even the most advanced hearing aid technologies can restore only approximately half of the degree of sustained hearing loss (Dillon, 2012; Lybarger, 1944). As such, many patients, even after the most successful hearing aid fittings, continue with significant restrictions to their active participation in various areas of their lives. For these individuals, augmentative training can be invaluable (see Chapters 13 and 16). Hearing rehabilitation training through a variety of venues has been demonstrated to be beneficial when implemented (Abrahamson, 2000; Kricos & McCarthy, 2007). A primary means of coping with a handicap, however, is often to try to appear no different than others (Hetu, 1996), which may create a desire to hide one’s hearing loss. The active use of perceptually visible hearing technologies or the advocated use of communication management and repair strategies often runs counter to this desire.
Patient motivation toward the acceptance of and action on professional recommendations has been successfully enhanced in a variety of health-related areas, including substance abuse, smoking cessation, changes in diet, medication adherence, and the establishment of exercise regimens (Tonnesen, 2012). Similarly, motivational enhancement techniques have proven successful in hearing loss management (Ferguson, Maidment, Russell, Gregory, & Nicholson, 2016). The purpose of this chapter is, therefore, to present the concept of motivational engagement as a means to help patients improve adherence to their audiologist’s recommendations of needed hearing technologies and communication management strategies.
A Readiness for Hearing Loss Help
As hearing aid technology has improved over the years, the bedrock of audiologic rehabilitation for most with hearing loss has become the proper selection, fitting, and adjustment to personal acoustic amplification. Certainly, as noted throughout this text, amplification alone often falls short of fully addressing all of the daily communication challenges the adult with hearing loss confronts in the home, at work, and within the larger milieu of society. Yet it remains that without the procurement of appropriate amplification when needed, little progress toward hearing rehabilitation can be made.
Historically, hearing aids once were of only marginal benefit for those with sensorineural hearing loss. Many potential consumers of hearing health services (and their physicians) remember the larger sized hearing aids of the past that provided limited benefit. This, coupled with the stigma of hearing loss, that—while arguably decreasing—still remains (David, Zoiner, & Werner, 2018; Gagné, Southall, & Jennings, 2011; Kochkin, 2012), can often place a direct obstacle in the path of audiologists when recommendations for improved hearing include the fitting of a visible prosthesis or the use of communication management strategies that necessitate drawing attention to the hearing loss itself.
The marketing of many commercial products panders to the desire for an appearance of maintained vitality if not Juan Ponce de Leon’s dream of eternal youth. Given human nature to avoid unwanted life changes that require a necessary alteration in one’s self-concept with aging (Clark & English, 2019), it is not surprising that hearing aid market penetration remains at approximately only 30% (Abrams & Kim, 2015). Those who do seek hearing assistance, inevitably come to the audiologist’s office within varying stages of readiness to accept recommendations.
Stages of Readiness
Nearly 40 years ago, Goldstein and Stevens (1981) described four levels of patient motivation that serve to build perspective on the spectrum of readiness for change so often encountered in the clinic. The first two levels of motivation represent the majority of patients seen for hearing consultations and include those with relatively high motivation for change. Specifically, Type I individuals anticipate treatment with a positive outlook and are the most likely to accept hearing care recommendations. Type II individuals hold similarly positive attitudes and the desire for improvement, although their particular case may present an additional challenge such as a coexisting condition that may limit treatment options, as in the case of significant dexterity or tactile issues, severe visual limitations, or cognitive decline. Still, the challenge in working with Type II individuals is not overcoming a lack of readiness to receive help but rather designing the most appropriate treatment plan to serve the patient best.
As can be surmised, the remaining Goldstein and Stevens patient readiness levels account for those individuals with more negative outlooks on hearing management. Whereas Type III patients are generally open to some level of treatment planning exploration, those classified as Type IV frequently display open rejection of amplification and audiologic rehabilitation, and possibly the existence of any real need for either.
But, using hearing aids, which often can be quite visibly discreet, is different from openly sharing your communication needs with others. As such, even the Type I and Type II patients may need coaching toward use of communication management strategies. The professional’s instruction on the use of strategies is frequently insufficient by itself.
