The art and science of - Massachusetts Academy of...
Transcript of The art and science of - Massachusetts Academy of...
The art and science ofmotivational influence
Dr Douglas L Beck, Director of Professional Relations, Oticon Inc.
As professionals, we often find ourselves engaged in conversations with reluctantpeople who have significant hearing loss, yet they're not ready to acquire hearingaids. Indeed, simply having hearing loss does not render one "ready, willing andable" to acquire hearing aids - far from it! Importantly, the quality and quantity of theconversation between professionals and patients matters a great deal with respectto the acquisition of hearing aids.1-2
Kochkin notes that within the USA there are slightly more
than 34 million people with hearing loss.' Of those 34
million, perhaps one of four (or five) seek hearing help. Of
those, only approximately half acquire hearing aids,2 leaving
plenty of room for improvement!
Of course, audiologists and other hearing health care
professionals are caring, compassionate and empathetic
people. In general, we try to not be pushy and we try to
avoid the appearance of 'sales people' whilst revealing
the intricacies of sensorineural hearing loss, the magical
and mysterious numbers from the audiogram and the
wonders of modern hearing aids. But maybe, just maybe
it's time to pause. In fact, maybe it's time to rethink the
whole approach. If there is a pool of 34 million people
with hearing loss, with only 7.5 million of them eventually
receiving an audiometric evaluation, and only half of those
acquire hearing aids - something seems terribly wrong!
Unfortunately, the status quo is not nearly as good as it
should be.
There are many reasons people don't seek help for
hearing loss. The actual list of aged, outdated, ridiculous,
stereotypical and incorrect notions and ideas (which many
people hold to be true) about hearing aids is epic and would
require an entire article to scratch the surface. Therefore, I
will not offer an exhaustive list of these notions and ideas
in this article - but, suffice it to say the most common
impediments include; technophobia (some people believe
hearing aids will be too complicated), cosmetics (some
patients fear their hearing aids will be extraordinarily large
and hideous looking), cost (some patients fear really, really
good hearing aids will cost a small personal fortune), and of
course sound quality misperceptions, loudness issues and
most unfortunately — personal reports from prior patients,
friends and relatives who argue (i.e. whine) incessantly that
hearing aids didn't help grandpa (back in the 1960s) and
that gramdma's hearing aid always whistled (in the 1980s) and
on and on, all of which serve to sink the ship before it leaves the
harbor.
So then what to do?
Extrinsic demands for behavioral change
Nothing works every time and each person is unique. However,
the psychology literature reveals, and each of us know intuitively,
one cannot help the person who does not want and does not
seek help. That is, the desire for change must be internally
driven (i.e., intrinsic) for change to be meaningful. The individual
must realize there is a problem, take ownership of the problem
and desire a solution (or a change) in order for the change to
become internalized and effective.
Lessons from psychology
Thousands of books and articles have been written with regard
to how to stop smoking, lose weight, and how to avoid (or
eliminate) excessive use of alcohol, drugs and other behaviors
with extremely negative consequences. However, people do not
always seek and do what's in their own, true, best self-interest.
There are many examples of change that does not occur when
an external source applies a correction in the absence of "buy
in" from the individual upon whom change is intended. The
significant negative consequences of hearing loss (reduced
quality of life, missing words and sentences, depression,
confusion, anxiety, compromised physical health, etc) are simply
not reason enough for most people to acquire hearing aids.
Drago, Galbiari and Vertova reviewed recitivism rates for 25,000
prisoners and determined "measures of prison severity do not
affect negatively the probability of recidivism."4 In other words,
even in light of severe punishment, change does not necessarily
occur. With regard to obesity, Bakalar reported when patients did
not request weight loss advice from their physicians, but advice
was given, there was no change in their weight some three
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•reulT?9Hmonths later.5 However, for people who embraced their
problem, internalized it and sought change and advice,
they did experience significant weight loss. Further, some
contemporary cigarette packages simply state "Smoking
Kills," yet smoking persists for perhaps 25% of the
population.6 There is no doubt every single smoker knows
it isn't healthy to smoke, but they choose to for whatever
their reasons may be. Clearly, external influence and the
degree of punishment does not necessarily impact chosen
behaviors.
