Counseling | May 2015 Hearing Review

Four objectives to insert into your Patient History that help transform it into a vital component of your Counseling Protocol

The answers to getting and accepting help have always resided within the patient, so we need to stop pretending that the answers for the patient reside in whatever we tell them.

Fitting hearing aids is about human interaction, and whether that interaction is effective in moving a patient with a hearing loss towards the help that they need.

As human beings, we relate to others in one of two ways: we treat others as a task, or as someone to whom one wishes to relate. I am sure you have noticed in a post office while buying stamps or in an airport while buying a ticket that you are, in most cases, just a task to be taken care of. When a doctor treats the patient, as well as the disorder, he/she is said to have a “good bedside manner” when exhibiting a relational approach to the patient.

Von Hansen

Von Hansen

For a moment I am going to ask for your logical indulgence as I talk about allowing the patient to become profoundly invested in not only their hearing loss but the remediation of that loss. I have had the privilege of spending a lot of time in the office with at least 100 hearing care professionals (HCPs) as they conduct a hearing evaluation. As the audiogram is created and the professionals prepare themselves intellectually and emotionally to explain the audiogram to a hearing-impaired patient, it is clear to me that the professional feels as if they have all the proof they need to move the patient to the obvious conclusion: that the patient should want to purchase hearing aids because the science of the audiogram fully explains their hearing problem. This is accomplished by telling the patient what their audiogram means and how their everyday hearing reflects the truth of the audiogram. In essence, the urge is to say, “You, Mr Patient, are not hearing the consonants, or you are not getting the power of the vowels, so communication for you is naturally difficult.”

Generally, the next step is to demonstrate how hearing aids will help the patient in real-world circumstances. After all, what more can be asked of an HCP than to allow the patient to experience the benefit that hearing aids can bring to the patient here and now?

Let’s move for a moment to another venue of human experience to test the power and effectiveness of telling the truth to someone (as professionals do when explaining the audiogram to a patient), and let’s examine how effective that is.

You have a dear friend named Tom. He is 5’ 10” and he weighs 300 pounds. The truth is obvious to you and all of Tom’s friends and family. Tom has been this way since high school and he is now approaching 60 years of age. Diabetes runs in his family, along with severe heart conditions. You want Tom to stay around and be present and vibrant for the formative years of his children’s lives. You want Tom around also because he is a valued friend.

As you know, many of your patients are reluctant to be in your office and have oftentimes been dragged in by a spouse or adult child that is exhausted from years of repeating and unfortunate misunderstandings. Tom, your obese friend, is skipping along in life oblivious to his impending heart attack and/or death, and you feel it is time to share the truth—nothing but the truth—with your friend whom you want to help and keep alive.

Summoning your courage, you tell Tom that he is morbidly obese and you fear for his life. You tell your friend that he needs to eat less and exercise more, because you want him to stick around.

So after 50-plus years, Tom slaps his forehead with that “I should have had a V-8 moment,” thanks you profusely, and immediately sets about changing his life. Or not.

You have done your best, right? After all, you have told your friend the absolute truth, and you know in your heart that Tom knows you have his best interests in mind. Yet, as time passes, it is apparent that Tom has no plans of heeding your advice.

Insight as the Missing Ingredient

I have a dear friend who was obese. His mother, a very heavy lady, died recently. As my friend and his father stood viewing the body, the father put a compassionate arm around his son and said, “That is you in a few years if you do not lose the weight.”

My friend had been overweight much of his life and blended in well with his family. However, at the precise moment his father spoke to him, he had a flash of insight and in the ensuing 3 months lost almost 60 pounds. This is not because weight loss was new information; the experience created a powerful personal insight that moved my friend to change his lifestyle.

In the hearing industry we are trained to test hearing, prescribe devices, help with financing, and prepare for follow-ups. Much of this activity is preceded or set up by what we collectively refer to as the “case history.” It is my experience that case history fails miserably in providing powerful life-changing insights for the hearing-impaired patient.

Questions such as “How long have you had trouble hearing and understanding?” or “Why have you waited so long?” have the net effect of annoying the patient more than bringing them to some kind of catharsis. These types of questions put patients in a defensive posture which hearing care professionals subsequently identify as “reluctance,” “denial,” or “lack of readiness/motivation” to deal with their hearing problem. And this is often without realizing the role the HCPs themselves have unintentionally played in patient resistance.

If the hearing industry was willing to devote itself to learning the art of creating insight for the patient—so the patient could come to greater self understanding—we would see a dynamic change in how HCPs do business.

