Difficult Conversations: Talking About Stigma

Kris English, PhD

Professor Emeritus

The University of Akron

Audiologists observe the impact of stigma on hearing loss (HL stigma) on a regular basis, and yet we haven’t addressed it much as a counseling issue.  HL stigma can be a complicated experience: for many patients, developing hearing loss can itself be stigmatic (associated with negative stereotypes of aging). And as we know, the added prospect of hearing aids can compound the stigma further. Recent research (David et al. 2018) supports this long-standing observation: that hearing aids can be “central to the stigmatic experience,” which is why we need to attend to “the importance of these devices for psychological wellbeing” (p. 133).

From a counseling perspective, we have to acknowledge that HL stigma has negative power and should be addressed. Stigma has been consistently found to impede help-seeking (e.g., Gagné et al., 2011; Heijnders & van der Meij, 2006; Wallhagen, 2009), so our challenge is to address it openly and therapeutically. This article will provide a basic background regarding the development of stigma, and suggestions on how to address stigma in clinic.

Stigma Develops in Stages

Corrigan et al. (2006) describe stigma development as a socially-constructed three-stage process:

1st stage: Stereotype Awareness, wherein we are aware of society’s negative beliefs about a health condition or disability: My grandmother says all of her friends are losing their hearing. She says they always seem confused, and she doesn’t enjoy their company anymore.

2nd stage: Stereotype Agreement, wherein we concur and endorse these negative beliefs, developing our own prejudice: When I visited my grandmother, I could see why she doesn’t enjoy her friends these days. They are in their own world and have no idea what anyone else is talking about.

3rd stage: Self-Congruence or Self-Stigma, wherein we internalize society’s negative attitudes and apply them to ourselves, risking adverse effects on self-concept and personhood: I am having the same hearing problem my grandmother used to complain about.  It’s so humiliating.

The final stage – self-stigma – includes self-rejection, a belief in a diminished self, and shame, wherein an individual feels “disqualified from full social acceptance” (Goffman, 1963, p. 9). Weiss et al. (2006) describes self-stigma as a “hidden burden” – our challenge is to help patients discuss that burden and perhaps free oneself from it.

Rosenstock, 1974

Our take-away: as described above, stigma is a belief, which in itself presents a challenge. Because of our scientific base, audiologists don’t pay much attention to beliefs, but we should. After all, common objections to hearing devices – the impact on self-image and self-identity, cosmetic sensitivity, the certainty of social rejection – are beliefs, not facts.  We may be familiar with The Health Belief Model (Rosenstock, 1974), created as a means to predict health-promoting behaviors (e.g., Saunders et al., 2013), but it has yet to impact clinical practices.

Preparing Ourselves

Before we respond to a patient’s perception of stigma, we must be comfortable talking about it. For instance, we may worry about the “elephant in the room” phenomenon: should we “go there?”  We may think that talking about it will increase a patient’s self-stigma, yet if we don’t talk about it, we can be fairly sure it will not resolve on its own.

As applied to audiologic counseling, we aim to help patients consider changing their negative beliefs about hearing loss and hearing help (Clark & English, 2019). Consider the following dialogue: how did the audiologist help the patient transcend stigma and move forward?

A Self-Stigma Conversation

Audiologist:   Mr. Petry, now that we’ve compared your initial concerns to your test results, we can shift gears and talk about next steps. You mentioned upfront that you just wanted information but had no interest in hearing aids – could you expand on that?

Mr. Petry: Wait, are you saying I need hearing aids?  I really don’t want to!

Audiologist:  Because ….?

Mr. Petry: (getting agitated) Because … hearing aid users are feeble and old. I don’t want to be that kind of person.

Audiologist: Are you thinking of someone in particular – someone you know? (Patient nods.) What might it seem like from his/her point of view?

Mr. Petry: Sure, there’s my old pal Jim. He doesn’t seem to mind how his hearing aids look – but I do.  Why advertise your problems like that?  No one wants to look weak.

Audiologist: OK. It sounds like he doesn’t see it that way, though. If you asked him, how might he describe hearing aid use?

Mr. Petry: I know him pretty well; I think he’d say he doesn’t care about what other people think.

Audiologist: Have you ever wondered how you developed your reaction to hearing aids?

Mr. Petry: Just from what people say, I guess.

Audiologist: Other people really can influence us, and often we don’t even notice it. My concern is this: your thoughts on amplification are keeping you from improving the problems you initially mentioned. Is there another way you could think about amplification that would make you feel strong instead of weak?

Mr. Petry: Well, I normally face my problems head on – like Jim, actually. It probably wasn’t easy for him to become a hearing aid user but he did it anyway. If he can do it, so can I.

Audiologist: Then we’ll tap into your past history of successful problem-solving. You might experience mixed feelings along the way, but we’ll keep talking about it. I agree, it’s not easy.

A Breakthrough in Self-Stigma

What Happened Here?

The audiologist attempted to:

  1. Accept the negative beliefs without judgment.
  2. Shift from “stereotype agreement” (“that kind of person”) to a specific relationship (Jim) and asked the patient to imagine a different perspective.
  3. Validate that different perspective (“sounds like he doesn’t see it that way”) and encouraged the patient to again consider his friend’s situation.
  4. Ask the patient to consider the source of his stigmatic belief.
  5. Ask the patient to reframe his belief (“Is there another way you could think about” hearing aids, like your friend does?)
  6. Validate his past history of successful efforts.

These steps helped the patient examine unquestioned negative beliefs about hearing aids and consider alternative points of view and choices.

Three Things Didn’t Happen

The audiologist took pains not to:

  1. Discount or overrule expressed self-stigma (“you shouldn’t feel that way/you shouldn’t let that belief hold you back”). Once a patient verbalizes a position, it’s hard to back down (Gardner, 2004).
  2. “Upshift,” as described by Goulston (2010): “Most people upshift when they want to get through to other people. They persuade. They encourage. They argue. They push. And in the process, they create [even more] resistance” (p. 4)
  3. Use the words stigma, stereotype, or beliefs, to avoid putting the patient on the defensive.

Not a One-Time Conversation

Developing stigma is a process; transcending it will also be a process. We should remind ourselves to continue the conversation in subsequent appointments regarding changes in perception, beliefs, acceptance.  Why? Because change is hard! “Stigma is powerfully reinforced by culture and its effects are not easily overcome by the coping actions of individuals” (Heijinders & van der Meij, 2006, p. 356).

Also: Invite the Conversation

Doherty (2016) reminds us. “Our patients will likely be sensitive to potential stigma, even if they do not mention it.”  As a matter of course, we can routinely bring it up ourselves: “Sometimes patients worry about [appearance, societal reactions, etc.]. What are your thoughts? Any qualms?”


Talking about stigma certainly qualifies as a difficult conversation!  Our skill in doing so could make the difference in patient decisions, but we have had virtually no guidance.  We need to develop our own guidance, and share our work with the profession.

7.5 Tier 1 CEUs in Counseling Available Here!




Clark & English (2019). Counseling-infused audiologic care. Inkus Press/Amazon.com

Corrigan, P. W., Watson, A. C., & Barr, L. (2006). The self-stigma of mental illness: Implications for self-esteem and self-efficacy. Journal of Social and Clinical Psychology, 25(8), 875–884.