The Change Circle
An alternate view of readiness for change was presented by Prochaska and DiClemente (1984b) (Figure 12–1). This visual representation of the various stages of readiness for change provides a framework for understanding the patient’s incoming perspectives. Self-assessment measures are particularly useful in facilitating focused discussion with our patients and providing clues for identification of a patient’s specific stage of readiness for change. (Editors’ note: For further information regarding self-assessment, the reader is referred to Chapter 6 in this book.) A patient’s specific location within the change circle reflects his or her readiness to work with hearing management recommendations and may reveal a need for further information or support prior to reaching a point of action.
Figure 12–1. The Change Circle used to envision the cycle of stages experienced when considering audiologic treatment options. All stages require some form of clinician support. Source: Adapted from Prochaska and DiClemente, 1984b, with permission from the Ida Institute, idainstitute.com
As audiologists, we are privy to only a small slice of each patient’s hearing loss journey. Much transpires before patients arrive at the audiologist’s door, and these patients frequently leave their last post-fitting follow-up appointment with a life of residual hearing challenges ahead of them. As we look at the change circle, we see that many begin their hearing loss journey in a precontemplative stage in which they may not fully recognize the negative impacts of hearing loss that others in their familial, vocational, or social lives more readily see. It is also possible that these patients are aware of decreased communication effectiveness but do not fully attribute the noted changes to deficiencies on their end but rather blame communication difficulties on the speaking habits of others. Gradually, as communication becomes increasingly frustrating for either the person with the hearing loss or those with whom he or she interacts, there may be movement into a more contemplative stage, which may hold considerable ambivalence toward change.
Prochaska and DiClemente’s circle of behavioral change notes a transitional “preparation” phase between contemplation and action in which one further prepares for what is beginning to be viewed as an inevitable change. While normal ambivalence toward change may continue, the patient is frequently not fully confident in how to proceed. This is an information-gathering stage, often beginning with closer attention to marketing, searches on the internet, or discussions with friends who have already obtained hearing aids, and often eventually culminating in seeking advice from a professional. It can be a mistake for the audiologist to assume that patients in this transitional preparation stage are ready to purchase hearing aids. It may be that, for patients in the transitional preparation phase, motivational engagement is most beneficial as an aid to transition into action.
As discussed in Chapter 6, audiology has a wide array of self-assessment measures that can shed light on a patient’s perceptions of hearing loss impact. The value of these measures in hearing loss management is second only to the results of routine audiometrics, and their use has been advocated as part of clinical best practice for years (AAA, 2006). Given the value that these measures bring to the rehabilitation process, it is surprising that only 15% of surveyed audiologists use these measures routinely and that 57% report they use them seldom if ever at all (Clark, Huff, & Earl, 2017). If Dr. Reeves, in the earlier case study, had more fully explored Mr. Rodrigues’ perceptions of hearing loss, he not only would have been able to relate his test findings more directly to his patient’s true concerns, he also would have been well poised to help Mr. Rodrigues explore the issues that would bolster his own internal motivation to pursue treatment.
Case Study 12–1
Dr. Reeves has completed the hearing evaluation for his 10:30 patient, Mr. Rodrigues, and is explaining his test results. As he explains the findings of Mr. Rodrigues’ high-frequency hearing loss and how this can impact speech understanding especially when listineing in noise, Mr. Rodrigues nods attentively. But when he says, “Actually, the degree of hearing loss we have here can benefit greatly with today’s hearing aids, especially with the newer microphone technology that helps to block out some of the bacground noise,” he senses a resistance. Mr. Rodrigues leans back in his chair, crosses his arms and says, “I’m not sure I need hearing aids yet. I just wanted to see where things are.”
Dr. Reeves is finding he is losing this patient and he isn’t sure why. He is discussing the hearing loss and its impact based on what he knows of the effects of diminished hearing on the reception of speech in different environments. But he has not explored the impact of the hearing loss from his patient’s perspective. What he does not know is that Mr. Rodrigues rarely finds himself in noisy environments. His primary concern is that his grandson is becoming more distant as he senses his grandfather’s frustrations when he can’t hear the boy’s softer, higher-pitched voice. Dr. Reeves is not talking to his patient’s concerns or needs as he never learned what these were. And he is failing to meet Mr. Rodrigues where he is: squarely in the transitional preparation stage and not quite ready for action.
