Patient Care | May 2019 Hearing Review
An improvisational approach to patient-centered care can be beneficial for all
Patients will often remember and appreciate your “bedside manner”– or the way you relate to them in a personal and caring way–over your knowledge, skill, education, and professionalism. Using an improvisational approach to the patient interview may, at times, be cumbersome. However, it is also likely to make your approach to their hearing-related problems more interesting, genuine, and meaningful—for both the patient and you.
Motivational Interviewing (MI) is a goal-directed, patient-centered approach to elicit emotional “change talk” from patients and increase their adherence to recommendations.1 After a workshop I conducted on motivational interviewing, an audiologist commented that he could see how MI could benefit his patients, but added that “It’s cumbersome.” I think I responded with something like, “Yeah, it’s a new skill but it gets easier with practice.” It was one of those comments that, in retrospect, you regret because you know it was an opportunity missed. This article is my attempt to more completely respond to his comment, and to describe some benefits for Hearing Care Professionals (HCPs) of doing what initially may feel cumbersome.
Improvisation in Music..and Counseling
I had always wanted to play the hammered dulcimer, a percussion-stringed instrument that consists of strings stretched over a trapezoidal resonant soundboard. So I signed up for a week-long, intensive hammered dulcimer training session. Because it was marketed as “chord camp,” I assumed it would be fun, an adult version of eating s’mores around a campfire, a reprieve from the routine of my psychology practice.
I was wrong. I found myself barraged by too much new and difficult material too fast (eg, “What the heck is an inverted chord?”), constantly anxious about playing the wrong notes or the wrong order of notes, falling flat on my face in front of the teacher and other students, etc.
During that very long week, my mind wandered back to more familiar territory, including the audiologist’s comment about MI being cumbersome. (He should attend chord camp!) But what most poignantly brought me back to our exchange was when the dulcimer teacher talked about the value of improvisation: “Playing different notes keeps it new and interesting for both the audience and performer,” he said.
I then realized how I should have responded to the audiologist: “Although adhering to a standard patient interview protocol with the same ‘notes’ may be comfortable for you in contrast to improvising with MI ‘notes’ which would be cumbersome and perhaps even anxiety-provoking, your improvisation may make the interview more interesting for you and your patients.”
I could have referenced a discussion among audiologists at the Ida Institute (https://idainstitute.com), an independent, nonprofit organization in Copenhagen, Denmark, that works to integrate person-centered care in hearing rehabilitation. The audiologists emphasized the value for themselves of using motivational interviewing:
“It’s also fun to have a completely different conversation with the client,” one audiologist began. “It’s not just the nodding client and the blabbering audiologist. It feels like a nice conversation, during which you get a lot of information in a short period of time.”
“So, it has benefited you, too?” he was asked.
“Yes, it certainly has. When I think about the way I used to consult, it may have appeared to the professional that I understood what I was doing. But they weren’t individual consultations. They were standard and they sounded good…I just wanted to appear professional on the outside.”2
Engaging with Patients
Inviting patients to articulate their motivation for improved hearing inevitably is also inviting patients to articulate a slew of raw emotions associated with self-identity and peer/familial/work relationships—often years of missing words and conversations, anxiety, and fear about inadequacies, loneliness, etc. Moreover, in an earlier publication, I described how the context of the audiologic visit inevitably sets the stage for more intimate patient self-disclosure.3 As an example, a mother recalled that, “While Dr Smith was showing me how the hearing aid worked, I couldn’t help blurting out that it’s so unfair for my poor little girl and I started to cry.”
As another example, Jill was a middle-aged woman who requested hearing aids around the time that her father was diagnosed with terminal cancer. When Dr Jones asked her the “Why now?” question, her response was short and to the point: “I want to make sure I understand everything my dad’s oncologist says.” Then, when he fitted her with hearing aids, seemingly out of nowhere, she suddenly began sobbing uncontrollably. Later, Dr Jones would understand that inasmuch as this procedure catalyzed joy and gratitude for her improved hearing, it had also catalyzed post-traumatic flashbacks of scenes that portrayed years of estrangement from her dying father.
The Changer and the Changed
There is a Buddhist saying that when the student is ready, the teacher will come. For our present discussion, the HCP becomes the student while the patient becomes the teacher. The HCP is given an invaluable growth opportunity by bearing witness to patients’ emotional self-disclosures. One audiologist described her profession as giving her life more contrast and texture:
“Sharing in the growth and development of another person as they cope with hearing loss is an honor, a life-altering, spiritual experience for those who are open to it. Our clients’ resilience promotes our increased respect for the human spirit.