David, D., Zoizner, G. & Werner, P. (2018). Self-stigma and age-related hearing loss: A qualitative study of stigma formation and dimensions. American Journal of Audiology, 27, 126-136.

Doherty J. (2016).  New thoughts on hearing loss and stigma.

Gagné J-P, Southall K, & Jennings MB. (2011). Stigma and self-stigma associated with acquired hearing loss in adults. Hearing Review, 18(8), 16-22.

Gardner, H. (2004). Changing minds: The art and science of changing our own and other peoples’ minds. Boston: Harvard Business School Press.  

Goffman, E. (1963). Stigma: Notes on the management of spoiled identity. NY: Simon & Schuster.

Goulston, M. (2010). Just listen: Discover the secret to getting through to absolutely anyone. New York: AMACOM.

Heijnders, M., & van der Meij. (2006). The fight against stigma: An overview of stigma-reduction strategies and interventions. Psychology, Health & Medicine, 11(3), 353-363.

Rosenstock, I. (1974). Historical origins of the Health Belief Model. Health Education and Behavior, 2(4), 328-335.

Saunder, G., Frederick, M.T., Silverman, S. & Papesh, M. (2013). Application of the health belief model: Development of the hearing beliefs questionnaire (HBQ) and its associations with hearing health behaviors. International Journal of Audiology, 52(8), 558-567.

Wallhagen, M. (2009). The stigma of hearing loss. The Gerontologist, 50(1), 66-75.

Weiss, M., et al. (2006). Health-related stigma: Rethinking concepts and interventions. Psychology, Health & Medicine, 11(3), 277-287.

Difficult Conversations: Screening for Bullying Problems

Kris English, PhD

Professor Emeritus

The University of Akron

We all know that childhood bullying is nothing new.  However, we now also know a great deal about the long-lasting effects of bullying victimization. Longitudinal cohort studies indicate that children with a history of being bullied are at increased risk for overall mental and physical health problems, anxiety, depression, and self-harm — toxic stress responses that extend far into adulthood (Copeland et al., 2013; Lereya et al., 2015).

The U.S. Department of Education (2011) has identified bullying as a public health/public safety issue, and Takizawa et al. (2014) have framed it in the clearest possible language: “Victimization by bullies is increasingly considered alongside maltreatment and neglect as a form of childhood abuse” (p. 777).  Excuses such as “kids will be kids” and “bullying is just a rite of passage” can no longer be tolerated.

As part of a child’s support system, we must understand that children who are being bullied might hesitate to ask for help, for a variety of reasons: embarrassment, fear of retribution, or worry that adults will make the situation worse. They may not even be sure of the difference between “tattling” (which they’ve been taught they should not do) and telling an adult about being bullied. Bauman and Pero (2010) unsurprisingly found that children with hearing loss were just as likely as other children to “not tell.”

Rather than wait for a child to disclose a problem, the American Academy of Pediatrics (AAP) (2009, 2017) adopted a policy to routinely screen for bullying concerns as a standard of care. Squires and colleagues (2013) have advocated for audiologists to assume the same responsibility. But how to broach this sensitive subject?

First, Do Our Homework

We should not screen for bullying until we have some basic information:

⇒ Review StopBullying.Gov for important information on “red flags,” at-risk children, cyberbullying, a child’s legal rights to a safe environment at school (Norlin, 2015), and bullying concerns outside of school.

⇒ Learn local laws and policies re: anti-bullying programs in the child’s school, and communicate with school administration when possible.

⇒ Develop a support team at your setting, and ensure you are ready for “next steps” should a child disclose a concern, including self-harm.  We should not screen until we are comfortable with the unpredictable nature of the subsequent conversation.

A Screening Conversation

The following bullets and flowchart can be used to frame the screening conversation (Clark & English, 2019). The approach starts from a safe and general context, shifting to a child’s social circle, and eventually to the child him/herself:

  • Here in our clinic, we now have a question we ask every child these days, and I hope you will help me with it. I understand all schools have a bullying prevention program; can you tell me about yours?
    • (If little information is shared, some follow-up questions include: is there a safety officer?  Posters around school about being safe? What do you think about the program?)
    • (If the audiologist is working in a school, the opening question would address the on-site program: We have a program here, but we always want to check to see what children think about it.  Do you think it works, etc?)
  • Do any of your friends have problems with a bully?
  • If it happens, do your friends know what to do/who to talk to?
  • How about you: do you know any bullies? Do they bother you…?

As We Screen:

Children may hesitate to describe a situation as bullying. We are listening for:

  • An imbalance of power
  • Ongoing recurrences
  • Intentional rather than accidental behavior
  • Behaviors that cause mental, social, emotional, or physical harm
  • Any sign of distress

Our follow-up steps:

  • Let the child know we will help
  • Communicate concerns with parent/caregiver (who may need help bringing the concern to school officials)
  • Share information on strengthening the child’s IEP (see Hands&Voices.org)
  • Monitor the child’s well being and school responses
  • Keep referral systems up-to-date: a child could be in a crisis situation and considering harm to self or others.
  • Document
    • Note: If working in a medical setting, the AAP recommends adding a screening query to the electronic medical records system, not only to document but also establish the process as a standard of care.

A Matter of Urgency

If the reader has any concerns or questions about this topic, please do not hesitate to contact the author.

7.5 Tier 1 CEUs in Counseling Available Here!




American Academy of Pediatrics. (2009). Policy statement – Role of the pediatrician in youth violence protection.

American Academy of Pediatrics. (2017). Protecting youth from bullying: The role of the pediatrician.

Bauman S. & Pero H. (2011). Bullying and cyberbullying among deaf students and their hearing peers: An exploratory study. Journal of Deaf Studies and Deaf Education, 16(2), 236-253.

Clark JG. & English KE. (2019). Counseling-infused audioloigc care. Cincinnati: Inkus Press/amazon.com.

Copeland W. et al. (2013). Adult psychiatric outcomes of bullying and being bullied by peers in childhood and adolescence. JAMA Psychiatry, 70(4), 419-426.

Hands&Voices.org. (n.d.) Silence is NOT an option: A parent driven plan to keep our children safe at home and at school”

Lereya S et al. (2015). Adult mental health consequences of peer bullying and maltreatment in childhood: Two cohorts in two countries.  The Lancet Psychiatry, 2(6), 524-531.

Norlin JW. (2015). Disability-based bullying and harassment in the schools: Legal requirements for identifying, investigating, and responding.

Squires, M., Spangler, C., Johnson, C., & English, K. (2013).Bullying is a safety and health issue: How pediatric audiologists can help. Audiology Today, 25(5),18-26.

Takizawa R et al. (2014). Health adult outcomes of childhood bullying victimization: Evidence from a five-decade longitudinal British birth cohort. American Journal of Psychiatry, 171(7), 777-784.

U.S. Department of Education. (2011). President and First Lady call for united effort to address bullying.