Most people with hearing loss will eventually reach a point in which they are ready to take positive action toward the help they need before they make an appointment with the audiologist. Those who may still be in the transitional preparation stage and not ready to act on improving their hearing when they arrive at the audiologist’s office may reach a readiness for action while in consultation with the audiologist. Either way, once in the action stage, these patients may still be experiencing the normal ambivalence we all face when we recognize the positive side of the action we have decided to take, but have not fully reconciled ourselves with the negatives of that action. At this stage, patients frequently need more than information alone, but also may need to explore actively their attitudes toward hearing loss and audiologic rehabilitation to bolster their decision to move forward. A common clinical mistake is to counter ambivalence with more information. Instead, the audiologist’s skills in motivational engagement are required to explore the fears and concerns a patient still may have even at this stage of behavioral change.
The change circle concludes with two final stages. In the maintenance stage, some degree of ambivalence may persist but generally patients are pleased with the decision to be fit with hearing aids. The audiologist must continue to provide attentive follow-up and support for patients into the maintenance stage after a sufficient readiness for change has been reached. This stage is designed to maintain the patient’s willingness to work through adjustment and acceptance of amplification and audiologic rehabilitation. The audiologist’s role becomes one of support and encouragement to maintain the successes that have been reached. At this stage, it is critical to establish a plan to address the residual hearing difficulties that are often present following successful hearing aid fittings and to provide continued routine patient follow-up.
The long-term goal of audiologic rehabilitation is to provide sufficient aftercare for patients so that they never enter the relapse stage. However, some patients do discontinue hearing aid use, which may suggest that the perceived benefit was insufficient to sustain the change. Support in the earlier stages—along with a well-implemented follow-up program and the provision of a more comprehensive treatment that includes communication strategy training—helps to avoid potential relapse. Should patients lose their positive attitude about treatment, however, the cycle continues via continuation of support as the patient prepares to reenter the action stage.
The circle of behavioral change is a visual reminder that our counseling and presentation of treatment options are to be customized to meet each patient in his or her current state. Thus, when used in conjunction with self-assessment measures, trained listening skills, and open discussion, this cyclical representation provides the audiologist a context in which motivational engagement can then increase success. Yet the success of any well-orchestrated and competently facilitated journey through the stages of behavioral change is highly dependent on trust.
Building Trust
Listening is a precursor to trust, and trust is a precursor to success. Without trust, acceptance of the information we provide to patients is compromised, attempts toward motivational engagement are jeopardized, and subsequent adherence to professional recommendations is threatened. Effective listening is a necessary foundation for trust and is facilitated by a concentrated effort to avoid known trust barriers (Table 12–1). Possibly one of the greatest of these barriers is communication mismatch, which occurs when clinicians respond to the content of patient’s statements but fail to recognize and acknowledge the emotions that may lie beneath the spoken words.
Patient Education
Within several stages building toward behavioral change, those with hearing loss will be seeking information and clarification. Of all the counseling that patients need in the course of audiologic rehabilitation, patient education (AKA content counseling) is an area in which most audiologists feel comfortable. Unfortunately, the delivery of further information is often poorly timed. The confirmation of a hearing loss may release a flood of patient questions and concerns ranging from potential progression, etiology, risk factors for future generations, implications for anticipated quality of life, and others. It is frequently at these most emotionally charged times that audiologists provide critical information on the implications of test findings or options for treatment (Clark & Brueggeman, 2009). However, neuroscientific research reveals that heightened emotional states directly impede cortical processing of new information (Cahill, Babinsky, Markowitsch, & McGaugh, 1995; Canli, Zhao, Brewer, Gabrieli, & Cahill, 2000; Richardson, Strange, & Dolan, 2004).
To aid comprehension, patients should be given the opportunity to express their thoughts and concerns prior to the delivery of information. Questions or invitations for dialogue that will serve to facilitate comprehension might include: “Tell me what you have been told before about your hearing loss (or about hearing aids)” or “Before I share details on your test results, or any of my recommendations, what questions do you have for me now that we have confirmed there is a hearing loss?”