“We have the experience of knowing intimately people we would otherwise not have known, and of sharing vicariously in others’ life choices and struggles, their most intimate feelings, needs, and concerns which get sparked by their loss of hearing. Our connections with clients through humor, love, and pain contribute enormously to our growth as individuals, add complexity to our lives, and increase our capacity for empathy and understanding.
“At times we have had glimmers of wisdom resulting from our work. Our clients teach us the things we might have learned from grandparents, wise elders. Sharing joy and sorrow, laughter and pain, wisdom and ideas with another person is at the heart of what it means to be human.”
Contrast and texture notwithstanding, there are professional concerns regarding eliciting patients’ emotions: that attending more to patients’ emotions in an “improvisational” manner runs the risk of “opening a can of worms,” going beyond professional boundaries, and consumes too much appointment time. Consider the following perspective:
“I think part of being a good audiologist is recognizing when an individual with hearing loss and/or family member is having a tough time coping with the hearing loss and making an appropriate referral to a psychotherapist who is trained to deal with these issues. You can only wear so many hats and we shouldn’t beat ourselves up if we can’t solve all of a given patient’s problems.”
These are valid points. Moreover, to return to the improvisation metaphor, playing notes in a random, haphazard manner typically produces dissonant noise (aka, a “can of worms”), is poor musicianship (aka, violating professional boundaries), and wayward performances (aka, consumes too much time).
Guidelines for eliciting emotional material in an effective and ethical manner have been provided elsewhere.4-10 Briefly, these include asking patients bounded open questions (eg, “In the limited time we have, would you give me a snapshot about how you’re feeling?”); validation and normalization of patients’ emotions; delineation of your role as a HCP (not a psychotherapist); and carefully making a therapy referral, as needed.10 Moreover, effective counseling can be incorporated into most clinical practice settings in an efficient and effective manner, without negatively impacting the time constraints of the practicing audiologist.11
Of course, I am not suggesting the elicitation of patients’ emotions solely because it would be more interesting and beneficial to the HCP. What I am suggesting, however, is that it can be a win-win; that the elicitation of a patient’s emotions, or “playing different notes,” can be psychologically beneficial for the patient and increase the effectiveness of the HCP. This is exemplified by the following report from an audiologist:
“Many letters have come from patients thanking me for changing their lives, or saving their marriage because of my kind, sincere, caring bedside manner. My patients really seem to remember those characteristics over how much knowledge, skill, education, or professionalism I have. I have had several patients say to me with full gratitude that I am the first person who has so much patience to listen to them, and understand them more than anyone else. It’s what keeps me warm on a cold winter’s day.”
After my MI workshop, I could have said to the audiologist that practicing MI, although initially cumbersome, could keep him warm on a cold winter’s day. That is, in the words of Carl Jung, “Find out what a person fears most [finds most cumbersome] and that is where he will develop next.” And I could have told him about the value for me of improvising with my hammered dulcimer —after explaining what a hammered dulcimer is. Maybe he’ll read this article.
Miller WR, Rollnick S. Motivational Interviewing: Preparing People for Change. 2nd ed. New York, NY: The Guildford Press;2002.
Ida Institute. Motivational engagement [videos]. Talks presented at: Skodsborg, Denmark; September 2009. https://idainstitute.com/what_we_do/seminars/motivation.
Harvey MA. The transformative power of an audiology visit. Hear Jour.2000;53(2), 43-47.
Beck DL, Harvey MA. Motivational interviewing. The Hearing Professional.2018;58-65. https://ihsinfo.org/IhsV2/CEUs/pdf/2018%20THP%20Q3%20p58-65+67.pdf.
Beck DL, Harvey MA. Creating successful professional-patient relationships. Audiology Today.2009;21(5):36-47.
Beck DL, Harvey MA, Schum DJ. Motivational interviewing and amplification. Hearing Review.2007;14(11):14-20.
Harvey MA. When a patient requests hearing aids but doesn’t want them: Psychological strategies of managing ambivalence. ADA Feedback. 2003;14(3):7-13.
Harvey MA. Audiology and motivational interviewing: A psychologist’s perspective. Audiology Online. October 20, 2003. https://www.audiologyonline.com/articles/audiology-and-motivational-interviewing-psychologist-1119.
Harvey MA. How to refer patients successfully to mental health professionals. Hearing Review.2008;15(7):22-26.
Clark JG, English KM. Counseling-Infused Audiologic Care. 3rd ed. Cincinnati, OH: Inkus Press;2018.
English K. Integrating new counseling skills into existing audiology practices. Audiology Online. January 4, 2001. https://www.audiologyonline.com/articles/integrating-counseling-skills-into-existing-1265.
Correspondence can be addressed to Dr Harvey at: [email protected]
Original citation for this article: Harvey MA. Playing different notes: The benefits of motivational interviewing in hearing healthcare. Hearing Review. 2019;26(5):22-23.