What works?Psychologist Robert Cialdini notes human behaviors are
(more often than not) predictable, and there are six core
principles which impact and direct human relationships.78
Briefly stated, people like to reciprocate (i.e., give back),
people like and value things when they are scarce (rarity),
people respond to and respect authority, people need to
be consistent with what they say and do (consistency),
people need to like the people they relate to (personally
and professionally) and people want to know how others
have handled and resolved the same situation (i.e.,
consensus).
Psychologists Miller and Rollnick report significant
success across multiple behavioral issues (obesity, drug
addiction, alcoholism, smoking, etc) using Motivational
Interviewing* Motivational Interviewing (Ml) explores and
develops the individual's intrinsic motivation to engage
behaviors and thoughts which facilitate healthy change. Ml
is a patient-centered technique which accomplishes these
goals by reducing ambivalence through "change talk." Ml
requires the professional to talk less and listen more, while
increasing the patient's intrinsic motivation to change. In
the context of an audiology-based interview (preliminary
discussion) the application of Ml is based in asking the
right questions and perhaps more importantly — not asking
the wrong questions!
Motivational influence
Combining the techniques and general principles of
Motivational Interviewing and influence has therefore
brought us to "Motivational Influence." Motivational
Influence is a conversational and counseling style which
directs the conversational discourse between patients and
professionals, to accomplish whatever is truly and ethically
in the best interest of the patient. To me, as an audiologist
involved in the diagnosis and treatment of hearing loss,
I truly and ethically believe hearing aid amplification is
generally the best course of action for the vast majority
of patients with sensorinerual hearing loss. With this as
a given, I try to avoid some questions and statements
which do not serve the patient well, while diecting the
conversation into topics and issues which are far more
likely to be advantageous.
Your verdict!Review by Cara Brown, student
from Queen Margaret University
Douglas Beck: confident, comic and charismatic.
From assessment to rehabilitation, Dr Beck has
some innovative ideas not usually associated with
traditional NHS patient contact. Can his ideas be
incorporated into the time pressured NHS clinic?
The primary focus of Dr Beck's lecture at the
BAA conference was Motivational Influence. Dr
Beck has combined the core components of well
established psychology protocols (Motivational
Interviewing and Influence) within the initial
assessment to establish the patient's views on
their hearing loss. Motivational influence can be
used in tandem with a traditional history and intake
conversation. Through motivational influence,
the patient's focus can be directed to the root
issues concerning their hearing loss and thus
better prepare them for their test results and aural
rehabilitation. It allows the audiologist to explore
and reveal more important information about
the patient and their lifestyle as well as possible
situations that may be problematic for them due to
their reduction in hearing. This is a patient-focused
approach and, if the correct questions are asked, it
takes the same time as traditional history taking.
Dr Beck also mentioned the importance of influence
in moulding the patient's pathway. He revealed that
if the patient can read articles their clinician has
written or see their qualifications on the waiting
room wall, they develop a respect for the clinician's
knowledge and expertise. This allows the clinician
to greater influence the patient to taking the
appropriate pathway.
In conclusion, applying these concepts does not
require any extra time during the appointment but
rather preserves time. The clinician can develop
greater knowledge about the patient and be better
equipped to provide rehabilitative measures via
Motivational Influence.
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For example, it appears (to me) to not be in the best interest of
the patient to ask questions such as:
• Do you think you have hearing loss?
• Does your hearing loss cause problems for you?
• Are you worried/concerned about your hearing loss?
And in particular, I would never recommend asking a new
hearing aid patient, wearing hearing aids for the first few
moments,..