Patients from any of the Goldstein and Stevens readiness stages or at any placement on Prochaska and DiClemente’s change circle may benefit from these or similar invitations to field concerns prior to the clinician’s information dissemination.
There is a significant body of literature across health care settings that reveals poor retention of information delivered by health professionals (Anderson, Dodman, Kopelman, & Fleming, 1979; Kessels, 2003; McGuire, 1996). While the emotional state of the patient plays a large role in reduced information processing, the sheer volume of information delivered in a single appointment can be overwhelming for many (Tirone & Stanford, 1992; cited in Lesner, Thomas-Frank, & Klinger, 2001). Therefore, audiologists must strive to support patients openly in the face of unanticipated and unwanted diagnostic discoveries, acknowledging the importance of processing the news. Movement away from a monologue-driven transfer of information is a solid first step to ensure greater comprehension (Clark & English, 2019).
A Neglected Need: Motivational Engagement
Even with the clear establishment of trust and well-delivered information, there will always remain some patients who find the transition to action difficult. When requisite patient motivation for positive action is lacking, audiologists may counter with further information on the hearing loss and the technological benefits of amplification or find themselves defaulting to other external motivators including celebrity endorsements, financial incentives, or third-party testimonials. However, life lessons have repeatedly shown that motivation that arises from within is both more successful and sustainable than any external motivator.
When amplification is indeed warranted, patient apprehension including cost and maintenance demands, cosmetic factors, stigmatic impact, and acquaintance with others who did not succeed with hearing aids can, for some patients, hold greater sway over the internal decision process than potential benefit that may be afforded through successful hearing loss treatment. Directly addressing the possibility of a patient’s negative perceptions of hearing aids and hearing loss can result in greater adherence to recommendations and a greater opportunity to provide hearing assistance to patients and their families. Toward this end, motivational engagement helps build the requisite internal motivation to accept and act upon recommendations (Rollnick, Miller, & Butler, 2008).
The need for an internal motivation to take action to address hearing difficulties has been addressed in the audiologic literature (Beck & Harvey, 2009; Beck, Harvey, & Schum, 2007; Harvey, 2003). The practice of motivational engagement helps audiologists guide patients in (a) reflection on the impact of hearing loss; (b) their own willingness to make the necessary changes to address this impact; and (c) their perceived abilities to make needed changes (Clark, 2010; Clark & English, 2019; Clark, Maatman, & Gailey, 2012; Fergusen, Maidment, Russell, Gregory, & Nicholson, 2016). As audiologists help patients find an internal motivation for successful hearing loss treatment, there are few better insights than those that may be obtained through self-assessment measures.
For patients who arrive ready to accept treatment recommendations (Goldstein and Stevens’ Types I and II, or Prochaska and DiClemente’s “action” stage), it is not external motivators that induce action, but rather the effect of these external motivators on preexisting internal motivation to accept treatment options, including amplification use. For more reluctant patients, whose internal motivation is low, trying to entice action through external motivators is generally a weak approach, as it ignores the patient’s true concerns.
The clinician’s interactions and experiences with patients from opposite ends of the readiness spectrum may be quite different. For those with relatively low internal motivation, the audiologist’s recommendations likely come as unwelcome news, often eliciting a number of defense mechanisms. But, for patients who are actively seeking an improvement of their hearing ability, little or no resistance may be encountered. Though the latter patient is often ideal, audiologists must be prepared to coach the full spectrum of readiness for change.
For those patients clearly not ready to proceed with treatment, audiologists frequently will acknowledge the lack of current motivation, provide what information they can, and offer a follow-up appointment to see if either hearing levels or impact recognition have changed. However, this approach should be a last resort after directly addressing motivation. When we fail to address lacking motivation, we have failed these patients and those who interact with them. These patients return to their lives with the same communication limitations they arrived at our offices with, destined to perpetuate the same failures and frustrations they have been contending with for some time.
