Yoga Principles and Audiologic Counseling

Kirsten Ellis, BA(Hons) MSc
Audiologist
Southend University Hospital
NHS Foundation Trust

In Yoga, we are encouraged to minimise distractions. Now, I am speaking from a student’s point of view, as I certainly don’t possess the in-depth knowledge that my dear yoga teachers do. When laying in Savasana (the prone relaxation pose at the end of a class, and sometimes at the beginning) we are reminded that there are no distractions, there is nothing else we need to do at that moment apart from being present in the space. Often easier said than done!So to my surprise, when relaxing in Savasana one evening and listening to the teacher guide us through meditation, she reminded us that we were there for ourselves, we had no expectations on us at that time, and that this was a safe space for us to just “be.”

“Don’t bring your story.” – The Breakthrough

On hearing this my mind lit up (probably much to the disappointment of my yoga teacher) – how can this be carried over into our counselling?  The clinical ego wants us to bring our “story” to each appointment.  It tells us to reassure the patient that we know best, that our experiences and training (our story) are how we can best manage someone seeking help.

Additionally, in a more literal sense we don’t want to belittle our patients’ experiences by comparing them to our own. How often have we felt disheartened at being told “I know how you feel,” or “I’ve been though that, it’s not so bad”?

To truly listen, we shouldn’t bring our story to the appointment. By releasing our story and subsequent distractions, we can truly be present to listen.

The Yogi and the Clinician

My yogi has helped me work through what feels uncomfortable, or through a busy state of mind to find peace in the present moment. When we are truly listening, are we also not working to find peace within ourselves to be fully present for the person in front of us?

I’ve often found myself in the midst of what I would feel is a difficult conversation, trying to push my clinical ego aside and allowing my patient to just talk. For me, this echoes working through what I feel is uncomfortable, allowing my patient to work through vulnerability to achieve a sense of calm (not necessarily a conclusion) in the appointment.

What are we doing to be self-aware, and how are we responding to this state?

To summarise my thoughts, I am reminded of a recent patient who attended for a review of his hearing aids. On the outside, one would assume he was a patient who could not hear well, felt his hearing had changed, and that an update was needed. However, once he came and took a seat, his body language communicated some further inner turmoil.

He confessed that he had been mishearing and forgetting important dates, the most recent being his daughter’s landmark birthday celebration. I let him talk. With tears in his eyes, he told me that he had sought an appointment at his GP for an assessment for dementia. My clinical ego wanted me to reassure him, and tell him everything is fine and to push on with the appointment. But instead, we sat and explored his concerns. We asked each other questions and we sat through conversation and silences that were uncomfortable for the both of us.  We came to an agreement that we would get his hearing aids as good as they can be for his dementia assessment, so that we can face things confidently with our heads held high.

My general feelings once the appointment ended were that because of our interaction and agreement, we were both fully self-aware, in a compassionate environment that allowed for vulnerability (Hanson, 2009). Upon further reflection, I was struck by the parallels of Rogers’ (1961) three conditions of person-centered counselling: congruence with self, unconditional positive regard, and empathic understanding – all essential audiologic counselling skills. Of the three conditions, the foundational skill of self-awareness/congruence with self seems to generate almost no interest among audiologists.

So let’s start, shall we? Let’s develop a professional version of the prone relaxation pose Savasana – and breathe.


Reference

Hanson, J. (2009). Self-awareness revisited: Reconsidering a core value of the counseling profession. Journal of Counseling & Development, 87(2), 186-193.

Rogers, C. (1961). On becoming a person.  Boston: Houghton Mifflin.

Can Patient Autonomy and Patient-Centered Care Co-Exist?

Kris English, PhD

Professor Emeritus

The University of Akron

The concept of patient autonomy is a fundamental right in today’s health care system (Bernstein, 2018). Per Walter and Ross (2014), classic textbooks teach us that “autonomy is all about individualism and the rights of patients to make decisions without paternalistic interference” (p. S18).  It is such a strongly held concept that, overall, we are likely left with the impression that respect for autonomy apparently “obliges clinicians to tell patients about health care options, then stand back and abide by their choices” (emphasis added)(Enwistle et al., 2010, p. 741).

