oblivious. During the 1980s and 1990s, as the patient’s perspective became a matter of increasing interest, research in the area of self-reported measures to assess patients’ perceptions of their hearing problems was particularly active. Some of the instruments were developed for screening purposes; others were designed to provide a global perspective of the individual’s experience of communication problems and associated adjustment difficulties. Still others were focused on specifics such as hearing aid use or tinnitus. As noted earlier, a wide range of studies has demonstrated that although correlations between audiometric and self-reported measures are statistically significant, they are not very strong. The following conclusions (Erdman, 1994) can be drawn from these findings:

■ The communication and adjustment difficulties evidenced in self-assessment are related to hearing impairment.

■ This relationship, however, does not permit the audiogram to predict the difficulties experienced secondary to hearing impairment.

■ The variability in the experience of hearing impairment indicates that other factors determine the extent to which hearing impairment does or does not become a disabling condition.

■ Assessment of hearing impairment is an inadequate means of assessing an individual’s rehabilitative needs.

In short, individual differences account for the variability in the experience of hearing impairment. Nonetheless, despite everything we know about individual differences in adjustment to hearing impairment and despite how often we see virtually identical audiograms from individuals with vastly different subjective accounts of hearing problems, we continue to concentrate our time, effort, and energy on fitting the hearing aid to the audiogram. As Kooser (2014) poignantly observes, all too often, audiologists never talk to patients about the actual communication and adjustment difficulties that prompted them to seek audiologic assistance.

There is evidence of a biopsychosocial approach to understanding the implications of hearing impairment in the body of international audiologic literature. Audiologists and psychologists in Australia, Canada, Denmark, England, New Zealand, Norway, Scotland, and Sweden have made innumerable contributions to the literature on hearing impairment as it relates to coping, well-being, family, marriage, occupation, psychological adjustment, and stigma. This invaluable body of work is noteworthy in many respects. Much of the work stems from systematic dedicated research that has advanced our understanding of the experience of hearing impairment and produced ongoing learning threads for the audiology community and beyond. A second point worth noting is the extent to which this work consistently draws on knowledge from other disciplines. It reflects an awareness of what the social and behavioral sciences can offer to a more holistic understanding of the wide-ranging effects of hearing impairment on the human condition.

The work of the late Raymond Hétu and his colleagues, for example, provides a systematic examination of occupational hearing loss (OHL). A qualitative analysis of hearing handicap among individuals with OHL (Hétu, Riverin, Getty, Lalande, & St-Cyr, 1988) and an investigation of the psychosocial disadvantages experienced by family members of individuals with OHL (Hétu, Lalonde, & Getty, 1987) were followed by a study of workers’ reluctance to admit to hearing problems (Hétu, Riverin, Getty, Lalande, & St-Cyr, 1990). These investigations led to the development of a rehabilitation program for individuals with OHL (Getty & Hétu, 1991; Hétu & Getty, 1991), an examination of how workers overcome difficulties in the workplace (Hétu & Getty, 1993), and an evaluation of coworkers’ attitudes toward individuals with OHL (Hétu, Getty, Beaudry, & Philipert, 1994; Hétu, Getty, & Waridel, 1994). The culmination of Hétu’s research is his seminal article on the stigma related to hearing impairment (Hétu, 1996). This critical work has been continued by Gagné, Southall, and Jennings (2009).

In the U.S., research related to spouses has frequently focused on the dyadic communication difficulties related to disparate perceptions of hearing-related problems and behaviors. Correlations between patients’ self-assessments and their spouses’ corresponding measures using the Denver Scale (McCarthy & Alpiner, 1983), the Hearing Handicap Inventory for the Elderly (HHIE; Newman & Weinstein, 1986), and the Communication Profile for the Hearing Impaired (CPHI; Erdman, 1995) consistently indicate discrepancies in couples’ perceptions of the communication difficulties experienced as a result of one partner’s hearing impairment. Mean scores are similar; correlations, however, albeit significant, are not strong. In short, this supports clinical observations that couples frequently have different perspectives on the problems experienced in relation to hearing impairment. This has important implications for couple or family counseling. It is not surprising that couples do not come to agreement on solutions when perceptions of the problem differ markedly. Common complaints such as “My wife mumbles all the time” and “He can hear just fine when he wants to” illustrate the lack of shared understanding of the problems hearing impairment creates. The spousal assessments of their partner’s hearing problems are not intended to corroborate the patient’s difficulties. Rather, they provide valuable insight into the nature of communication difficulties that develop subsequent to those caused by the hearing impairment. For example, when spouses come to believe that their partners simply “do not care enough to listen,” the nature of the communication problems becomes significantly more complicated.