How does that sound?In general, these questions allow the patient to state out loud
their arguments which negatively reinforce (in their own mind)
they do not have a hearing problem, that people do not speak
clearly, that they do not want hearing aids, that other people
are the problem, that the hearing loss is not a real problem,
and that if only other people tended to conversational speech
as they should (i.e., speak slowly, dearly and perhaps louder),
there would be no issue, no problem and no need to address
it. In other words, many of the typical questions we ask, allow
the patient to take a stance contrary to the mission (the mission
is addressing the hearing loss in a constructive way). Cialdini
indicates once the patient has stated their negative beliefs and
concerns, they will attempt (perhaps need) to be consistent with
those same words and beliefs. And frankly, unless you are a
highly skilled counselor, if/when you disagree with or correct the
patient, you potentially cause them to dislike you (maybe a little,
maybe a lot!) and Cialdini cautions that for positive relationships
to be built - they must like you.
It would be safer, wiser and more congruent with the mission
to ask questions which allow (and arguably lead) the patient to
admit and discuss their hearing loss, such as:
• When did your hearing loss start?
• Is your hearing loss worse or about the same as it was twoyears ago?
• Which is more difficult, a restaurant or a cocktail party?
• Who's voice is harder to understand, children or women?
In other words, regardless of the responses to these questions,
the professional engages the patient in a discussion which
addresses their hearing loss and the difficulties they experience.
SummaryMotivational Influence is not dependent on the quantity of
information or the many ways one can access information. As
noted, smokers know all about the damage smoking does and
they usually do not need healthcare professionals to tell them
to quit - although they may need healthcare professionals to
help them once they've decided to quit. People with obesity
issues know it is better for their long term health issues to
better manage their caloric intake. Alcoholics and drug addicts
already know the damage they cause to themselves and others.
Likewise, the majority of people with significant hearing loss
know they are not hearing as well as they would like to, yet in
general, they avoid hearing healthcare professionals (again,
simply having hearing loss does not render one "ready, willing
and able" to acquire hearing aids).
Motivational Influence helps the individual with hearing loss
work through their ambivalence as the professional directs
the conversational discourse to discover and underscore the
patient's goals and desires. Motivational Influence is not "another
thing to do." Rather, it is a conversational and counseling style
which helps directs the conversational discourse to accomplish
whatever is truly and ethically in the best interest of the patient.
1. Beck, DL., and Harvey, MA. (2009). Creating Successful Professional-to-Patient Relationships. Audiology Today, September/October, pages 36 to 47.
2. Taylor, B. (2009). Survey of current business practices reveals opportunitiesfor improvement; Hearing Journal: September, Volume 62, Issue 9 http://jour-nals.lww.com/thehearingjournal/Fulltext/20Q9/Q9QOQ/Survey_of_current_busi-ness__practices_reveals.5.aspx
3. Kochkin S. (2010) MarkeTrak VIII. Consumer Satisfaction with HearingAids Is Slowly Increasing. Hearing Journal. 63(1):19-32, As reported in "Mar-keTrakVIII: Consumer Satisfaction Increasing," http://www.audiology.org/news/Pages/20100211.aspx
4. Drago, F., Gatbiati, R., Vertova, P. (2009). Prison Conditions and RecidivismFrancesco. CELS 2009 4th Annual Conference on Empirical Legal StudiesPaper. http://papers.ssrn.com/sot3/papers.cfm?abstract_id=1443093
5. Bakalar, N. (2010). Approach May Matter tn Advice On Weight. New YorkTimes online, Oct 25. http://www.nytimes.com/2010/10/26/heatth/26weight.html
6. NIH (National Institutes of Health) 2010. NIDA InfoFacts: Cigarettes andOther Tobacco Products; http://www.drugabuse.gov/infofacts/tobacco.htmt
7.Cialdini, RB. (2007). Influence - The Psychology of Persuasion, New York,Harper-Collins.
8. Cialdini. BR. (2008). Influence - Science and Practice. Fifth Edition. Pren-tice-Hall.
9. Miller, WR., Rottnick, S. (2002). Motivational Interviewing - Preparing PeopleFor Change. 2nd Edition. The Guilford Press. New York, London.
The BAA Conference 2011 will be in Llandudno, North
Wales from 9-11 November.
The conference will take place place in the recently refurbishedVenue Cymru Conference Centre. Set beneath the gloriousfoothills of Snowdonia and occupying spectacular views out tosea, Venue Cymru is one of the finest locations for professionally
managed conferences.
Watch this space for more information!
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