While protecting and empowering patients, the principle of patient autonomy might give an audiologist pause. When the standard definition of patient autonomy isolates the patient as decision-maker and ignores the influence of the clinician, how do we provide patient-centered care? If we are expected to “stand back and abide,” then PCC conversations such as shared decision-making would be inappropriate. If these two principles — patient autonomy and PCC — are at odds, how do we reconcile the values each principle represents?

A Bright Idea: Expand the Definition

The tension between these two concepts has not gone unnoticed. In the 1980’s, bioethicists saw the need to revisit the narrow “self-sufficient” version of patient autonomy – not to limit patient rights but also to include the clinician. The point was made that “in the clinical setting, perhaps more than in any other, patients are not self-sufficient, and an expanded definition of autonomy is required to preserve their sense of self-governance and the ability to assume the responsibility of making choices” (emphasis added)(Tauber, 2005, p. 123).  Incorporating the basic tenets of autonomy within a relational context came to be known as relational autonomy.

Relational Autonomy in Audiology

Mackenzie and Stoljar’s (2000) description of relational autonomy will resonate with audiologists:

Relational autonomy perspectives are premised on a shared conviction that persons are socially embedded and that agents’ identities are formed within the context of social relationships and shaped by a complex of intersecting social determinants, such as race, class, gender, and ethnicity.

And a comparison of clinic variables is certainly consistent with patient-centered audiologic counseling (from Wilson & Ross, 2014):

Treading Carefully

Needless to say, patients vary in their comfort level with autonomy of any kind. Variables include patient education levels, age, the nature of decisions being considered, and the type and severity of health concerns.  Cultural differences must also be considered: in many societies, patients and families prefer health care providers to assume a paternal role, and prefer a different balance between personal autonomy and the involvement of the family in decision-making (Tauber, 2005).

So… Can Patient Autonomy and Patient-Centered Care Co-exist?

Yes — as long as we evolve with the field of bioethics.

  1. We can recognize that the classic definition of patient autonomy serves the patient well but inadvertently (and unhelpfully) overlooks the role and impact of the clinician.
  2. We can mindfully define ourselves as practitioners of relational autonomy: always honoring patient choice and agency, within a relationship-based context.

And in all likelihood, even though the terminology may not be familiar, audiologists already practice relational autonomy. We already understand how patient choice and agency is integrated into patient-centered care and shared decision making. One indicator: the communication and interpersonal skills involved in relational autonomy are already represented in audiologic counseling.


References

Bernstein. (2018, May). Take control of your health (exert your patient autonomy). Harvard Medical School, retrieved December 27, 2019.

Entwistle, V., et al. (2010).  Supporting patient autonomy: the importance of clinical relationships. Journal of General Internal Medicine, 25, 741–745.

Mackenzie, C, & Stoljar, N. (Eds.).(2000). Relational autonomy: Feminist perspective on autonomy, agency, and the social self. New York, NY: Oxford University Press.

Tauber, A. (2005). Patient autonomy and the ethics of responsibility. Cambridge, MA: MIT Press.

Walter, J., & Ross, L. (2014). Relational autonomy: Moving beyond the limits of isolated individualism. Pediatrics, 33(Suppl 1), S18-S23.

New Year’s Resolution, 2020: Notice More Clues

 

 

Kris English, PhD

Professor Emeritus

The University of Akron

A Conversation Overheard in Clinic:

New Patient:  My bridge party friends roll their eyes when my friend Mary joins us. Her hearing aids don’t help her and we have to shout at her all afternoon. I think my hearing is getting as bad as hers.

Audiologist: Feel free to give her my number, I could probably adjust her aids.

Oops.

The attentive reader will immediately spot a communication mismatch (Clark & English, 2019). The patient was dropping a clue regarding her own hearing, but as professional problem-solvers, we can find it hard to resist the fixable problem. As a consequence, the audiologist didn’t notice that the patient used an indirect opening to discuss her worries. (Fortunately, her next attempt was quite direct and everyone was back on track.)