Of course, many audiologists in the clinical arena do focus on how hearing impairment affects their patients, and they provide counseling to ensure that patients adjust to their hearing problems and manage them successfully. Many more audiologists would do so if institutional resistance did not exist on several different levels. Professional training in audiology typically is not approached from a biopsychosocial perspective. Physical sciences dominate the curriculum with less emphasis on social and behavioral sciences. This mirrors the situation that existed in medical schools, although in those programs, change has been mandated; as stated above, communication and interpersonal skills are now considered critical competency areas (ACGME, 2012). In practicum settings for audiology students, the emphasis is on quickly and accurately administering the battery of audiologic measures and determining a diagnosis from those findings. Service delivery is based on a top-down biomedical model in which the clinician provides the diagnosis and recommends the treatment. In view of the fact that dramatic changes are occurring throughout health care, audiology must address the need to modify its service delivery approach. In many respects, this will entail a return to our roots.

The Military Experience

This program has changed a lot of people since Day 1.

—Army officer, one of a 12-member, 9-day, AR group (1989)

■ social and psychiatric treatment to overcome possible trauma associated with combat related hearing loss and to rule out “hysterical” deafness,

■ medical and surgical treatment as necessary,

■ hearing aid fittings for those who were anticipated to accrue benefit from them, and

■ “education for social living” (p. 449).

Education for social living included a program of recreational and educational activities, training in lipreading and speech correction, and “indoctrination of the soldier’s family” (Morrissett, 1957). Absent the technologic advances in diagnostic audiology and hearing aids, the emphasis on rehabilitation focused directly on the patient and his communication and adjustment difficulties.

A special effort was always made to make clear to each patient precisely what he could expect from the rehabilitation course. It was explained unequivocally that a . . . person could not expect to regain his full hearing but that he could be taught methods of compensating for his disability. It was emphasized that nothing could be accomplished without his own full cooperation; and it was only in the exceptional case that such cooperation was not given. (p. 469)

In 1945, Truex (1957) conducted a follow-up survey of patients from the AR program at Deshon General Hospital at least 6 months after their hospital stay. Of the 261 respondents, only two did not consider the time spent in the program worthwhile. Of even greater significance is the fact that 91.6% indicated that they were using their hearing aids. Among those who were not wearing their hearing aids, the primary reasons given included headaches, difficulty obtaining batteries, the hearing aid was in need of repair, they did fine without aid, the aid was too noisy or too cumbersome, and symptoms of external otitis. In terms of daily use, 23% indicated they wore their hearing aid 5 to 8 hours per day, 21% reported 9 to 12 hours of hearing aid use, and 22% said they wore their hearing aids more than 12 hours per day. Of those who only used their hearing aids 1 to 4 hours per day, the vast majority indicated they did not wear their hearing aids at work in factories or on farms, and so forth. Not surprisingly, the results of this study sparked an interest in establishing similar programs in the civilian sector after the war.

Following the war, the military AR programs were consolidated and based at Walter Reed General Hospital, later designated Walter Reed Army Medical Center. With the move to Walter Reed, audiologists rather than otolaryngologists managed the AR program. The vast majority of patients presented with bilateral high-frequency sensorineural hearing impairment secondary to long-term noise exposure. Referrals for psychiatric evaluations were essentially nonexistent. Although changes in the program were implemented over time, an AR program was offered at Walter Reed for more than 50 years. Northern, Ciliax, Roth, and Johnson (1969) conducted a study of patients who had attended a 3-week AR program. The results indicated that 93.5% of the respondents wore their hearing aids “always” or “often.” Only 4.5% said they “never” wore their hearing aids, and 2% indicated they seldom wore them. When asked if they would refer a military colleague with hearing loss to the program, only one of 199 patients indicated that they would not.

