How often have you been flossing? Haven’t you been meaning to exercise? Why aren’t you eating better? There are many things we know we should be doing about our health—but aren't. It’s not that we haven’t been told about them many times and in many ways. We are just ambivalent about change. Perhaps we don’t have the desire, ability, reasons, or need to change our behavior.
Why then, should we be surprised when patients do not accept our recommendations for amplification? According to the MarkeTrak IX survey (Abrams, 2015), hearing aid adoption rate among adults with perceived hearing difficulty is approximately 30.2 percent. The study also found that patients often view their initial visit to a hearing care provider as an information gathering appointment and will visit more than one before moving forward with amplification and hearing rehabilitation (Abrams, 2015).
It is tempting to view patients who refuse amplification as “resistant to change,” “in denial,” and “non-compliant.” Instead, we should realize from these low adoption rates—and our own experiences as patients—that such resistance is part of a normal process. Better understanding this process and how to accelerate it can increase adoption rates, thereby improving our patients’ quality of life and our bottom line.
The intention of this article, then, is to introduce audiologists to a method of counseling and begin a conversation about how it might be successfully used in any clinical setting. Patient-centered approaches to care and self-motivation are familiar concepts in the field of audiology. Motivational interviewing is a set of concrete techniques that can make those concepts a reality.
Theory and Phases of Motivational Interviewing
Motivational interviewing (MI) was developed to work with another highly “change resistant” population: substance abusers. Alcoholics and drug addicts know very well about the negative consequences of their behavior, and yet they persist. The theory behind motivational interviewing is that the strongest motivations for behavioral change are the ones patients develop for themselves. But “waiting” for patients to develop their own resources can be a difficult task for a clinician. When a counselor sees a patient in difficulty, it is all too tempting to label the problem and offer a quick fix. William Miller, founder of motivational interviewing (2012), calls this the “righting reflex,” our natural tendency to offer help to others by solving their problems.
We’ve all seen how telling a toddler “no” can cause a tantrum. It can be harder to see that trying to direct an adult’s behavior evokes a similar psychological reactance. When someone tries to tell us what to do, it’s as if they are dealing a blow to our autonomy, and our autonomy wants to push back. It’s only natural if we feel angry, defensive, uncomfortable, or disengaged. (We may just be better at minimizing and hiding our distress than the toddler!) This is all to say that we may feel like we have done our job when we “tell our patients what they should do,” but it is the least effective way of getting them to do it!
First Phase: Engaging
The first phase of motivational interviewing is engaging the patient by affirming their autonomy and offering compassion. Asking open-ended questions will elicit deeper patient engagement, and counselors must listen more than they talk, especially in the beginning stages. After listening, counselors can reflect back what they’ve heard. Affirm the patient’s strengths and positive choices, rather than mentioning shortcomings. If patients feel understood, it builds an atmosphere of trust and collaboration. The patient must feel that they are being placed in the driver’s seat when it comes to their care. More accurately, clinicians need to let go of the burden of superior power and judgment that they never had in the first place!
Here’s what it might sound like: “Why would you want to make this change?” “How might you go about it in order to succeed?” “What are the three best reasons for you to do it?” “How important is it for you to make this change, and why?”
Second Phase: Focusing
As the counselor is establishing a compassionate, trusting relationship, they start to elicit the patient’s goals and focus on an agenda. This is not yet the time to offer treatment recommendations! Rather, the patient needs to fully vent all of their concerns, after which time the clinician can help the patient decide what should be tackled first. Helping the patient create an agenda is critical when working on a wide range of issues over a longer time frame, which is more common in psychotherapy or social work. In situations with a narrower focus, like addressing a newly-identified hearing loss, let the patient draw their own conclusions about what needs to happen and when. Allow the patient time to reflect and share where they are. Resist the temptation to fill up silence with talking; you will better alleviate any discomfort your patients might feel by empowering them. If you need to raise possibilities that definitely wouldn’t occur to your patient themselves, use hypothetical language when bringing them up.
Third Phase: Evoking
The next phase is the linchpin of MI: evoking change talk. Says Miller (2012), “people who are ambivalent about change already have both arguments within them—those favoring change and those supporting the status quo. This means that most clients do already have pro-change voices on their internal committee, their own positive motivations for change. These are likely to be more persuasive than whatever arguments you might be able to provide. Your task, then, is to evoke and strengthen these change motivations that are already present.”