The Challenge of Indirect Comments: Easy to Miss

This patient’s indirect approach is likely more common than not. For instance, Adams et al. (2012) recorded 79 patients’ encounters with 27 physicians, and identified 190 patient emotional-state comments. Of these, 58% were indirectly stated (e.g., “that’s the hardest part”).

From their evaluation of 116 clinical conversations, Levinson et al. (2000) provide an instructive dialogue with an indirect — and missed — clue:

“Most often, emotional clues were embedded in a biomedical examination (e.g., during pauses in measurement of blood pressure). Typically, such clues were raised indirectly when the conversation touched on an emotional issue…

Physician: Your blood pressure is looking good; 140 over 70, pretty good.

Patient: My sister was in a car accident 4 weeks ago, and she’s been…

Physician: How’s she doing?

Patient: She’s staying with me, she’s doing better, she gets dizzy a lot.

Physician: Dear me, any neck injuries?

Patient: I know they checked her, and they said it’s OK” (p. 1024).

Why Indirect?

We can certainly understand the indirect approach: patients may feel embarrassed, or worry about what will happen if they put their thoughts into words. They may not be sure they can trust their clinician with personal disclosures. We “test the waters” like this ourselves, to determine if a communication partner is attentive and receptive.

Understanding the reasons for indirectness is a start; if we hope to be helpful, we also need to notice the clues.

“Try to Be One of Those People…”

An achievable goal for the New Year might be to channel our inner Sherlock Holmes and be more alert to patient clues. As Charon (2017) puts it, “Henry James’s dictum to novelists, ‘Try to be one of those people on whom nothing is lost’ … can also be said to listeners” (p. 166).

A Note to Preceptors and Clinical Instructors

For those who supervise students, consider this assignment: keep a journal or log of patient comments, organized as direct or indirect clues, to determine the proportion of each over a period of time. Learning objectives: (1) Demonstrate attention to patient concerns; (2) Demonstrate “close listening” skills relative to patient concerns; (3) Demonstrate journaling/reflection skills (a recommended practice for professional growth per Schön, 1987).

If learning outcomes are fruitful, please consider submitting a report! Contact Kris: ke3@uakron.edu


References

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

Charon, R. (2017). Close reading: The signature method of narrative medicine. In R. Charon, et al., The principles and practices of narrative medicine (pp. 157-179)NY: Oxford University Press.

Clark, J., & English, K. (2019). Counseling-infused audiologic care (3rd ed.). Cincinnati OH: Inkus Press. https://www.audiology-counseling.com

Levinson, W., et al. (2000). A study of patient clues and physician responses in primary care and surgical settings. JAMA, 284(8), 1021-1027.

Schön, D. (1987). Educating the reflective practitioner. San Francisco: Jossey-Bass.

Listening and Ethics

Kris English, PhD

Professor Emeritus

The University of Akron

Like most health care professions, Audiology is guided by codes of ethics (e.g., by the American Academy of Audiology). Although codes of ethics are essential, they are not immutable. Over time, ethics evolve in response to new information and new insights (Calman, 2004). For instance, 40 years ago, it was not unusual – and considered ethical – to fit one hearing aid on a patient with a bilateral hearing loss without much thought. What changed? Initially, our knowledge base: we learned about neural plasticity and the effects of acoustic stimulation counteracting neural atrophy. This new knowledge then changed our practices, which then affected our ethical understanding of unilateral HA fittings.

Importantly, our codes of ethics tend to be broadly stated and do not single out specific changes in thinking. It’s up to us to interpret our codes of ethics in light of new evidence and accepted best practices (Palmer, 2012). Borrowing from the field of narrative medicine (Charon, 2017), we can consider this interpretative process as a type of “close reading,” defined as the thoughtful, critical analysis of text in order to develop deeper understanding (Moss et al., 2015).

What Else Has Changed?