Difficult Conversations: Screening for Dementia

John Greer Clark, PhD

Professor, University of Cincinnati, OH

Audiologists must always be prepared to view their patients in a context wider than the immediate condition for which they may be seen. One of the seven primary components of person-centered care in audiologic practice is that of a holistic outlook for patients which dictates “a continued vigil for the safety and well-being of those served both within the clinic and within the patient’s broader life context” (Clark & English, 2019, p. 5).  Both hearing loss and dementia can have negative impacts on patients’ emotional well-being, psychological status, and societal and family interactions.  The incidence of dementia increases with advancing age, as does presbycusis, presenting significant challenges to the audiologist when these conditions coexist (Cacace, 2007).

Hearing loss is one of the noted modifiable risk factors for dementia (Livingston et al., 2017), and if identified and treated early, its impact on dementia may be lessened (Beck et al., 2018).  Similarly, early detection of dementia has the potential to lessen the negative impact of hearing loss on one’s quality of life.

Broaching the Subject

One means of broaching the subject of possible cognitive decline with patients is to include inquiry of concern within the case history (Amero et al., 2017).  The following scenario depicts how to segue into a discussion about screening.

While reviewing case history information with Mr. Baxter and his wife, Dr. Collier says, “I see that you answered ‘Yes’ to the question ‘Do you or any members of your family have any concerns about memory challenges or confusion that you appear to have?’ Can you tell me a bit about your concerns?”

Mr. Baxter looks over at his wife hoping that she might respond to this topic that he tries his best not to think about.  After a brief pause, Mrs. Baxter responds, “Well we aren’t sure if it is anything really, but we have noticed that Jim seems to lose things a lot.  His glasses… keys… his watch the other day.  We all lose things, but this just seems to be so much more frequent than before. And last week he called me from the grocery parking lot.  He said he wasn’t sure if home was to the left or the right from the store.  We downsized four years ago and it used to be a right turn out of the lot, but now it’s a left turn.  We haven’t really talked to anyone about this.  Not yet, anyway.”

“Well, you are correct,”Dr. Collier says.  “We all do forget things and lose things, even lose our direction sometimes.  But what you are saying does seem to make one pause.” Turning to Mr. Baxter, she continues,“Would you be willing to have me give you a brief screening to see if we should be concerned?  If the results of the screening suggest that further exploration on this would be in order, I know a wonderful doctor I could recommend for you.”

(From: Clark & English, 2019, with permission)


And Then What?

As noted by Beck and colleagues, the very act of completing a cognitive screening, or even suggesting such, can serve as a post-traumatic trigger for the memories, sometimes all too recent, of the many unwanted changes (of all kinds) that frequently accompany aging.  As such, these authors suggest empowering patients at this juncture by relinquishing the lead and asking if they would like information on how the results of the screening may be beneficial.

Subsequent conversation should emphasize that no screening is definitive and that poor performance (that is, not failure) can be related to prescription medications, vitamin deficiencies, or depression.  It should be stated that the audiologist’s goal is to ensure that patients remain as socially active as possible and that further evaluation is recommended to help achieve that goal.  At this juncture, and in keeping with the audiologists’ code of ethics, audiologists should have well established referral networks. Conversely, when the patient performs well on a cognitive screening, discussion should include mention of the fact that screenings are imperfect, and if the family’s present concerns continue or increase they should discuss them with the patient’s physician.

And What If?

Patient-centered ethics dictates that a patient’s desire to decline professional recommendations take precedence over the professional’s desire to provide treatment (Clark, 2007).  Even so, when a patient initially selects to decline recommendations, explorations of underlying reasons through practices of motivational engagement are often successful in helping a patient find the internal motivation and resources to engage with recommendations (Clark & English, 2019).  But in the end, accepting the supremacy of patients’ decisions on the direction of their care should never be viewed as a case of failed intervention.

And Now What?

A support system can help us increase confidence and reduce discomfort with difficult conversations

Each of us must examine our comfort level in discussing issues of cognitive decline with our patients and providing screenings when indicated.  When we feel uncomfortable with providing services our patients may need, we are ethically bound to research the area of discomfort, discuss it with colleagues and prepare ourselves to provide the best care possible.  When screening patients for dementia, two useful cognitive screening tools are the Mini-Cog Screener (Borson et al., 2003) and the Saint Louis University Mental Status Examination (see video for more info: http://bit.ly/2ofDNBf).


7.5 Tier 1 CEUs in Counseling Available Here!



Armero O, Crosson S, Kasten A, Martin V. &, Spandau C. (2017).  Cognitive screening model expands health care delivery. Hearing Journal, 70(6), 12-13.

Beck DL, Weinstein BE, & Harvey MA. (2018). Dementia screening: A role for audiologists. Hearing Review, 25(7), 36-39.

Borson S, Scanlan JM, Chen P, & Ganguli M. (2003). The Mini-Cog as a screen for dementia: Validation in a population-based sample. Journal of the American Gerontological Society, 51(10), 1451-1454.

Cacace AT. (2007). Aging, Alzheimer’s disease, and hearing impairment: Highlighting relevant issues of additional research, Editorial. American Journal of Audiology, 16, 2-3.

Clark JG. (2007). Patient-centered practice: Aligning professional ethics with patient goals. Seminars in Hearing, 28(3), 163-170.

Clark JG. & English KE. (2019). Counseling-infused audioloigc care. Cincinnati: Inkus Press/amazon.com.

Livingston G, Sommerlad A, Orgeta V, et al. (2017). Dementia prevention, intervention, and care. The Lancet, 39, 2673-2734.


Alzheimer’s Association and Centers for Disease Control and Prevention. (2013). The Healthy Brain Initiative: The Public Health Road Map for State and National Partnerships, 2013–2018.

Centers for Disease Control and Prevention. (2011). The CDC Healthy Brain Initiative.

National Institute on Aging. (2017). Basics of Alzheimer’s Disease and Dementia.

Prince, M., Bryce, R., Albanese, E., Wimo, A., Ribeiro, W., & Ferri, C. P. (2013). The global prevalence of dementia: A systematic review and meta analysis. Alzheimer’s Dementia, 9(1), 63-75.

Teaching Empathy: Evaluating Skills and Habits (Part 3/3)


Kris English, PhD

The University of Akron/NOAC

In Part 1 of this series, we considered empathy as an act of “sharing space” with another’s experience and emotional state. In Part 2, we highlighted the importance of actively checking our impressions of another’s experience and state, to avoid the disconnect of “rejected empathy.”

Taking this learning process to its logical conclusion, as educators we are charged to evaluate the development of these interpersonal skills. However, to date very little has been written in audiology as to how to go about it.  Fortunately, there are several valid and reliable assessment tools (Batt-Rawden et al., 2013), including the Four Habits Coding Scheme, described and referenced below.  Before testing out the Four Habits, though, let’s consider one habit not included on this rubric, a habit that we may need to break: a tendency to try to “make things better” by saying “at least.”

“At least” … Creating Distance, Not Sharing Space

Such a seemingly innocuous phrase! And yet, consider the following comments and their impact on empathy:

  • At least we can improve your hearing problems with modern technology.
  • At least we identified your child’s hearing loss early.
  • Lots of people have hearing loss far worse than you do (“at least” is not spoken but implied).

