Counseling, Psychosocial Therapy, Assertiveness Training Perry C. Hanavan, Au.D.

Counseling Benefits Understanding of hearing loss and effects on communication Self-disclosure and self-acceptance Managing communication difficulties Stress reduction and discouragement AR satisfaction Motivation Adherence/compliance with AR

Patient Motivation and Compliance Professional Advice Model Patient Centered Model Professional advice provides patient information and prescription Patient partners with professional to identify and express needs and attitudes Persuades patient to move from unaware of condition to complete compliance Patient acknowledges readiness to change then enabled Advice perceived as critical and intrusive resulting in increased resistance to change Patient participation motivates compliant behaviors

Prochaska’s & DiClemente “Stages of Change Model”

Improve Communication 2. Agenda-Setting Chart Hearing Aid HAT Communication Therapy Managing Environment Responsibility Organization Improve Communication

“Readiness to Change” Ruler Not Prepared to Change Already Changing

Questions using the “Readiness to Change” Ruler Answer the questions below that apply to you. If your mark is on the left side of the line: How will you know when it is time think about changing? If your mark is somewhere in the middle: What might make you put your mark a little farther to the right? If your mark is on the right side of the line: Pick one barrier and list some things to help you overcome this barrier.

Changing habits We are all familiar with patients not doing what has been recommended Rejecting a hearing aid Using facilitative communication strategies Not adopting an assertive communication strategy However, knowing is not automatically followed by doing

Stage of change We seem to follow the same pattern, when changing habits Therefore we can often use the same simple tools to support the changing process The lines The box The circle

How to begin ? We often want the patients to do what we think is the best We recommend We persuade We stress It is better to let the patient do this themselves

Building up the dialogue First Ask, listen, observe, feel, accept Recognize that there is a problem but do not tell that patient that he or she has a problem let the patient tell you

Continue to building up Then Establish a burning platform So the patient has to respond Focus on a few crucial elements

Focus Go to Identification of how important it is for your patient to change habits how much the patient believe in his or her ability to change

The importance of changing now 1) How important is it for you to improve your hearing/communication right now ? 10 The lines go from ‘0 = not at all’ to ‘10 = very much’. Rollnick 1999

The importance of changing now 2) If you really tried, rank your willingness to use HA, CI, HAT, communication strategy: 10 The lines go from ‘0 = not at all’ to ‘10 = very much’. Rollnick 1999

The core part of the dialogue ASK: What is the reason for giving yourself 6 and not 1 ? RESPONSE: The patient begins to phrasing the reasons You are always more open to become convinced by listening to your own arguments and voice

The core part of the dialogue ASK: What would it take to increase the importance from 5 to 9 ? ASK: What would it take to increase your belief in your ability to change habits from 3 to 8 ? ASK: What can I do to help you to go from 1 to 7

Decisional Balance 1) Benefits of status quo 2) Costs of status quo 3) The potential costs of change 4) The potential benefits of change Janis and Mann 1977

The changing process Stages of changes or Wheel of fortune Maintainance Relapse Con-templation Action Preparation Pre-con-templation Permanent Change Stages of changes or Wheel of fortune

Pre-contemplation He or she Recognises comments and information as misplaced or ill-timed involvements Excuses him- or herself Does not think that he or she will succeed in changing habits Becomes surprised when presented for problems

Contemplation=Ambivalence He or She Feels comfortable in the present habits / is afraid of the consequences of continuing the present habits Rejects to change habits / wants to change

Preparation He or she Is looking for information on consequences Would like to talk about changing habits Would not like to talk about it at the same time Looks for support Would like to do it him- or herself

Action He or she Is happy and proud Talks about the change and looks for acknowledgement and appreciation Feels that it is not as difficult as expected Fears to give up the change and relapse

Maintenance He or She Feels successful Is sad and seeks the conflicts Wants to take up the old habits –sometimes Forgets why he or she wanted to change habits

Relapse He or she Feels like a failure Relaxes and enjoys the freedom Is angry and annoyed Feels like being a weak character Is motivated for new attempts regarding changing habits again …

Permanent change He or she Feels safe and comfortable with the new behavior Is integrated with the new habits

Maintainance Relapse Con-templation Action Preparation Pre-con-templation Permanent change Encouragement Support Continued support Education Information