We also now know a great deal more about patient-centered care (PCC) (e.g., Stewart et al., 2014), especially the primacy of “close listening” to patients’ stories (Irving & Charon, 2017). Like hearing aid practices, PCC as an evidence-based practice is usually not explicitly reflected in codes of ethics. However, a “close reading” of our ethics strongly suggests, as a predicate, the need to closely/fully listen and understand our patients’ narratives. “Close listening” is essential if we are to ethically provide services with compassion and meet our patients’ best interests.

Close listening to patient stories involves narrative competence, defined as “the fundamental human skill of recognizing, absorbing, interpreting, and being moved to action by the stories of others” (Charon, 2017, p. 126). Depending on our backgrounds in counseling, this concept may be obvious but we shouldn’t assume so; as Charon notes (supported by abundant evidence), “Despite the range of sources and skills bent toward the effort to improve clinical listening, patients continue to complain that their doctors don’t listen to them” (p. 158).  One reason might be that “close listening” has not been recognized as an ethical practice.

 Listening as an Ethical Practice

A close reading of our ethics texts leads us to appreciate the ethical implications of listening (or not listening) to our patients.  If we don’t fully absorb patient narratives, we are less likely to be “moved to action” toward personalized and comprehensive care. Promoting “close listening” (in the context of PCC) as an ethical practice warrants review and discussion within the profession.


References

Calman, KC. (2004). Evolutionary ethics: Can values change? Journal of Medical Ethics, 30, 366-370. doi: 10.1136/jme.2002.003582

Charon, R. (2017). Close reading: The signature method of narrative medicine. In R. Charon, et al., The principles and practices of narrative medicine (pp. 157-179)NY: Oxford University Press.

Irvine, C. & Charon, R. (2017). Deliver us from certainty: Training for narrative ethics. In R. Charon, et al., The principles and practices of narrative medicine (pp. 110-133)NY: Oxford University Press.

Moss, B. et al. (2015). A close look at close reading: Teaching students to analyze complex texts. Alexandria, VA: ASCD.

Palmer, C. (2012). Ethics of best practice. In Teri Hamil (Ed.), Ethics in audiology: Guidelines for ethical conduct in clinical, educational, and research settings (2nd ed.)(pp. 237-245. Reston, VA: American Academy of Audiology.

Stewart, M. et al. (2014). Patient-centered medicine: Transforming the clinical method. Abington, UK: Radcliffe Medical Press.

Can We Be Person-Centred and Sell Hearing Aids?

Anna Pough, BA MSc

Hearing Therapist Audiologist

British Society of Hearing Aid Audiologists

Everything we do in our hearing care consultations must have a purpose. Given our daily time crunch, it is a true challenge to purposefully apply person-centred practices such as shared decision making, ownership and rapport – and simultaneously work with the realities of the retail imperative. We need to support the person in the purchase and use of a product that no one wants, all the while working with barriers of stigma, bereavement of selfhood, and limited understanding of hearing instrument technology.

These responsibilities take up a lot of “bandwidth,” and it can be very tempting to resort to habits, shortcuts and routines. Hence the question: can we be person-centred and also sell hearing aids?  Following are three ways we can answer with YES.

YES: Begin with Carl Rogers’ Concept of “Person-Centredness”

Psychological therapy was initially based on the professional’s didactic perspective of how therapy should be undertaken and how success would be measured. Rogers was a radical thinker and changed this perspective. He believed that genuine meaningful therapeutic change would only occur when certain core clinician behaviors were applied: empathy, unconditional positive regard (acceptance) and congruence (being genuine)(Rogers, 1961). Specifically:

  • The clinician should work alongside the client as an equal partner in the therapeutic intervention;
  • By building on ‘unconditional positive regard’ and ‘empathy,’ the client is supported to recognize and acknowledge their own behaviours and responses through ‘congruence’ from the therapist;
  • A person’s own life experience provides the basis for their own standards of living in the real world, and influences their acceptance of therapy.

Rather than the therapist controlling the clinical interaction, Rogers explicitly addressed the issue of power and challenged the presumption of expertise. When he was described as “giving power back to the patient,” he insisted on clarifying: “It is not that this approach gives power to the person; it never takes it away” (Rogers, 1977, p. xii).