On the surface, our intention is commendable: to help a patient or parent feel better (Lundberg & Lundberg, 1997). However, ironically, to say or imply “at least” only makes the speaker feel better, and at the same time diminishes the patient’s experience. By offering impersonal reassurances, we inadvertently distance ourselves from our patient.  We convey access to some special knowledge, that we know more about the situation than the person experiencing it. Such distance-creating signals are inconsistent with what Carl Rogers (1979) called “the subordination of self.” Discuss!

Applications to Audiology

Learning Objective #1: Catch/break the habit of saying “at least.”

Learning activity:  View this 3-minute animated segment of a popular TED talk:
Brené Brown on Empathy.

  1. Give three examples of how an audiologist might be inclined to “empathize” with an “at least” response.
  2. Name three emotional reactions a patient or parent might experience when presented with an “at least” response.


Learning Objective #2: Evaluate empathy skills with a valid, reliable rubric.

Learning Activity: Ask students to self-evaluate their present ability to communicate empathy using one section of the “4 Habits Coding Scheme” (Jensen et al., 2010; Krupat et al., 2006), summarized in the table below.  Conduct your own evaluation of each student and then compare notes. What seems to be your next step to improve empathy skills?

Coding Scheme: Code each item below using categories 1, 3 or 5. If you feel strongly that the behavior being coded is directly between these categories, use the values 2 or 4.

5 = Exemplary

  1. Clearly accepts/validates patient’s feelings (e.g., I’d feel the same way… I can see how that would worry you…)
  2. Makes clear attempt to explore patient’s feelings by labeling them (e.g., It seems to me you are feeling quite anxious about ….)
  3. Displays nonverbal behaviors that express great interest, concern, and connection (eye contact, tone of voice, body orientation) throughout appointment

3 = Acceptable

  1. Briefly acknowledges patient’s feelings but makes no effort to accept/validate.
  2. Makes brief references to patient’s feelings but does little to explore or label them.
  3. Nonverbal behaviors show neither great interest or disinterest (or behaviors over course of appointment are inconsistent)

1 = Poor

  1. Makes no attempt to respond to/validate the patient’s feelings, possibly belittling them (e.g., It’s ridiculous to be so concerned about …)
  2. Makes no attempt to identify patient’s feelings
  3. Nonverbal behavior displays lack of connection (e.g., little or no eye contact, body orientation or use of space inappropriate, bored voice)

(Sources:Jensen et al., 2010; Krupat et al.,2006; Lundeby et al., 2015)

A Final Thought (For Now)

When it comes to teaching empathy, Batt-Rawden et al. (2013) suggest we think about “walking the walk:”

Bayne (2011) highlighted the importance of role models and the reciprocal nature of empathy development in training, suggesting that “Indeed, perhaps students need to receive more empathy from faculty… before they can truly understand how to establish empathic connections.” Thus, educators should consider using the practice of relationship-centered care as the fundamental building block for their educational interventions to teach empathy” (p. 1175).


Batt-Rawden, S., Chisholm, M., Anton, B. & Flickinger, T.  (2013).  Teaching empathy to medical students: An updated, systematic review. Academic Medicine, 88(8), 1171-1177.

Bayne, H. (2011). Training medical students in empathic communication. The Journal for Specialists in Group Work, 36, 316-329.

Krupat, E., Frankel, R., Stein, T., & Irish, J. (2006). The Four Habits Coding Scheme: Validation of an instrument to assess clinicians’ communication behavior. Patient Education and Counseling, 62, 38-45.

Jensen, B., Gulbrandsen, P., Benth, J., Dahul., Krupat, E., & Finset, A. (2010). Interrater reliability for the Four Habits Coding Scheme as a part of a randomized controlled trial. Patient Education and Counseling, 80, 405-409.

Lundberg, G., & Lundberg, J. (1997).  “I don’t have to make everything all better”: Six practical principles that empower others to solve their own problems while enriching your relationship. New York: Penguin Books.

Lundeby, T., Gulbrandsen, P., & Finset, A. (2015). The Expanded Four Habits Model – A teachable consultation model for encounters with patients in emotional distress. Patient Education and Counseling, 98, 598-603.

Rogers, C. (1979). Foundations of the person–centered approach. Education, 100(2), 98-107.

Teaching Empathy Skills: “Checking” (Part 2/3)

Kris English, PhD

The University of Akron/NOAC

In Part 1, a vignette depicts a patient informing her physician that her spouse had recently passed away. Unfortunately, the physician assumed too much about the patient’s life and experience, and expressed empathy for a situation that didn’t exist. The patient decided to correct the physician’s assumptions, an awkward counter-response that Frankel (2017) calls “rejected empathy.” Although hypothetical, we should spend a moment imagining the rest of this scenario: once the first exchange went off the rails, the physician would hopefully apologize, clarify, and try again — still appreciated by the patient but not an optimal outcome (Derksen et al., 2017).

An Avoidable Misstep

We would never intentionally cause hurt or harm by offering empathy that a patient will need to reject, but we may find ourselves taking similar missteps. Perhaps we still think of empathy as Barrett-Lennard (1981) did when he described an “empathy cycle” consisting of three phases:

  • Phase 1: the inner process of empathetic listening to another who is personally expressive in some way
  • Phase 2: the attempt to convey empathetic understanding of the other person’s experience
  • Phase 3: the other person’s reception or awareness of this communication

In light of Frankel’s vignette, it seems fair to say that this “empathy cycle” is incomplete. All three phases were involved, and yet the outcome was ineffective. Perhaps Barret-Lennard suspected as much, since he does point out, “There is room for considerable slippage” (p. 91).

Teaching “Checking”

When we take on the task of teaching empathy skills, we should base our instruction on the most complete definition possible.  Like Frankel, Mercer and Reynolds (2002) include the aspect of “checking for accuracy”:

  1. Understand the patient’s situation, perspective, and feelings (and their attached meanings)
  2. Communicate that understanding and check its accuracy (emphasis added)
  3. Act on that understanding with the patient in a helpful (therapeutic) way (p. S9)

In other words, regarding #2 above, “If you don’t get that confirmation, you aren’t done” (Coulehan et al, 2001, p. 225).

Applications to Audiology

Our time with patients and family is usually limited, and we certainly don’t want to spend time repairing rejected empathy if we can help it. Ideally, we keep the encounter on track by assuming nothing and inviting/waiting for relevant details that we can respond to with accuracy, or as Brené Brown describes it, “climbing down into the hole” (described in Part 3).  For example:

Learning objective #1: Identify “checking for accuracy” skills.

Learning activity: View this 2.5 minute segment from the animated movie Inside Out. Find an example of a listener who did not check for the accuracy of another’s feelings. What was the result? Find an example of a listener empathizing with another’s feelings who did check for accuracy of her perceptions. What was the result?

Learning objective #2: Demonstrate “checking for accuracy” skills.

Learning activity: With a partner, write an alternative dialogue for this video segment with an intentional “rejected empathy” exchange, plus a second version that checked for accuracy. Present your script to classmates. On a 0-10 scale, (0= easy, 10=very difficult), how challenging is it to listen to another’s story without assumptions or solutions?  How difficult is it to check for accuracy?


