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 The actual list of aged, outdated, ridiculous,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

BAA_WmtefJ010_11jiic6.indd 12 07/02/2011 12:32

•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.

BAA_Wintei_2010_11_nic6.indd 13 07/02/2011 12:32

•npfuffiH

14

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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