Just as patients are afraid of change, so are hearing care professionals. To rework one’s approach while moving the patient to acceptance and insight regarding their hearing impairment takes a willingness to do more than reflexively recite the questions on an uninspired case history.

Patient Insight and Revelation: Overcoming Reluctance and Denial

When patients reach an understanding of the motivational forces behind their actions, thoughts, and behavior, they gain a self knowledge that they could not be “told” into. This is the essence of counseling: asking, listening, then allowing the patient to reveal their own truth. Nothing else is counseling. The art of counseling leads the patient to self revelation—which is where the desire for remedial action and personal growth reside.

Confidence as a barrier to professional growth. Like you, I have seen those case histories found on the back of many audiograms. Most represent little more more than a cascade of simplistic questions that are annoying to the patient and unhelpful at best. I can only guess that the dispensing professional hopes that the case history questions will accomplish two primary objectives: point to any red flag conditions present and elicit an epiphany of acknowledgement that will help the patient gain insight—while giving the professional confidence that the patient is now willing to accept help.

But the precise work of helping the patient gain insight into his/her impairment is unlikely to emerge from a staid case history. The goal is irrevocably moving the patient beyond “denial” and “reluctance” to acceptance of help for a hearing problem.

Replacing the Case History (the What) with the Counseling Protocol (the Why)

I am going to use the term “Counseling Protocol” to be interchangeable with the “Case History.” But, in addition to the general goals of information gathering in a Case History, there are four major goals of the Counseling Protocol:

1) Help the patient take complete ownership for the visit in your office;

2) Help the patient explain clearly, without confusion or equivocation, what is going on in their daily life regarding their hearing;

3) Help the patient understand why they have come in now to see you (what really prompted the initial visit);

4) Enumerate and place a real value on those everyday environments in which the patient struggles, as well as the emotional impact of those daily struggles.

If you (and your professional staff members) are able to accomplish these four objectives with the majority of your patients, the impact on your practice and your ability to serve your patients will grow exponentially. Fulfilling these four objectives seems easy enough—that is, until you actually try to do it. A good deal of it boils down to the confidence to do the work, while becoming skilled and proficient at “good bedside manner.” (In fact, I make a portion of my living teaching these skills, so it’s obviously more nuanced than reading questions from the back of an audiogram.)

But here is the bottom line: when the hearing professional learns how to listen and ask questions in a helpful non-offensive way is when patient satisfaction and practice can grow exponentially.

But it’s not easy. The new skills required to master the Counseling Protocol must be consciously developed and practiced. However, when you take this approach, it opens up a new world for you and your patients.

The Art of Asking the Right Questions Is the Answer to Patient Insight

If one of the primary goals is to help the patient take complete ownership for the visit to your office, the first step is to get the patient to commit to the appointment.

HCP: Mr Jones, who encouraged you to come see a hearing professional today?

Mr Jones: This was my wife’s idea. She thinks I can’t hear well, while I have to put up with her mumbling all the time.

While the primary question acts as a guide post, the ability to ask clarifying follow up questions is, in fact, the key to helping the patient understand both their motivations and their fears.

HCP: Mr Jones, please say more about that so I have a better understanding of how communication is at your home.

Mr Jones: Mary is always saying that she has told me something before, and she gets mad at me because she thinks I don’t listen to her. She is always complaining about the TV, and she says she has to repeat too much.

Try getting this response with your normal case history. Follow-up questions fill out patient answers and bring the patient to present their auditory circumstances. This helps the patient gain insight.

The difference between the patient gaining personal insight and being told what the HCP wants them to know is the difference between the patient taking ownership of their hearing impairment and noncompliance with the HCP’s recommendations.

To create a mental image of the necessary follow-up questions, imagine writing on the palm of your left hand, “Please say more about that.” Then, on the palm of your right hand, imagine writing “Help me understand what you mean when you say…”

For example:

Mr Jones: My wife is unwilling to go to the movies with me anymore.

HCP: Please say more about that.

Mr Jones: My wife says that when she has to constantly repeat dialogue it ruins the movie for her.

The patient has just said aloud that his hearing impairment has an impact on his wife (and therefore on himself) because she won’t go to movies with him.

HCP: Mr Jones, when your wife, Mary, refuses to go to the movies with you, what is the impact of that on you?

Mr Jones: Well, it makes me mad because I don’t want to go to the show alone. In fact, I won’t go.

HCP: Mr Jones, what is another environment in which you find communication to be less than you’d like it to be? [Notice the phrase, “your hearing” isn’t used; instead, the word “communication” is used. It is far easier for the patient to comment on communication rather than address their inability to hear effectively.]