Improving our empathy skills requires consistent reflection of empathic opportunities and how we respond to them. Just by trying to empathize, we are bound to make mistakes occasionally. But as students of the process, we must ask ourselves: Why did the physician in Frankel’s scenario assume incorrectly? How do we avoid assuming too much? What do we routinely assume about our patients, and are we right in doing so? How do we know we are right?

And what skills will serve us best?  Every article and book on empathy offers the same answer: genuine listening.  But how do we describe and evaluate empathic listening? The final entry in this series will focus on the relationship between listening and empathy, and also breaking the habit of saying “at least.”


Barret-Lennard GT. (1981). The empathy cycle: Refinement of a nuclear concept.  Journal of Counseling Psychology, 28(2), 91-100.

Coulehan JL, Platt FW, Egener B, et al. (2001). ‘Let me see if I have this right…’: Words that build empathy. Annals of Internal Medicine,135(3), 221-226.

Derksen, F., et al. (2017). Consequences of the presence and absence of empathy during consultations in primary care: A focus group study with patients. Patient Education and Counseling, 100, 987-993. 

Frankel, R. (2017). The evolution of empathy research: Models, muddles, and mechanisms. Patient Education and Counseling, 100, 2128-2130.

Mercer, S., & Reynolds, W. (2002). Empathy and the quality of care. British Journal of General Practice (Suppl.), S9-12.

Teaching Empathy Skills: Sharing Space (Part 1/3)

Kris English, PhD

The University of Akron/NOAC

The concept of empathy is a foundational aspect of audiologic care – foundational but elusive. Students and instructors generally know how to define it, for example, “the ability to understand the patient’s situation, perspective and feelings, and to communicate that understanding to the patient” (emphasis added) (Coulehan et al., 2001, p. 221).

However, as is often said in counseling texts, “knowing is not enough.” Knowing a definition does not mean a skill has been acquired. How can instructors bring the concept of empathy to life, and actively support the develop of empathy through course content and clinical training?

Guidance is available in related fields. For instance, Batt-Rawden et al. (2013) provide a systematic review of methods designed to teach empathy to medical students. These methods include a range of educational interventions that effectively maintain and enhance students’ personal capacity for empathy, such as:

  • Patient narratives
  • Reflective essays
  • Communication skills training
  • Problem-based learning
  • Interpersonal skills training (role-playing, standardized patients)

Applications to Audiology

For our purposes, we can start with two simple exercises on the process of “sharing space” with another. Here is a combination of reflective essay and communication skills training, for both students and instructors:

Learning objective #1: Develop “empathic understanding” (Mercer & Reynolds, 2002), or more specifically, “the passive emotional response of one individual to the emotions of another” (Batt-Rawden et al, 2013, p. 1171).

Learning activity: View this popular 4-minute video developed by the Cleveland Clinic: Empathy: The Human Connection to Patient Care.   Then, write down at least four specific scenarios that made an impact on you, and describe what the persons in those scenarios were experiencing. Include adjectives that describe emotional states. Repeat the exercise one month later; do any scenarios have a different impact than before? Again, write down your perceptions of patient and family experiences.

Learning objective #2: Demonstrate “empathetic communication” (Mercer & Reynolds, 2002); described as “an active skill that can be acquired and is amenable to nurturing” (Batt-Rawden et al.,2013, p. 1171) and “a visible communication behavior that is enacted when a clinician recognizes and responds to another person’s suffering” (emphasis added) ( Frankel, 2017, p. 2129).

Learning activity: Ask a friend or family member to view the same video, then ask for their reactions and listen carefully. Listen but do not insert your own reactions into the dialogue. Find ways to express that you are trying to understand. Provide some prompts: what else caught your attention?  Other scenarios you’d describe as important or memorable? Later, evaluate your skills: did you refrain from interrupting? Was it difficult or comfortable to “just listen”? Did you understand the other’s experiences and actively communicate that understanding at least once?

Caution: “Empathic Communication” Could Go Awry

Empathic communication can be difficult at times. It can also be unintentionally inaccurate. Frankel (2017) offers this example:

Patient     My husband of 67 years passed away last week.

Doctor     Oh my goodness. I am so sorry. This must be awful for you have been married for such a long time.

Patient    Well, actually, he had dementia for the last 15 years and it was hard work tending to his needs at home because his insurance ran out. It was actually kind of a relief when he passed (p. 2103).

Frankel describes the doctor’s effort as “rejected empathy.” Lacking relevant information, the doctor assumed too much, and the patient had to correct the assumption. Her need to do so neutralized the empathy the doctor was trying to provide. Because of this risk of “empathy breakdown,” Frankel suggests we keep in mind all four of these components to empathic communication:

  •          Recognizing emotions
  •          Sorting (assigning meaning to patient input)
  •          Responding
  •          Listening for evidence of response accuracy 


Part 1 of this short series introduces a simple strategy for teaching empathy skills to audiology students. In Part 2, we will consider how not listening for evidence of accuracy per Frankel can cause a breakdown in the “empathy cycle” (Barret-Lennard, 1981).


Barret-Lennard GT. (1981). The empathy cycle: Refinement of a nuclear concept.  Journal of Counseling Psychology, 28(2), 91-100.

Batt-Rawden, S., Chisholm, M., Anton, B. & Flickinger, T.  (2013).  Teaching empathy to medical students: An updated, systematic review. Academic Medicine, 88(8), 1171-1177.

Coulehan JL, Platt FW, Egener B, et al. (2001). ‘Let me see if I have this right…’: Words that build empathy. Annals of Internal Medicine,135(3), 221-226.

Frankel, R. (2017). The evolution of empathy research: Models, muddles, and mechanisms. Patient Education and Counseling, 100, 2128-2130.

Mercer, S., & Reynolds, W. (2002). Empathy and the quality of care. British Journal of General Practice (Suppl.), S9-12.

Ask About Peer Support, and Parents Say YES

Kris English, PhD

The University of Akron/NOAC

Recently, a panel of pediatric audiologists asked parents for guidance in developing a Childhood Hearing Loss Question Prompt List (CHL QPL). QPLs are used in many specialties in health care, to help patients and families remember the questions they want ask, suggest questions they may not have thought about asking, and broach questions they’d like to ask but don’t know how. As a counseling tool, QPLs are very effective for patient education as well as for the open invitation to discuss important or difficult topics, and to equalize the power dynamic in a health care appointment.

One Question Stands Out

The CHL Question Prompt List underwent several stages of review, and the final version can be found here.  The report on this QPL does not include a breakdown of each question and degree of support, but one result is a stand-out and is worth highlighting here: of all the questions reviewed to keep or reject, the only question that was approved by 100% of parent reviewers (N = 122) was this one:

Any unanimous response is rare, but this one really should come as no surprise: research has long reported parents’ desire to connect with other parents for support. Parents in Mueller et al.’s (2009) study valued access to other parents as a source of information and emotional support, and a sense of being in a larger family. Other benefits include gaining new skills to deal with day-to-day issues, increasing a sense of power and belonging (Law et al. 2009), and reducing stress (Hastings & Beck, 2004). Parents of children with hearing loss have specifically identified their “predominant need” as meeting other parents (Luterman & Kurtzer-White, 1999), and the provision of these support services is described as a “state-of-the-art practice in family counseling” (Jerger, Roeser, & Tobey, 2001).