His theories developed further through psychological research and have become a cornerstone of most current interventions. [Read more about the Rogerian approach here.]

YES: Review Maslow’s Hierarchy of Needs

Abraham Maslow and Carl Rogers were both considered founders of a humanistic approach to psychology.  Maslow’s now-classic pyramid-shaped model (“hierarchy of needs”) reflects five states, starting with the need for sustenance, procreation, and existence, and then for safety and security. When these needs are met, relationships become important, leading to a need to be liked, respected, and to have a place in the group, which allows us to have an identity or self-actualisation; we can be who we choose to be. He later amended and addressed some concerns about this model, but as a concept it remains a useful visual tool.

If we accept that behaviours are based on these needs being met or not met, then we can place Rogerian principles of acceptance, congruence and empathy within this hierarchy as being integral to function within a “normal” life. In other words, a person-centred approach is positioned within the concept of having a “normal life” and being valued as “normal.”

By understanding better where the concept of person-centred services originated, we can appreciate the work required to maintain its principles in our day-to-day practice. By being congruent, empathic and by practicing real reflective listening, we can help people move from denying they have a hearing problem to purchasing and wearing hearing instruments – in effect, achieving a degree of self-actualization by improving a “self” problem. [Read more about Maslow’s theories here.]

YES: Remember that “Change is Hard” – But Achievable

Providing support as recommended by Rogers, and helping a person advance along Maslow’s stages, involves change — which can make people feel uncomfortable, insecure, and off-balance. And yet, people do change, and the process is often described by the Transtheoretical Model (TTM) (Prochaska and DiClemente, 1983). Developed in the 1980s, this construct helps therapists help their clients understand how and why they behave as they do, and how they could change.  TTM is a combination of several ideas examining change and influence, habit and acceptance, and describes the progression through various elements, each having their own response.  Anyone who has used the Ida Institute Motivational Tools, or anything similar, will recognise these stages of change pathway as the foundational model. [Read more about TTM here.]

Applying Theory to Practice

These models and theories can be directly contextualized to hearing healthcare and the consultation process. I began this piece by stating that everything we do in the consultation process must have a purpose. Each element of the consultation process must have a solid theoretical and clinical rationale, but embedded within this, each element also should also have a clear commercial perspective.

  • The decision to attend the hearing assessment should be rewarded with value within that person’s concept of worth, value and self esteem. They should be able to recognise the empathy and positive regard we as Audiologists afford them.
  • They should feel that their time and effort to attend the appointment is worth their while. This implies consequently that our time and effort as audiologists and therapeutic partners, are valuable too. This is a value construct and is a commercial transaction, even if no money has passed between us at this point. People have begun to think about the relationship in a transactional manner: they give us their time, and in return we give them information, advice and professional expertise. This has a tangible value. We go further to establish the need for our expertise, services and, in time, amplification products.
  • We ask open questions, eliciting answers where we actively listen, noting salient clues about attitudes, behaviours, needs and expectations which we reflect back, thereby demonstrating empathy. We gather commercially pertinent information in a non-judgmental manner about communication difficulty, domestic and work relationship conflicts, and the relative importance of those communication ecologies.
  • The consultation process should also allow us to understand the person’s place on their own cycle of the stages of change. This will help us to support and frame their expectations, work with them to acknowledge and/or accept their hearing loss, and build the desire to make a shared decision to purchase hearing amplification where that’s the most appropriate solution.

Conclusion

As Audiologists, we must maintain an ethical and congruent relationship with the people with whom we work. Understanding the theoretical foundations of a person-centred approach enables us to be effective and efficacious in our relationships, within the parameters of the commercial reality of the retail imperative.


References

Maslow, A.H. (1943). A theory of human motivation. Psychological Review, 50(4), 370–96.

Prochaska, J. & DiClemente, C. (1983) Stages and processes of self-change in smoking: Toward an integrative model of change. Journal of Consulting and Clinical Psychology, 5, 390–395.

