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

2. 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

3. 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

4. Prochaska’s & DiClemente “Stages of Change Model”

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

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

7. 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.

8. 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

9. 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

10. 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

11. 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

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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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 …

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

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

28. 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

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

30. 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

31. 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

32. 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 {{{{{

33. 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

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

36. 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

37. 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…”

38. 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

39. 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

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

41. 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

42. 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.”

43. 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?"

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