What to Do With This Information?

This web forum focuses on audiology counseling, but we must recognize our limitations. We cannot help parents the same way other parents can. In addition to providing every professional support possible, we can also:

  • Support a parent group in our community (provide space, communication mechanisms [newsletter, website], etc.)
  • Provide parents contact information about existing groups in our community and online (e.g., Hands&Voices)
  • Maintain and share a list of “veteran parents” who generously volunteer to provide one-on-one support, especially to those new to “the journey.”


Once again, parents have spoken. Will we act as well as listen? What can we do in our communities to meet this full-throated request for support?


Hastings, R., & Beck, A. (2004). Practitioner review: Stress intervention for parents of children with intellectual disabilities. Journal of Child Psychology and Psychiatry, 45(8), 1338-1349.

Jerger, S., Roeser, R., & Tobey, E. (2001). Management of hearing loss in infants: The UTD/Callier Center Position Statement. Journal of the American Academy of Audiology, 12(7), 329-336.

Law, M., King, S., Stewart, D., & King, G. (2002). The perceived effects of parent-led support groups for parents of children with disabilities. Physical and Occupational Therapy in Pediatrics, 22(2/3), 29-48

Luterman, D., & Kurtzer-White, E. (1999). Identifying hearing loss: Parents’ needs. American Journal of Audiology, 8(1), 13-18.

Mueller, T.G., Milian, M., & Lopez, M.I. (2009). Latina mothers’ views of a parent-to-parent support group in the special education system. Research and Practices for Persons with Severe Disabilities, 34(3/4), 113-122.

Patient-Centered Care, Part 5/5: Patient Relationships

Kris English, PhD

The University of Akron/NOAC

This entry concludes a discussion on Patient-Centered Care with several applications to audiology practices. The first four entries are:

As mentioned in Part 4, finding common ground is often assumed to be our final step, since we’ve agreed on next steps and are ready to conclude the appointment. But the difference between a transaction and patient-centered care includes one more component: our skill in enhancing patient relationships.

Stewart et al. (2014) described these four components as interactive, and here is where we see it most clearly: forward-moving steps to an ultimate goal. We don’t explore for exploring’s sake, but to understand (and actively indicate that we understand) our patient’s needs as prerequisites to finding common ground.

However, the linearity of this model doesn’t do justice to the interactive impact of each component. Perhaps we can envision a set of cogs, each one vital to the process and each one affecting the others. Regardless, we are ready to consider some aspects of our last component:

Enhancing Patient Relationships

Stewart et al. (2014) list several characteristics associated with each interactive component of patient-centered care. Among those related to “Enhancing Patient Relationships,” we will focus on two that could be considered two sides of the same coin: empathy and self-awareness.

A piano sounding board

§ Empathy: Gallese et al. (2007) describe empathy as “intentional attunement” to another person’s experience, bringing to mind the metaphor of a sounding board. As clinicians dedicated to sound, we might especially “resonate” to Josselman’s (1996) definition: the ability to “put aside our own experience, at least momentarily, and reverberate to the feelings of another” (p. 203).

Interestingly, recent fMRI studies confirm that humans do in fact need to “put aside” other thinking as we empathize. Jack et al.’s 2013 report on fMRI studies indicate that humans seem to have a built-in neural constraint that prevents us from thinking empathically and analytically at the same time. The need to “toggle” from one mental state to another requires mindfulness, i.e. “a constant awareness of the encounter at multiple levels” (Scott et al., 2008, p. 319). We don’t give ourselves enough credit when we say “All I did was listen” – since “just listening” means an intentional decision about where we direct our attention.

§ Self-awareness: Epstein (1999) identified five types of self-awareness:

  1. Intrapersonal awareness of our own strengths and limitations
  2. Interpersonal awareness of how we are seen by others
  3. Learning awareness of our knowledge and skill levels, and the means to achieve learning goals
  4. Ethical awareness of our values and how they shape treatment decisions
  5. Technical awareness of our need to correct procedures in process, including communication

Readers will likely agree that, except for ethics, these types of self-awareness are not discussed much in audiology.  However, it has been observed time and again, including by McWhinney (1989), that “We cannot begin to know others until we know ourselves” (p. 82).

Intrapersonal awareness would include knowing our strengths as helpers, dedicated to hearing and balance health. If we are consistent with the general population, we are probably extroverts, but about one-fourth of us, as introverts, may not be fully aware of experiencing a greater energy drain from daily patient care compared to our extroverted colleagues. Our energy levels can affect patient care, but the toll is rarely acknowledged (although colleagues half-jokingly suggest a support group for “Introverted Auds” — as long as it doesn’t involve meeting and talking).

It seems we may not be like the general population when it comes to temperament. Informal data suggest we are twice as likely to be Guardians as classified by the Keirsey Temperament Sorter, which provides food for thought when we consider typical characteristics. Might Guardians sometimes struggle with patient-centeredness? An AuD student  recently gave himself the opportunity to transcend this tendency.

As for interpersonal awareness: what is our reaction to potentially difficult patient/family conversations? Are we inclined to avoid them altogether, rather than risk opening a “can of worms” (English et al., 2016)?  And do we recognize that we signal that reluctance? Or do we convey a willingness to work with them, as this audiologist reported during a workshop:

“A female patient felt her old hearing aids needed replacing. She had had three sets over the past 13 years. At today’s appointment, she posed many questions about her audiogram, wanting a ‘thorough explanation’ of her long-standing HL.”

Here is where the audiologist stepped “into the breach.” He did not have to ask any follow-up questions, but he did: “When I asked her how she was feeling, she got very emotional and left the room to compose herself. When she returned, she explained that she now realized for the first time that her hearing loss was not going to get better.”

Was this conversation uncomfortable for the audiologist? Yes — but he approached it anyway. What it therapeutic for the patient? She indicated it was: she felt grief but also relief, after all those years of holding on to false hope. We will find ourselves occasionally challenged to decide between our discomfort and potential patient catharsis and clarity. Those who are comfortable with difficult conversations could serve as mentors to those who are not. Avoidance helps no one, and is the antithesis of patient-centeredness.

Enhancing Relationship Tip #1: Empathy is Teachable

If empathy is not an innate skill, or was not nurtured (or even crushed!) in graduate school, clinicians can still evolve as empathizers, especially with self-evaluations or feedback from colleagues. Lundeby et al. (2015) provide a “teachable consultation model” that could serve as a study-group project with like-minded audiologists. (Contact the author [ke3@uakron.edu] to request a copy.)

Enhancing Relationship Tip #2: Know Your Temperament

Are you a Guardian like most audiologists? Or an Artisan, Realist, Idealist?  And how does your temperament align with your clinical goals? Find out at the Keirsey Temperament website. (Tip #3: after setting up an account, answer 71 questions; your results will follow in a Mini Report. Paying for additional information is not necessary!)

The Ultimate Question: Are “Enhancing Patient Relationships” an Evidence-Based Practice?

In addition to research and our own clinical expertise, EBP also considers patient values. For one patient’s (and her readers’) perspective, see “Are Audiologists from Mars?”  We must ask ourselves: if she had enhanced relationships with her audiologists, would she need to create a wish list?