Engaging the Patient Toward Change
While detailed descriptions of audiologic test results and their relation to speech understanding are informative (if a patient is in a state to process the information effectively), when readiness is not previously existent, this information delivery cannot instill the same level of motivation as does a personal exploration of the negative impact of hearing loss and the perceived barriers to treatment. Building motivation to accept audiological treatment recommendations requires patients’ acknowledgment and understanding of the influence of hearing loss within the context of their daily life activities. While a first step in more effectively working with our patients should be to increase our consistent use of self-assessment tools, a close second would be to engage the patient’s primary communication partner in the consultation process, a resource that continues to remain underutilized in the clinic (Clark, Huff, & Earl, 2017; Stika, Ross, & Cuevas, 2002). Together, these may be keys to jump-starting internal motivation. Motivational engagement, when combined with a horizontal approach to patient management in recognizing the valuable contributions of both patients and communication partners to the rehabilitation process, facilitates a guided patient encounter that is as individualized as our treatment recommendations. (Editors’ note: For further information on communication partners, the reader is referred to Chapter 19 of this text.)
In audiology, denial of hearing loss, unwillingness to make a life-altering change, opposition to diagnostic findings, and indecision to proceed demonstrate how uncomfortable change can be (Clark, 1999). As such, it is paramount that we accept each patient’s feelings and attitudes of the moment (Rogers, 1951). Motivational engagement allows for that acceptance while helping patients to challenge themselves to view their perceptions differently, thereby moving them in a positive direction.
The need to engage our patients and enhance their motivation through guided self-realization is obvious; the exact method of choice, perhaps less so. In practical health care, the chosen protocol must be time efficient, especially when utilized within a busy facility and when discussion of any recommendations is not the sole planned activity during a given appointment. Unless explored, the audiologist rarely knows the patient’s readiness for change and motivational level. Clinicians quickly discover that when the patients’ readiness level is relatively high, the stages of motivational engagement move rapidly and take an insignificant amount of time. The up-front time investment is a bit greater when it is discovered that patient readiness and motivation are low. However, the net amount of clinical time saved is high when clinical time is not spent on recommendations that the patient likely will not pursue or may ultimately reject after attempting to follow.
Drawing the Line: Assessing Perceptions
Using a clean and simple scaled line, patients can visually rank their perceived importance for change and their belief in their own ability to make a needed change (Figure 12–2). Earlier responses to self-assessment measures may reveal specific difficulties resulting from untreated hearing loss, such as frustration when talking with others (e.g., Hearing Handicap Inventory for the Elderly, Ventry & Weinstien, 1982) or others expressing concern or annoyance with hearing abilities or being less social due to difficult communication (e.g., Self-Assessment of Communication, Schow & Nerbonne, 1982). The paramount factor is that the importance-ranking line links to the patient’s own story, providing a self-reported internal motivator capable of compelling him or her to make a significant change.
Where Do We Go Next?
The paths to follow in motivational engagement differ at this point depending on the patient’s answer. We ultimately will want to know two things: (a) how important change is, and (b) how strongly the patient believes he or she can make needed changes. (Note: For further information regarding self-efficacy, the reader is referred to Chapter 13 of this text.)
Case Study 12–2
Audiologist: It sounds like you’re experiencing quite a few frustrations with your daughter when she comes to visit on the weekends. She seems to think it might be related to your hearing, but you feel that she talks too softly and mumbles. Am I listening to you accurately?
Patient: Yeah, I always tell her to speak up, and she never does. I try to hear her, but it’s like she doesn’t care if I understand or not. I feel like she’s wasting her time coming over to talk sometimes because we argue so much over this.
Audiologist: I definitely agree with you that the way people talk can have a significant impact on our ability to understand what they’re saying, and it would be helpful to address that with your daughter at some point. But also, as we discussed, the test results do show that you have some hearing loss. There are clearly several factors contributing to the frustration you and your daughter are experiencing, and certainly your hearing loss is enough to be a part of this.
Patient: Sure, it’s probably a combination of things, but I’m sure it’s not all me.
Audiologist: I agree. And we may need to tackle things from more than one front. But just so I have a better understanding on how to help you, can you tell me, say on a scale of zero to 10 with zero being not important at all and 10 being extremely important, how important is it to you, in light of the frustrations you have described, to improve the communication between you and your daughter.
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