It has been said that adolescence begins when children stop asking questions—because they know all the answers. Fifteen-year-old Paul fit that definition perfectly. He had been fitted with hearing aids because of a moderate hearing loss, but proclaimed, “They’re no good; I don’t need them! And tell my mom I don’t need to be dragged in here for counseling.” Although his objections were undoubtedly interwoven with embarrassment, shame, self-consciousness, and fear of stigma, I decided, at least for now, to respond to what he said at face value.

“Why don’t you need hearing aids?,” I asked.

“They don’t help me understand anything better,” Paul replied.

“How much do you think you understand at school without them?”

“It doesn’t matter. School’s boring. I’m gonna be a fisherman like my dad. You don’t need hearing aids to fish.”

Paul had a point. He certainly didn’t need hearing aids to fish like his father. However, emulating his father had an ominous feel to it, as his dad was an unemployed, chronic alcoholic who routinely sat at the closest lake with a case of beer and sometimes a fishing rod. There had to be a better way to motivate him to use his hearing aids, but Paul was not about to offer any suggestions. His mantra was “School’s boring.”

New tactic. I beckoned him to my computer, went online, double clicked a search engine, and accessed various Web sites devoted to fishing. One example:

Fish lead dual lives as predators and prey. As predators, fish are opportunists. Whenever the opportunity arises, they will eat anything that appears to be edible, including other fish, insects, and even small birds and mammals that blunder into the water. Predatory fish are efficient: They attack when their prey appears to be fleeing, crippled, or so abundant that it will be easy to get without expending much energy.

Now Paul perked up a bit, and asked me what “predator” meant. Accordingly, we double-clicked the dictionary icon and looked it up. For the remainder of the session, we discussed trout fishing, predators, prey, food chains, and ecosystems. When I wondered aloud about how to justify procedure “#90806- individual psychotherapy” to his insurance carrier, Paul let out his first smile. We were making progress, at least in terms of rapport building.

Motivational Interviewing
Paul’s presenting attitude exemplified what psychologists Prochaska & DiClemente1 termed the precontemplation stage: when a respective person is not yet considering the possibility of change and there is no real awareness of a problem. Needless to say, “precontemplators,” like Paul, seldom present themselves for treatment. In these cases, it is often important for therapists (or hearing care professionals) to establish credibility with a powerful, protagonist member of a family system—in Paul’s case, it was his mother—who could mandate treatment and buy you time for rapport building.

Then the challenge is to guide the person to the “contemplation” stage, characterized by having at least some awareness of a problem, albeit with much ambivalence. A psychological technique called motivational interviewing1 is particularly helpful in this regard. It is an interview protocol specifically designed to help people make a commitment to discontinue harmful addictive behaviors, such as drug and alcohol abusers. Such persons are often poorly motivated to change, even in the face of reason, gentle persuasion, or badgering. This technique is also applicable to help those who are “addicted” (using this term loosely) to denying hearing loss or the benefits of amplification.

One key objective in motivational interviewing is to “develop discrepancy.” In Paul’s case, this means there is a need to help him see that his current choices are hindering him in getting what he wants (discrepancy). This is often easier said than done. If Paul had aspired to attend college, then my task would have been easy: I could have “developed discrepancy” by pointing out that inadequate (unaided) understanding of his teachers obviously affects his learning. But right now, we only had trout fishing.

The Research Experiment
I began our second session the following week by returning to an earlier dialogue. “You said school doesn’t matter, but humor me,” I said. “In percentage terms, how much do you think you understand at school without the hearing aids? Pick a number: 50%, 70%, 95%, 30%, 46%, 100%.”

“Maybe 75%,” he shrugged.

“Well, this is very interesting,” I replied. “Your audiologist told me that, based on your hearing loss and the acoustics of your classroom, you probably understand, at best, 50%! There’s a discrepancy here! I wonder who’s right?” My question was delivered in the most provocative manner I could muster.

“I dunno,” Paul shrugged back, perhaps in the most provocative manner he could muster.

“Well, I dunno either, but maybe we could test it! Like a kind of research experiment. Let me ask you: If—just if— wearing hearing aids actually helped you understand more in the classroom, would that feel important to you?”

“I understand people just fine,” Paul persisted.

“But, as you said, if, just if, wearing hearing aids helped you better understand what people at school say, what would the value of that be?” I persisted.

“I told you before, I’m gonna be a fisherman,” he retorted.

“There’s a lot to learn about being a fisherman,” I retorted.

Back to the Internet. We found Web sites that described many kinds of trout: Yellowfin, Gillaroo, Atlantic Sea, Lough Melvia, Steelhead, etc. We discussed these varieties for the next couple of sessions—for me, two very long hours, as I’m not the least bit interested in fishing. But Paul was engaged and curious. And more importantly, I believed (or hoped) he understood my implicit message—my attempt to develop discrepancy—that “if you learn more about these things, you’ll catch more trout.”

The next step would be to make this message explicit, while supporting his autonomy and self-efficacy. I needed to prompt him to wonder whether or not his failure to follow audiologic recommendations was in his best interest. “I get it that school’s boring,” I told Paul. “But if you understood more what others were saying, would it be more or less boring?”