Prochaska & DiClemente 1991 Permanent Exit ATTITUDE PROCESS BEHAVIOURAL PROCESS Encouragement Support Continued support Education Information Action Preparation Maintainance Con-templation Relapse Pre-con-templation Prochaska & DiClemente 1991

A pedagogic trick A logbook / diary to measure the use the hearing devices You always try to improve your outcome, when measured

Types of Counseling: Goals Informational Rationale Acceptance Adjustment Counseling Patient/family learns about hearing loss, hearing assistance technologies, communication, etc. Patient/family learns how to manage hearing loss and communication difficulties ………. Patient/family works through negative feelings regarding hearing loss and decreased sense of worth

Types of Counseling: Outcomes Informational Rationale Acceptance Adjustment Counseling Patient/family understands hearing loss, hearing assistance technologies, willing to participate in AR Patient/family uses communication strategies, structures listening environment, participates in AR Patient/family views disability separate from self, regains positive self-image, willing to participate in AR sin

Types of Counseling: Techniques Cognitive Behavioral Affective Modifies thought process Focus on logic to direct & redirect thoughts, beliefs, perceptions, values, ideas, opinions Modifies behavior Focus on observable and measurable behaviors ))))))))))))))))))) )) Modifies emotions Focus on feelings and on fostering emotional adjustment {{{{{

Listening Techniques in Counseling When listening to verbal messages: Make eye contact Fully face the patient Lean forward about 200 so your forearms can rest on your thighs Be consistent in your attending postures to communicate interest in the patient

Assignment: Try communicating with a person using the listening techniques and strategies Report back at the next class

Listening Techniques in Counseling When observing nonverbal messages Appearance: Sloppy appearance, slow movements, sad expressions may suggest low energy levels and minimal readiness for help Behavior: Uncooperative or disagreeable behaviors may signal person is unwilling or unable to cope with the communication situation Punctuality: Chronically late or missed appointments may signal lack of motivation Lost Hearing Aid: Leaving hearing aids at home or in purse or carrying case may be expressing distress or frustration

Patient Messages “I’m not vain but…” “I would never spend that…” “If everyone talked like you…” “I will never wear a HA that is visible.” “I won’t wear a HA.” “I don’t have a hearing loss…”

Psychosocial Therapy Group therapy Implemented as part of communication training in AR Usually incorporated when person’s emotional response to hearing loss is seen as negative

Psychosocial Therapy Purpose: To discover possible causes for a person's negative feelings about hearing loss, hearing aids, AR, etc. Helps the patient understand himself or herself better Self-understanding may help the patient overcome the problems associated with hearing loss One form of psychosocial therapy is called cognitive-behavioral therapy Help the patient to recognize negative thought patterns about hearing loss, hearing aids, AR, etc. Trained to change those negative thought patterns to positive patterns

Psychosocial Therapy Problem Solving Framework: Problem identification (setting an objective) Problem exploration Problem resolution

Assertiveness Training Key Elements: Ways to indicate a hearing loss Means to request a change in the communication environment Ways to suggest how the communication partner can facilitate the patient’s understanding of spoken messages Means to provide positive feedback to communication partners to reinforce desirable behaviors

Assertiveness Training Increase the cooperation between person with hearing loss and communication partner Ways to indicate a hearing loss “I have a hearing loss and may not understand.” Ways to request a change in the communication partner “The lights are dim. Could we move to another room.” Ways to suggest how the communication partner can facilitate understanding of spoken message “It helps me understand if I can see your face.” Ways to provide positive feedback to communication partners to reinforce desirable behaviors “I appreciate your talking to me face to face.”

Assertiveness Training STEP ONE: Realize where changes are needed and believe in your rights STEP TWO: Figure out appropriate ways of asserting yourself in each specific situation that concerns you Example: Situation: You have just been introduced to someone, but you did not learn his/her name. Response: As soon as appropriate, ask, "What is your name again?" Use it the first chance you get, so you won't forget it again. Poor responses: Let it go and try to avoid situations where you need to use his/her name. An aggressive response would be to blame him/her, "You don't speak up very well, what's your name again?"

Examples Dr. Sam Trychin HearWell Dr. Mark Ross (Assertiveness)