Mr Jones: Well, I have stopped going to my weekly poker party.

HCP: Mr Jones, help me understand what has caused you to stop playing poker with your buddies?

Mr Jones: I don’t always understand what is being said, and that has cost me money and the guys razz me unmercifully when I don’t understand things, including their jokes—I feel picked on and I’ve started not to enjoy myself.

Getting the patient to talk about their difficulties requires further questions. Topics might range from communication on the telephone, to conversing with daughters and sons, as well as grandchildren.

A lot of your follow-up questions can start with “What is the effect/impact/result when…” The intent of these questions is to shed more light on the hearing impairment and to get the patient to express themselves in their own words. There is nothing more powerful than patients voicing their own thoughts and then coming to a necessary and logical conclusion on their own. In many cases, they’ve already come to this conclusion but never expressed it verbally.

Let’s take the same example of Mrs Jones’ unwillingness to go to the movies with Mr Jones and expand upon it with different follow-up questions:

Mr Jones: My wife says that when she has to constantly repeat dialogue it ruins the movie for her.

HCP: When your wife says that repeating dialogue in a movie ruins the experience for her, how does that affect you?

Mr Jones: Well, it makes me feel bad. I don’t want to be the reason my wife doesn’t go to the movies. We went to the movies all the time when we first married.

Now we have introduced a new dynamic into our questions. We have gotten to emotion. The patient is now saying he feels badly when he is the reason that his wife does not want to go to the movies with him—specifically because he can’t hear the dialogue well.

What is not particularly effective at this point is asking, “How does it make you feel when your wife doesn’t want to go to the movies with you?” This question will both confuse and possibly anger the patient, because he does not truly know what you are asking or getting at. Defensive patients don’t buy hearing aids; after all, they don’t think that they really need them. (By the way, I sometimes recommend we drop the word “feel” from the clinical vocabulary. It’s fraught with peril for the HCP.)

From your conversation with Mr Jones, you now know who encouraged the patient to come into your office, and you have some idea of what is going on between husband and wife around his hearing. We have come to this by asking, “Who encouraged you to come see me?” and we have gotten to the emotional aspect of the answer by asking a follow-up question.

Now we take all of the difficult listening environments that we have uncovered and ask:

HCP: Mr Jones, if I could help you understand the dialogue in the movies, so that you didn’t have to ask about your wife to repeat the dialogue; if I could help you hear the bets and raises at the poker games, as well as the jokes around the table so you could win more often and take part in the banter; if I could help you communicate more clearly on the telephone so you didn’t have to hand the phone to your wife, which you say is sometimes embarrassing; and, if I could help you communicate with your grandchildren in a way that would let them know that you care about them, are those results that you are looking for? [The patient will say yes every time. How can they say no when you are simply paraphrasing what they have just told you?]

HCP: Mr and Mrs Jones, I am now going to show you what is possible with the most current hearing technology, and give you a demonstration using [BTEs/ITEs/etc]…

The final follow-up question after a demonstration might not necessarily be addressed to the patient, but rather to the third-party person attending the appointment:

HCP: Mrs Jones, what will be the daily impact on your life when your husband can hear you like this all the time?

And to emphasize the fact that, as you counseled them, hearing aids take a commitment to acclimitization and understanding how to use them:

HCP: Mr Jones what will be the daily effect on your life when you are able to communicate with your wife like this the majority of the time?


When the HCP is unclear about something that the patient or third-party says, it should be viewed as a gift because it affords the opportunity to ask for clarification. What you will find is that when you, as the HCP, are unclear as to what the patient means, so is the patient.

To review:

1) Always remember those two important clarifying questions indelibly written on your right and left hands:

  • Please say more about that.
  • Help me understand what you mean when you say…

2) Try to avoid questions likely to confuse or elicit anger (I would submit that “How does it make you feel when…” type questions can be too broad and add more complexity than necessary).

3) Instead use slightly more objective and to-the-point questions that can reveal the emotional impact of hearing loss, such as “What is the effect/impact/result/significance when…”

4) At the end of the Counseling Protocol, summarize the information that the patient and third-party person have given you, and ask for agreement or clarification.

The answers to getting and accepting help have always resided within the patient, so we need to stop pretending that the answers for the patient reside in whatever we tell them.

Von Hansen is a business and communications consultant for the hearing healthcare field. His office is located in Lebanon, Ore. Hansen lectures extensively throughout the US on topics pertaining to hearing healthcare.

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Correspondence can be addressed to Von Hansen at: [email protected]

Original citation for this article: Hansen, V. Maybe the Professional Is the One “in Denial”! Hearing Review. 2015;22(5):28.