The AR program at Walter Reed featured individual and group counseling sessions that included assertiveness training, stress management techniques, and problem solving based on results of patients’ self-assessment inventories and on analysis of the patients’ written reflections on specific communication and adjustment difficulties. The group format was invaluable. As one patient stated in a review of the program,

I really didn’t think I needed to come to this course. But so many things were helpful, especially the feelings others expressed as to their personal problems with hearing loss and the suggestions everyone gave each other. I’m a bit of a loner, but I felt really comfortable being with others who are experiencing the same problems I’ve been having.

This statement exemplifies just some of the therapeutic factors that commonly occur in group counseling: universality, group cohesion, imparting information and altruism (Erdman, 2009).

Routine follow-up of the AR patients through the 1980s consistently revealed hearing aid use rates comparable to those reported by Truex (1957) and by Northern and colleagues (1969). Erdman and Demorest (1987) compared pre- and post-program CPHI) (Demorest & Erdman, 1986, 1987) results for former AR patients (N = 70) 8 months to a year following their enrollment. Hearing aid use rates in the 90% range were reported. Moreover, significant improvements in scores were demonstrated in all areas of communication performance, attitudes of others, maladaptive strategies, and verbal strategies, and all but one scale (displacement of responsibility) in the personal adjustment area (see Erdman & Demorest, 1998a, 1998b, for a review of the current CPHI scales and Erdman, 2006, for CPHI interpretation guidelines). The results indicate broad-based treatment effects for new hearing aid users attending the counseling-based AR intervention.

Throughout the counseling and rehabilitation professions there is widespread evidence that group counseling is as effective, if not more effective, than individual counseling (Berg, Landreth, & Fall, 2018; Burlingame, Fuhriman, & Mosier, 2003; Fuhriman & Burlingame, 1990; Holmes & Kivlighan, 2000; McRoberts, Burlingame, & Hoag, 1998; Payne & Marcus, 2008). This is especially true for individuals with problems or conditions that can be isolating, stigmatizing, chronic, or recurring (Huebner, 2004; Yalom & Leszcz, 2005). The interactive nature of group counseling provides unique and powerful mechanisms of change that are evident in virtually all counseling groups regardless of the focus or purpose of the group, the theoretical approach, or age of its members. These therapeutic factors are also readily apparent in AR groups (Erdman, 2009). Excellent reviews of these mechanisms of change can be found in Corsini and Rosenberg (1955), Kivlighan and Goldfine (1991), and of course, in Irvin D. Yalom’s classic, The Theory and Practice of Group Psychotherapy, now in its fifth edition (Yalom & Leszcz, 2005).

John Hersey Pratt, a physician whose practice included treatment of tuberculosis patients, appears to have serendipitously discovered the therapeutic value of the group approach when, to save himself time, he organized group meetings for tuberculosis patients who could not afford treatment in a sanatorium (Pratt, 1906, 1912). After recognizing the healing qualities that stemmed from patients becoming concerned about and helping one another, he adopted the group approach with other patient populations as well (1922). Sabin (1990), who reviewed Pratt’s work, hails the comprehensive, empathic, biopsychosocial nature of Pratt’s group approach and emphasizes its relevance for reforms throughout health care. Given the overall effectiveness and the economic benefits of group approaches, it is not surprising to see their use now being encouraged throughout health care, particularly for patients with chronic health conditions.

It is encouraging to see recent developments in the implementation of group approaches to AR (Habanec & Kelly-Campbell, 2015; Hickson, Worrall, & Scarinci, 2007; Jennings, 2009; Marrone & Harris, 2012; Tucker, Compton, Mankoff, & Rulison, 2011) and the enthusiasm these approaches are generating among patients and clinicians alike. Audiologists who have worked with groups recognize how instrumental they are in promoting adjustment to hearing impairment and to hearing aid or cochlear implant use. The rationale for a group approach in AR does not only relate to its clinical benefits; the group approach is also optimal in terms of resource allocation. More patients, therefore, can be seen by fewer clinicians in less time.