Clinicians should listen for phrases that indicate willingness to change. These will be interspersed with “sustain talk”—phrases in favor of continuing the existing state of things. This is normal, and clinicians shouldn’t suppress or contradict sustain talk. Rather, they should ask questions that solicit change talk, and reflect and reinforce the change talk that patients produce. Over time, the proportion of sustain talk should diminish.
The acronym “DARN CAT” can help you identify kinds of change talk and sustain talk. The first four indicate a preparatory phase:
These three categories of “mobilizing change talk” indicate an advanced stage of readiness to change:
Clinicians should aim for a less directive style of communication. When they do need to provide information, it should be surrounded by questions. Miller calls this strategy “Elicit-Provide-Elicit.” This reinforces the autonomy of the patient and guards against the righting reflex. First, the clinician could ask permission to share information, or ask clarifying questions. Another good technique is to ask, “What do you already know about….”
Then, when providing information, the clinician should offer small amounts in clear language without interpreting its meaning for the client. Afterward, ask for the client’s reaction, allowing them to process the information in their own way.
As the proportion of change talk increases, and patients start using more advanced change language, the clinician can try to consolidate this motivation. The clinician can summarize all of the motivations for change that the patient has already expressed. They can ask a big question, like “What do you think you’ll do?” or “So what comes next?” It’s useful to allow a pregnant pause here and there, to encourage patients to process their feelings vocally. Don’t appear rushed, even if you are! As Miller says, “If you act like you have only a few minutes, it may take all day; act as if you have all day, and it may only take a few minutes.”
Fourth Phase: Planning
Only once the client is voicing a clear commitment to change should conversations about next steps or planning start. It’s still critical that patient motivations drive the planning process: it can be tempting to throw all of our recommendations at a patient when they indicate readiness for planning. It would be better to take two appointments for a patient to enthusiastically select a hearing aid than to sell them something in one appointment that winds up in a drawer! If your patient trusts you enough to admit the limitations of their commitment, you can help them devise a more realistic plan.
A recent case may serve to illustrate the benefits of employing the techniques of motivational interviewing in a typical hearing evaluation, hearing aid consultation, and hearing aid trial.
“Betsy R.” is an 80-year-old female whose chief complaint was “difficulty hearing clearly.” The visit began with a discussion regarding her general medical history and then more specifically any otologic symptoms. She reported being under the care of her family doctor for blood pressure issues and denied any tinnitus, vertigo, perception of asymmetry, fullness, or any other otologic symptom, other than her chief complaint. Questions regarding her difficulties in hearing speech were intentionally reserved for after completing the hearing evaluation. Before testing, she volunteered the fact that “an ENT office tried to sell me hearing aids a few years ago and I wasn’t ready.”
The hearing evaluation revealed a very typical case of presbycusis. Thresholds were very symmetric between ears, sloping from mild in the low frequencies to moderately-severe in the higher frequencies. Word recognition scores were good at elevated presentation levels.
After very briefly describing to Betsy the nature of her hearing loss, she was asked the question, “You stated earlier that you weren’t ready for hearing aids several years ago, how do you feel about hearing aids now?” Betsy’s reply was, “it’s something I need to think about, but I know I need to hear better” to which she was then asked, “What types of things do you need to think about?” Betsy replied with several factors including appearance and cost, and the audiologist noted these. By asking these questions, the audiologist was able to determine that Betsy is motivated to hear better, which was reinforced by her own statement, and still has some apprehension.
The audiologist agreed that the factors Betsy stated were very valid concerns. She was then asked for permission to temporarily turn the discussion to specific listening situations that Betsy encountered that caused her the greatest difficulty or were most troubling to her. Betsy listed several situations and the audiologist asked for more information, at times, in order to make sure that the situations were fully described. At this point, the audiologist then said, “So, if I understand you correctly Mrs. R., you would like to understand people better in meetings, around the house, and in the occasional restaurant. Is this fair and accurate?” Betsy confirmed this with a smile on her face. This is an example of reflective listening and a summary statement, which not only elicits change talk but also provides an opportunity to verify that the clinician understands the patient’s thoughts as accurately as possible.
The discussion then turned to specific devices that would fit into Betsy’s budget and appropriately address the listening situations that she was prioritizing. The specific devices were ordered and a fitting visit was scheduled and performed several weeks later. What is important to notice is that at no point in the conversation did the clinician tell the patient what course of action she should take. Instead, the conversation allowed Betsy’s own internal motivations to be brought forward, while not discounting her apprehensions about receiving help. In addition, the conversation was professional, but relaxed, which allowed the patient to freely express what she viewed as positives and negatives towards embarking upon a hearing aid trial.