Rogers, C. (1961). On becoming a oerson. Boston: Houghton Mifflin

Roger, C. (1977). Carl Rogers on personal power. NY: Delacort Press.

 

Challenge: Staying Patient-Centered While Taking Electronic Notes. Solution: Signposting

Kris English, PhD

Professor Emeritus

The University of Akron

An ongoing challenge in today’s health care system is managing computer use during patient encounters. Documenting each appointment is essential, but it can also disrupt our goal of providing patient-centered care (Ratanawongsa et al., 2016). In their literature review, Duke et al. (2013) noted that “the first minute of the consultation is often taken up with interacting with the computer rather than the patient” (p. 362), and that “patients worldwide express one major concern about computers in the office – the fixation of the physician’s eyes on the computer screen” (p. 359).

To manage the potential conflict between maintaining patient relationships and electronic records, let’s consider a relatively simple communication skill called signposting. The following definitions of signposting will resonate, since they are already routine practices in audiologic practice:

  • “A signpost is an explicit statement used to inform your patient what you are about to say or do. Signposts are often used to transition or change directions during a consultation. It makes clear to the patient what is going to happen” (Center for Health Care Communication, n.d.)
  • “Signposting progresses from one section to another using transitional statements; may include rationale for next section” (Silverman et al., p. 111)

Less routine might be the application of signposting while entering electronic notes:

  • “Signposting (telling the patient what you are doing as you transition to the computer) will signal that you are making a shift but still attending to his or her needs. Reading back what you have written, and then looking at your patient, also demonstrates active listening” (Duke et al., p. 362)

Applying a Familiar Skill to a New(ish) Situation

Even if not familiar with the term, audiologists “signpost” throughout an appointment: “Now that we’ve chatted about your concerns, let’s have you step into our testing booth …. That’s it for the testing portion. Let’s step into this area and talk about the results,” and so on. Like providing a roadmap, signposting reduces uncertainty and anxiety.

Applying the signposting skill to computer use includes these steps::

  1. “Introducing the computer” – “Our office uses an electronic medical record so I will occasionally need to type in information.” This process is no longer a novel experience to most patients, but mentioning it early provides the courtesy of a “heads up.”
  2. As needed, clearly signal any shifts from patient-focused to computer-focused moments by changes in posture, focus of visual attention, and a brief explanation such as, “I should summarize our chat so far in your record. This will take about a minute.”
  3. When done, either read what was typed to the patient (for transparency and accuracy checks) OR verbally indicate task completion as well shifting away from the screen, removing hands from the keyboard and mouse, and again facing the patient to re-establish eye contact and our undivided attention.

Importantly, signposting can involve both verbal and non-verbal cues.

Knowing the Name of a Skill Can Increase Its Use

Clinicians may not have known the name of a communication skill they already use, but to paraphrase Ursula LeGuin, “To know the name of a thing is to have power over it.” Signposting is a relatively straightforward patient-centered communication skill, but when it comes to computer use, applying it might require mindfulness as we break old habits and establish new ones. How will we teach ourselves the application of this important skill?  How will we monitor our efforts?


References

Center for Health Care Communication (n.d).  Signposting: An effective communication skill!

Duke P, Frankel R, & Reis S. (2013). How to integrate the electronic medical record and patient-centered communication into the medical visit: A skills-based approach. Teaching and Learning in Medicine, 25(4), 358-365.

Ratanawongsa N, Barton J, et al. (2016). Association between clinician computer use and communication with patients in safety-net clinics. JAMA Internal Medicine,176(1),125-128. doi:10.1001/jamainternmed.2015.6186

Silverman J., Kurtz S, & Draper J. (2013). Skills for communicating with patients (3rded.). Boca Ratan: CRC Press.

 

Shared Decision-Making Requires Counseling Skills

 

Kris English, PhD

Professor Emeritus

The University of Akron

 

“Nothing About Me Without Me”

For more than 20 years, patient-centered care (PCC) has been defined by the slogan “Nothing about me without me” (Quinlan, 2018). These five words represent years of effort by a grass-roots movement that demanded an end to a “doctor knows best” culture and the establishment of an informed and participatory role for patients.