For more than half a century, the military AR programs achieved successful hearing aid outcomes at a rate that has yet to be replicated anywhere in the clinical arena. Ironically, the influence of the biomedical model on audiology triggered an end to this remarkable program just as efforts to improve treatment outcomes for chronic conditions are leading to an integration of psychosocial interventions throughout health care. Patients’ belief in the program and support for it remained solid throughout its life span. Unfortunately, as audiologists who worked in the program moved on or retired, replacements became difficult to find. Failure to emphasize the human element in audiology training programs has led to fewer audiologists who are counseling oriented. Unlike the convalescent centers that housed the AR programs during the war, military hospitals are acute care facilities, and it became increasingly difficult to justify intervention for a chronic condition, albeit one that was service related. The lack of standard referral and funding procedures for outpatient rehabilitative care, in conjunction with scarce housing options, resulted in a recurring need to justify the AR program. The paucity of audiologists committed to rehabilitation and the combination of logistical factors ultimately led to discontinuation of the program.

The image of audiology as a microcosm of the health care system makes it easier to address how the limitations and inadequacies of the biomedical model have affected our practice. Addressing these issues and the ways in which a biopsychosocial approach can transform our practice is a necessity on all levels ranging from the individual clinician, to clinical supervisors, to clinic directors, to the hearing aid industry, to faculty members and deans, to the governance of professional organizations, to third-party payers, and government agencies. A comparable range of stakeholders participated in the Changing Health Care Landscape Summit (American Speech-Language-Hearing Association, 2012), a conference to address issues related to the ongoing changes in health care, including:

■ how do we create new, timely, cost-effective models to dynamically update clinical best practices, and

■ what changes are needed in how care is delivered and/or documented that will help assure payers, employers, and consumers of the value of our services?

Not surprisingly, but encouragingly, following 3 days of deliberation among audiologists from academic, clinical, and research facilities and representing American Academy of Audiology (AAA), Academy of Doctors of Audiology (ADA), Academy of Rehabilitative Audiology (ARA), and the American Speech-Language-Hearing Association (ASHA), a dominant and consensual theme that emerged is the need to infuse a patient-centered approach to all aspects of audiologic care with, importantly, this emphasis beginning at the point of academic entry into the profession. In essence, there is widespread agreement that, especially in view of impending changes throughout health care, a fundamental change is necessary that reflects a shift in perspective from the hearing impairment to the person with hearing impairment—a simple thought with myriad implications.

Just as some have disputed the need for a biopsychosocial approach in medicine, some may debate the need to shift audiology’s focus. As one colleague, a basic scientist at heart, has argued, “Fixing what’s wrong, fixes everything.” Still others will argue, “The biopsychosocial approach and all it entails will only make things more complicated.” Certainly, expanding the focus of practice to facilitate diagnosis and patient engagement entails looking at more factors, but it also means we are more likely to discover the variables that ultimately can facilitate adjustment and enhance outcomes.

We need to see what can be changed so that it is easier for us to live with ourselves, so that the public can readily perceive how we contribute to the welfare of clients, and so that, at the same time, we do not compromise our ethical standards. For if we are not comfortable with the way in which we offer service, if we are unable to believe in ourselves, then how can we expect others to believe in us? (p. 272)

In their discussion of service delivery models, Erdman, Wark, and Montano (1994) concur with Heaton’s observation and state:

The minimal emphasis on rehabilitation perpetuates the perception of audiology as a diagnostic profession with adherence to a medical model of service delivery. Failure to modify service delivery to better meet the needs of individuals with hearing impairment, when we know change is needed and when we know we can do better, is unethical. To assume the position that change is not possible because of time constraints or reimbursement constraints when we know change is indicated is indefensible. (p. 55)

Clinicians and patients should maximize the therapeutic effects of communication by explicitly orienting communication to achieve intermediate outcomes (e.g., trust, mutual understanding, adherence, social support, self-efficacy) associated with improved health.

—Street, Makoul, Arora, and Epstein (2009)