And finally, some food for thought: ever wondered about the consequences of putting other priorities ahead of patient-centered care? Consider this essay.

1. I am aware of the attention required to toggle between empathy and problem-solving.

Yes            Working on it          Not sure what this means

2. I can explain how a “Guardian” temperament might be at odds with patient-centered practices.

Yes        I haven’t given this much thought

3. I am generally comfortable engaging with difficult conversations in clinical settings.

Yes            Working on it          Would rather avoid them

4. I can explain how all four components to patient-centered interact with each other.

Yes            Working on it          Not sure what this means



English, K., Jennings, M.B, Lind, C., Montano, J., Preminger, J., Saunders, G., Singh, G., & Thompson, E. (2016). Family-centered audiology care: Working with difficult conversations. Hearing Review, 23(6), 14-17.

Epstein, R. (1999). Mindful practice. JAMA, 282(9), 833-839.

Gallese, V., Eagle, M., & Migone, P. (2007). Intentional attunement: Mirror neurons and the neural underpinnings of interpersonal relationships. Journal of the American Psychoanalytic Association, 55(1), 131-175.

Jack, A., et. (2013). fMRI reveals reciprocal inhibition between social and physical cognitive domains. NeuroImage, 66, 385-401.

Josselman, R. (1996). The space between us: Exploring the dimensions of human relationships. Thousand Oaks, CA: Sage Publications.

Lundeby, T. Gulbrandsen, P., & Finset, A. (2015). The expanded Four Habits Model: A teachable consultation model for encounters with patient in emotional distress. Patient Education and Counseling, 98, 598-603.

McWhinney, I. (1989). A textbook of family medicine. NY: Oxford University Press.

Scott, J., et al. (2008). Understanding healing relationships in primary care. Annals of Family Medicine, 6(4), 315-322.

Stewart, M., Brown, J.B., Weston, W.W., McWhinney, I.R., McWilliams, C.L., & Freeman, T.R. (2014). Patient centered medicine: Transforming the clinical method (3rd ed.). London: Radcliff Publishing.

Patient-Centered Care, Part 4/5: Common Ground

Kris English, PhD, The University of Akron/NOAC

We are working through a discussion on Patient-Centered Care per Stewart et al.’s (2014) model. Part 1/5 provides an introduction; Part 2/5 (Exploring) and Part 3/5 (Active Understanding) apply the first two interactive components of their model to audiology. In this entry, we will consider the 3rd component, Finding Common Ground.

It’s Time to Focus

Finding common ground is an intentional move toward a mutual “meeting of minds,” with the goal of matching our patients’ goals with our expertise and recommendations. Gone are the days of “paternalism” in health care, when clinicians authoritatively informed patients of the treatment plan and expected unquestioning compliance (Emanual & Emanuel, 1992). An alternative approach, called the “informative model,” involves providing all options but with no attempt to motivate or inspire patients toward a particular direction. Needless to say, neither of these approaches supports the process of finding common ground. Patient-centered care requires what the Emanuels called an “interpretive model,” wherein the clinician not only explains all options but also works with the patient’s goals and values to ensure they co-develop a shared understanding of the plan moving forward. Gawande (2014) explains:

[As patients] we want information and control, but we also want guidance. The Emanuels described a third type of doctor-patient relationship, which they called “interpretive.” Here the doctor’s role is to help patients determine what they want. Interpretive doctors ask, “What is most important to you? What are your worries?” Then, when they know your answers, they tell you about the red pill and the blue pill and which one would most help you achieve your priorities. (p. 201)

In other words, we seek to combine our knowledge and experience with patient needs to help us agree on a plan for preferred outcomes, land on the same page. We are in no way a neutral bystander; in a very real sense, we are the “most important instrument” in the room.

Moving Toward Common Ground

Finding common ground in health care is a 2-step process: (1) agreeing on “what is wrong” and (2) agreeing on “what to do about it.”

We readily learn “what is wrong” from the patient’s point of view as we explore and actively understand a patient’s concerns and needs. We may be inclined to begin our formal assessments at this point to determine “what is wrong” from an audiologic perspective, but that step could interrupt the “finding common ground” process. It can be a challenge to disrupt what Stewart et al. (2014) call the “canonical organization” (p. 112) of an audiology appointment, but let’s give it some thought.

It’s true that without test results, it’s too soon to “agree on what to do” about hearing help, but we can lay some preliminary groundwork to that conversation by seeking input regarding “what to do about it” from the patient’s point of view. We are fully aware that hearing help recommendations are often met with resistance, objections, distress. A first-time patient is surely harboring many questions about amplification, and it can help to open up those questions before confirming a hearing loss. Once we collect our patient’s ideas on “what to do about it,” we can pick up on the testing process.

Some “Common Ground” Tools

Until we ask, we do not know how hearing loss affects what matters most in our patients’ lives, and what they want to do about it. To understand these concerns, audiologists can use some simple tools to elicit and document patient input. Following are screen shots of 3 readily-available tools:

  1. The Client Oriented Scale of Improvement. The COSI is a classic patient-centered tool that helps the patient articulate desired changes.  As mentioned above, when patients effectively write their own treatment plan, they are more likely to adhere to it.

2. Ida Institute Scales. The two scales below ask the patient to rate importance and also self-efficacy (“how much do you believe in your ability…”). When the ratings are low, we are once again reminded we cannot assume anything. A follow-up on our part should include the queries: what would it take to move your answer higher on the scale?  What is on your mind that holds you back?  To access these tools, first create an account here: 

3. The Characteristics of Amplification Tool (COAT). Developed by Sandridge and Newman in 2006, this is one of the first tools to ask about motivation and also expectations (“how well do you think HA will improve your hearing?”). Their original article explains how to use the tool; a recently modified version is available to download here.

Also: Simple “Readiness Scales”

Palmer et al. (2009) found an important correlation between hearing aid decisions and a patient’s answer to the question,”On a scale from 1 to 10, 1 being the worst and 10 being the best, how would you rate your overall hearing ability?’’  Most patients are familiar with the 1-10 scale concept; a simple way to determine readiness is pose the question, On a scale of 1-10, how ready are you to:

“The readiness is all” (Hamlet V, ii)

  • hear better?
  • try amplification?
  • try an assistive device?
  • advocate for yourself at work?

Shakespeare had it right: we don’t make any changes or decisions until we are ready — a psychological state that is hard to explain but easy to quantify. Asking patients to think about and rate their state of readiness helps them organize their priorities, acknowledge their doubts, and hopefully clear away misgivings.

Finding Common Ground = Intentionally Sharing Power

Please note: finding common ground means “mutually influencing each other, each potentially ending up in a place different from where they began, with different understandings than either would have reached alone. It is not a matter of who has power and who does not.” (Stewart et al., 2014, p. 138).  (More on “sharing power” here.)

Closing Thought

Finding common ground is often mistakenly assumed to be a final step, occurring after all the information about the patient’s problem is obtained and sorted out by the clinician. But patient-centered care includes one more component, to be explained in Part 5/5 of this series.

The Ultimate Question: Is “Finding Common Ground” an Evidence-Based Practice?