The Institute of Medicine (2001) has defined patient-centeredness as “Care that is respectful and responsive to individual patient preferences, needs and values, ensuring patient values guide all clinical decisions” (p. 3)  Patient preferences, patient values: we can usually glean these perspectives during our intake consultations, but how do we use them to guide clinical decisions?  This question brings us to a feature of PCC called shared decision-making, defined as “the conversation that happens between a patient and their healthcare professional to reach a health care choice together.” These conversations require advanced counseling skills: active listening, empathy, respect for patient autonomy, a willingness to share control, the ability to find common ground.

Not Yet a Practice Norm in Audiology

Based on our literature to date, shared decision-making (SDM) is almost an orphan topic, although a few tools – decision aids – have been developed to guide balanced discussions through hearing care options and choices (e.g., Laplante-Lévesque et al., 2010; Pryce et al., 2018). While the profession continues to explore SDM, we need to appreciate now how this process can drastically change our clinical conversations.

On the surface, SDM seems straightforward. As described by Alston et al. (2014):

  • The clinician shares information with the patient about test results and treatment options
  • The patient explores and shares with the clinician his/her preferences regarding these options, and
  • After discussion, clinician and patient reach a mutual decision about subsequent treatment.

This template assumes the clinician welcomes and supports SDM. Unfortunately, our available evidence suggests this assumption is not a given (e.g., Ekberg et al, 2015; Grenness et al., 2015). Our limited research has also only focused on decisions related to hearing aid acceptance and options. However, there are other SDM opportunities in an audiology appointment, and these could be easily overlooked.

Example: SDM and HA Orientation

Consider the moment when hearing aids are first fitted. If only from habit, our interactions could disregard patients as decision-makers and rely on directives and advice-giving.  For example:

Standard Instructions? Shared Decision-Making (SDM)
You will need to wear these new hearing aids at home and every other possible environment before your next appointment. Our best practices recommend listening with hearing aids as much possible. What would that look like for you? Are there specific situations you’d like to start with? What would be a manageable target of hours of use per day?
It’s normal to dislike the sound of your voice, but you will get used to it. Let’s start by giving it a little time. How many days would you like to try to get comfortable with your voice? After that trial period, call or email and let me know how you’re doing.
You’ll realize that what you thought was “people mumbling” is really your hearing impairment. Earlier you mentioned “people mumbling.” Are you interested in testing those impressions?  It’d help me confirm if these devices are helping. Your observations would be invaluable.
You will still have problems in noise. It’s unavoidable. It’s quiet here now, but let’s anticipate noisy situations. What might those be in your life? …I have some brochures on easy communication strategies. If they fit your situation and you have an opportunity to try them out, let’s talk about it next time.

A student exercise: How do these comments differ? How might a patient respond/react to each, and why? What counseling/communication skills do you recognize? These essays provide some relevant background:

Conclusion

The point of the slogan “Nothing about me without me” is to include the patient in every decision, not just the obvious one (for audiology) regarding amplification. Ultimately, each patient is “an autonomous decision-maker” (Pryce et al., 2018, p. 638); if patients do not participate in hearing aid management decisions, they may decide to do nothing. Even without decision aids, we can use counseling skills to develop shared decisions now.


Acknowledgement: My appreciation to Ida Institute for sharing helpful materials.


References

Alston, C. et al. (2014). Shared decision-making strategies for best care: Patient decision aids. Institute of Medicine.

Ekberg, K., Grenness, C., & Hickson, L. (2015). Addressing patients’ social concerns regarding hearing aids within audiology appointments for older adults. American Journal of Audiology, 23, 337-350.

Institute of Medicine. (2001). Crossing The Quality Chasm: A New Health System For The 21st Century. National Academies Press, Washington, DC.

Grenness, C., Hickson, L., Laplante-Lévesque, A., Meyer, C., & Davidson, B. (2015).  The nature of communication throughout diagnosis and management planning in initial audiologic rehabilitation consultations. Journal of American Academy of Audiology, 26(1), 36-50.