Several weeks after the fitting, Betsy R. returned to the clinic in order to evaluate her progress in the trial period. Betsy began the discussion pleasantly, but apprehensively, with several complaints regarding the hearing aids. The audiologist listened carefully, and responded, “Okay, thank you for sharing that information. We will try to come up with some solutions to remedy those issues. Tell me though, how did you perform with the devices in meetings, around the house, and at restaurants?” Betsy responded with very positive reports regarding those situations and stated that she felt they were clearly providing considerable benefit. By asking about targeted experiences, the audiologist was not only able to verify that there were positives in Betsy’s mind (since she had not volunteered them), but also, the answers helped to reinforce the progress that was being made during the action stage of treatment.
The audiologist finished up the appointment by creating some solutions for the issues that Betsy brought up at the beginning of the follow-up visit. Betsy successfully completed the trial period several weeks later.
As an audiologist, the temptation is to test the patient’s hearing, explain to them the audiogram, explain to them the problems they are having, and then tell them that they need to make a significant investment in hearing aids. Motivational interviewing is a much different approach that requires much more listening and less talking on the part of the audiologist. When done effectively, it has the potential to greatly increase the probability of a patient agreeing to move forward to improve their quality of life.
Additional approaches for Application to Audiology
The field of audiology also has a few existing tools that are already consistent with motivational interviewing. The Client-Oriented Scale of Improvement (COSI) has the patient self-identify situations of hearing difficulty that they would like to improve. It grew out of a previous tool called Goal Attainment Scaling. These tools were modeled after those used in mental health programs, but their goal was not patient-centered treatment. Instead, it was found that patient-specific goals were much more reliable in validating treatment efficacy than global measures (Dillon, 1997). As regards MI, the COSI impels patients to find their own motivations for hearing aid adoption. These goals then become concrete “anchors” for clinicians in focusing their counseling.
The Ida Institute, an independent non-profit organization, has developed various motivational tools and opportunities for training in person-centered hearing health care. It is beyond the scope of this article to review all of these resources. It is worth pointing out, however, that “The Line” is remarkably similar to a tool Miller mentions, the “importance ruler.”
The concept underlying both is a linear scale—perhaps numbered 0–10—for patients to assess themselves, say, on how important it is for them to make a certain change. Miller (2012) continues, “In itself, this question is of limited usefulness. The value...comes with the follow-up question about the number that the person chose: ‘And why are you at a ____ and not [a lower number]?’ ...[this] is likely to evoke change talk—the reasons why change is important.”
A related , original idea for maintaining patient autonomy during the hearing aid selection process is externalizing a decision tree onto laminated cards. Several manufacturers already produce a chart of listening situations that help patients find their appropriate technology level. Patients could also identify themselves on scale from “set it and forget it” to “I want to control my hearing aid performance,” or “I want my aids to be invisible” to “I don’t care what they look like.”
Additional cards could be used to rank the importance of various hearing aid features, like smartphone connectivity or extended frequency response. As a result, patients should be much more invested in the instrument they have selected.
We hope this introduction has interested you in how motivational interviewing might enhance your clinical practice. But as William Miller stresses, while the concepts behind MI are very simple, putting them into practice is not easy. Audiology’s recent focus on a medical model of care is associated with behaviors like professional distance and top-down expertise that run counter to MI’s culture of collaboration and true patient-centeredness. Working with elderly and/or handicapped populations—as audiologists so often are—makes the righting reflex even more tempting. Understanding MI intellectually will not guarantee better patient outcomes; it may even make things worse when practitioners prematurely believe they “know how to do MI.”
Rather, MI may demand an attitudinal change in its practitioners and a cultural shift in organizations. Miller devotes special emphasis to the “spirit of MI.” “...MI involves a collaborative partnership with clients, a respectful evoking of their own motivation and wisdom, and a radical acceptance recognizing that ultimately whether change happens is each person’s own choice, an autonomy that cannot be taken away no matter how much one might wish to at times.”
MI demands our vulnerability: we must acknowledge that no one truly needs hearing aids, that patients are making a choice not to wear hearing aids which confers benefits to them, and simply telling patients they should do otherwise means we have not fulfilled our real responsibility—helping them embrace change.