See Stewart et al. (2000) to learn more.

NEXT: Patient-Centered Care, Part 5/5: Patient Relationships

1. I can explain the difference between “informative” and “interpretive” models in patient care.

Yes            Still working on it

2. I am willing to disrupt the “canonical organization” of an audiology appointment in order to learn what a patient “wants to do” re: hearing help before I begin testing.

Yes              Not sure

3. I already use at least one of the “common ground tools” described above.

Yes              No

4. I actively strive to “share power” with patients and families.

Almost always       Sometimes         I haven’t given this much thought

5. I can explain why “finding common ground” is an evidence-based practice.

Yes            Still working on it


Emanuel, EJ & Emanuel, LL. (1992). Four models of the physician-patient relationship. JAMA, 267(16), 2221-2226.

Gawande, A. (2014). Being Mortal: Medicine and what matters most in the end. NY: Henry Holt.

Palmer C. et al. (2009) Self-perception of hearing ability as a strong predictor of hearing aid purchase. JAAA, 20, 341-347.

Sandridge S, & Newman C. (2006). Improving the efficiency and accountability of the hearing aid selection process – Use of the COAT. 

Sandridge S, & Newman C. (2014). Characteristics Of Amplification Tool, v2. 

Stewart, M., Brown, J.B., Weston, W.W., McWhinney, I.R., McWilliams, C.L., & Freeman, T.R. (2014). Patient centered medicine: Transforming the clinical method (3rd ed.). London: Radcliff Publishing.

Patient-Centered Care, Part 3/5: Understanding

Kris English, PhD

The University of Akron/NOAC

As mentioned in Part 1/5 and Part 2/5 of this series, Stewart et al. (2014) provide a framework to implement Patient Centered Care (PCC), organized around four interactive components. In this entry, we will consider the 2nd component, Understanding the Whole Person.

Understanding: Patient-as-Person

Already we are seeing the interactive nature of each component, since the first PCC component encourages us to “explore” by finding out about our patients. Relative to their hearing circumstances, what are their personal backgrounds, their current situations, and what is important at this time?  A person’s life- and world-context matters for everybody, but particularly for our patients, whose hearing loss can have direct impact on their life and their world. Factoring those contexts into our understanding of the “whole person” is considered “a hallmark of the patient-centered clinician” (Stewart et al., p. 89)

Understanding: Patient-in-Context

The additional layer to this component is understanding the patient as part of an eco-system, in a way.  “Proximal context” generally includes one’s immediate family and other important persons in our patient’s living circumstances. Expanding outward, we would like to know about living circumstances (neighbors, care-givers), employment status and associated listening challenges; social supports within one’s community, and so on. Additionally, “distal context” may be relevant to many patients, if their culture and community play an active part in their life.

“Listen and Learn” — But Don’t Stop!

There is more to the “understanding” component than meets the eye. To be of any value, our understanding must be actively communicated to the speaker. Merely listening and processing the input does not help a patient “feel heard.” We must actively respond. Consider these details from a study that tracked patient comments, subsequent physicians’ responses, and ultimate patient outcomes to get a sense of how important it is to actively convey understanding.

Adams et al. (2012) recorded, transcribed, and evaluated 79 patient-physician office visits. They identified 190 instances of patients expressions of emotional state, coded the physicians’ responses, and then categorized the responses as follows:

  • Responses that focused away from emotion
  • Neutral (Focused neither away from or toward)
  • Responses that focused toward emotion

They also took the additional step of evaluating consequences: what were the outcomes relative to patient care?  The flow chart below tracks the three “response choices.”  When physicians ignored patient emotions, outcomes were unproductive at best: when distance and even antagonism develops, we know we are going in the wrong direction. However, when physicians responded to emotions (i.e., what patients actually wanted to talk about) with neutral or actively focused responses, outcomes were productive: additional discussion led to a confirmation of goals; support was conveyed; patients and physicians understood they were on the same page.

Fig. 1. Physician responses to patients’ expressions of emotion: immediate effect on communication and associated patterns of further communication. (Adams et al,, 2012, p. 47)

Did Responses Make a Difference?

Of course they did. Let’s assume that physicians in the first column of boxes did hear their patients’ emotional concerns, but simply failed to respond in an active way to let the patients (and the researchers) perceive it. It is quite easy to become distracted, anticipate other topics, notice the time and rush ahead. But missed opportunities have consequences; our efforts to be patient-centered must keep “active understanding” a high priority.

Following are three tips to support our endeavors to convey understanding:

Active Understanding Tip #1: Use Observable (Measurable) “Understanding Responses” 

The following kinds of responses are within everyone’s repertoire; the only concern is remembering to communicate them. Recommendations from the Patient-Centered Observation Form (PCOF) (Keen et al. 2015) include:

  • Use continuer phrases (OK; hmm-mm) and attentive body language
  • Validate emotions (you’re worried about changes; it sounds like you were uncomfortable?)
  • Elicit more input (Could you help me understand with an example? Anything else?)
  • Confirm what is most important to patient (So let me confirm: you indicated the following problems need our attention…)

Audiologists interested in improving this skill might consider partnering with a colleague to observe/count instances of active understanding by using the PCOF.

Active Understanding Tip #2: Include Family

Research (e.g., Singh et al. 2016) consistently supports the value of including family members (“proximal context”) in audiology appointments.  This essay provides some food for thought.

Active Understanding Tip #3: Try Ida Institute’s Communication Rings

This easy-to-easy and literally patient-centered tool helps the audiologist understand not only our patients’ family/”proximal” contexts but also their “distal” contexts. Organizing and prioritizing one’s “communication world” has the double benefit of helping both the audiologist and the patient understand the impact of hearing loss.


PCC is a Process

At this point, we see that Patient-Centered Care does not involve a singular change in practice, but rather a commitment to an integrated process. We have applied the first two steps to audiology; the next steps will be examined in Parts 4/5 and 5/5

The Ultimate Question: Is “Active Understanding” an Evidence-Based Practice?

See Tzelepis et al. (2015) to learn more.

NEXT: Audiology Counseling and Patient-Centered Care, Part 4/5: Common Ground

  1. I routinely inquire about a patient’s proximal and distal contexts.

Almost always         Sometimes        I tend to skip this step

  1. I am aware of the risks of not actively conveying understanding about a patient’s emotional responses to hearing loss.

Fully aware        Sometimes aware           Hadn’t realized it until now

  1. I would find it helpful to review my responses to determine if they conveyed active understanding.

Yes              Not sure

  1. I actively include family members in appointments (per patient preference).

Almost always       Sometimes         I often skip this step

  1. I can explain why “active understanding” is an evidence-based practice.

Yes            Still working on it


Adams K et al. (2012). Why should I talk about emotion? Communication patterns associated with physician discussion of patient expressions of negative emotions in hospital admission encounters. Patient Education and Counseling, 89, 44-50.

Keen, M., Caswe-Lucas, J., Carline, J., & Mauksch, L. (2015). Using the patient centered observation form: Evaluation of an online training program. Patient Education and Counseling, 98, 753-761.

Singh, G., et al. (2016). Family-centered adult audiologic care: A Phonak position statement. Hearing Review, 23(4), 16-21.

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