Laplante-Lévesque, A. et al. (2010). Factors influencing rehabilitation decisions of adults with acquired hearing impairment. International Journal of Audiology, 49, 497-507.

Pryce H. et al. (2018). Shared decision-making in tinnitus care – An exploration of clinical encounters. British Journal of Health Psychology, 23, 630-645.

Quinlan, C. (2018, April 25). “Nothing about me without me”—20 years later.  Retrieved May 12, 2019.

Boundaries

David Luterman, D.Ed.

Professor Emeritus

Emerson College, Boston MA

The American Speech-Language-Hearing Association (2018) has delineated two aspects of counseling as within the scope of practice of audiologists: information and personal adjustment. The information aspect of counseling is relatively easy for audiologists to manage as it fits comfortably within the medical model of service delivery and also fits the expectation of clients.

The personal adjustment aspect, on the other hand, often presents difficulty; it means encountering clients on a psychosocial level involving their emotions and in this realm, audiologists often feel a lack of training (Meibos et al., 2017). The discomfort in psychosocial counseling is reflected in several studies: Ekberg, Grenness, and Hickson (2014) analyzed the clinical interactions between audiologists and 63 elderly hearing aid clients. They found that audiologists did not address the clients’ social and emotional needs but continued in content based communication. Cienkowski and Saunders (2013) examined the communication of audiologists during hearing aid fittings, and found that over 66% of the communication was content based. They also concluded that clients would benefit greatly if audiologists became more comfortable with personal adjustment counseling.

“Whole Person Care”

mind + heart

In actual practice, however, there should be no distinction between the informational aspect of counseling and the emotional component. There is considerable research evidence indicating that clients do not retain much content after a diagnostic evaluation (Margolis,2004; Martin, 1990) and the reason for the low retention of content is directly related to their anxiety level (Kessels, 2003). We know this on an experiential level: when we are emotionally upset, our cognitive ability becomes limited. Our brain goes into fight or flight mode and if we try to read something we can read the words, but they do not connect in the brain; we are essentially in our right brain. What this means: if we do not address the emotions of our clients, then information will not be processed. Therefore, to be effective as clinicians, we need to address both content and personal adjustment.

Personal adjustment counseling is often not addressed because it is lacking in training programs (Wicker et al., 2018), and it feels professionally risky to practicing audiologists because there is a lack of structure and no clear guidelines. The primary experience of our clients is grief. They have lost the life they thought they would have, and this is a painful loss. At heart we need to be grief counselors.

In emotion based counseling, clients’ primary need is to be listened to non-judgmentally, not made to feel better. This is a hard concept for professionals to acquire, as our assumed  mandate is to fix, and in the personal adjustment realm the fix is not apparent. Our clients are not emotionally disturbed; they are emotionally upset, which is appropriate to their life situation. The conventional response to someone who is upset is to try to make them feel better. The two favorite strategies are to instill hope (“Cochlear implants will make him normal”) or use positive comparisons (“It could be worse. He could have cancer, be deafer, etc.”).

Neither strategy is effective because it invalidates the client’s emotional pain. Now they feel guilty because they are still upset, and their feeling are stifled. We need to give our clients permission to grieve by listening to them and validating their feelings. We are not putting the feelings in, just giving them permission to be expressed and validated. The notion we need to convey to our clients is that feelings just are; you never have to be responsible for how you feel. Behavior which stems from feelings can be judged as self-enhancing or not. This notion builds in emotional safety for our clients, giving them the permission to express their deep and painful feelings. We have to do nothing but listen and validate and not try to fix or cheer up. I have found that clients self-limit in their emotional expression, and they have their own capacity to make themselves feel better. Embracing painful feelings is the first step in healing. And when this begins to occur, emotions settle down and clients can begin to absorb information.  We cannot damage clients by listening and validating their feelings. Giving them information when they are not ready for it can be overwhelming and often diminishes their self-esteem.

Boundaries and Referrals

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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

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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

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