“More boring,” Paul instantly replied.

“So that’s one reason not to wear your hearing aids?”

“You got that right, doc.”

“I get it, patient.” With an attempt at humor, I gave him my best empathic response. “But maybe, just maybe, might you learn stuff like this—fish, oceans, predators, etc?”

“I doubt it,” came his dismissive reply. But this was progress. I was privately excited about a glimmer of hope. Whereas he could have used his usual, definitive curse words, his current use of the word “doubt” implied a possibility.

“Maybe not,” I said. “But do you wanna do an experiment?”

“Experiment about what?” Paul asked.

My proposal: “You will wear your hearing aids every day at school, at least for the next month. But every morning before you wake up, your father will, in secret, flip a coin. If it’s heads, he’ll remove the battery; if it’s tails, he’ll leave it in. He will then give the hearing aids to your mother who will give them to you. Neither you, your mother, nor your teachers at school will know if the batteries are in or out.” I explained that this is a so-called “double-blind study.”

“Every day this month, you and your teachers will fill out a form and estimate what percentage of classroom conversation you’re able to understand: between 0% and 100%. At the end of the month, your father will reveal what days your batteries were in your aid, and we can correlate these days with your and your teacher’s estimations of how much you understood. My prediction is that either you or your teachers will rate you as understanding at least 10% more communication when your batteries were operative in your hearing aid. Apparently, your prediction is that it would make no difference.” (Author’s Note: It should be apparent that I am a clinical psychologist and not a hearing scientist; I make no claims regarding the audiological validity of this experiment.)

Paul said that he would think about it. I couldn’t have hoped for more; at least he didn’t say no. I telephoned his parents to give them a “heads up.” With some prodding and external reinforcement from his parents—the psychological jargon for bribing—Paul agreed to this experiment. And we had a family meeting to work out the logistic details.

f05a.gif (5181 bytes) Figure 1. The results of Paul’s “experiment.” The green bars indicate speech understanding when the batteries were in; blue bars when the batteries were out.

Paul and I met for the next few weeks. The experiment had begun, with everyone doing their respective tasks. Again seated at my computer, I taught Paul how to use PowerPoint and helped him enter the data. The final data was tabulated after a month had elapsed, as shown in Figure 1. On the 16 out of 30 days that the hearing aid battery was installed, Paul and his teachers rated his understanding as 73% and 54%, respectively; and on the “off” days, Paul and his teachers gave a rating of 65% and 32%, respectively.

We had a family meeting soon afterwards. My plan was to review the data. However, Paul’s mother put that on hold and instead shared an instructive story about when he had seen another therapist several years prior: “In the middle of their meeting,” she said, “he excused himself to go to the bathroom. But instead, he bolted straight to my car and refused to come out, even though, in the hot, humid, afternoon sun, it was broiling inside. He later told me that he didn’t understand something the therapist had said, and couldn’t bring himself to ask him to repeat himself. I was devastated for him!”

She began to cry. Perhaps in an effort to distract his mother from her visible pain, Paul responded to her story with his own vernacular: “That guy was a dork. It was no big deal.”

But it was a big deal, and he was eventually able to talk about his own pain. During the session, the three of us discussed how Paul had lacked the cognitive tools to protect his self-esteem from the handicapping effects of his disability, a “simple” failure to effectively speechread his therapist shattered his sense of self. It caused not just embarrassment or even guilt, but catapulted him into the dark, murky abyss of shame. Better to be imprisoned in his mother’s car.

I privately noted that his shame was not entirely past tense, but exploration of that would wait until later. Paul’s disclosure was a testament to why the first statement in this article—that adolescents know all the answers—must be modified. Adolescents may appear overly confident and even rebellious because they are privately quite unconfident; because they, in fact, do not know the answers that everyone around them seems to know.

Hard-of-hearing adolescents, in particular, are often more vulnerable to such feelings of inferiority, and may be more likely to put on a mask of knowing all the answers and engage in power struggles with helping professionals. They may perceive adult power as arbitrary, with no invitation for collaborative decision-making. A paradox: It is often harder to do something good for yourself when so many others are trying to convince you that a particular action is in your best interest.

Effective Counseling Approaches
The interventions I made with Paul can be effectively made by hearing care professionals. Although hearing care professionals do not (and should not) practice psychotherapy, they do implement powerful psychological interventions in the context of diagnosing and treating hearing loss.

While I’m not suggesting that one discuss trout fishing with a patient(s), the relational aspects of my work with Paul have generalized applicability—namely that I avoided a power struggle of whether or not he would use his hearing aids. That would have resulted in a lose-lose outcome. Instead, we found a way to have a collaborative dialogue which had elements of fun and curiosity, and which included hearing loss but wasn’t limited to it.

Did Paul live happily every after? It is never that simple. Presently, he only sometimes wears his hearing aids (not surprisingly, almost routinely when his biology teacher lectures about marine life), and he still engages in similar kinds of conflicts with his parents, in part, because his self-identity still depends on rebellion. But there has been progress. And as for me, whenever I go to my favorite restaurant and order trout almandine, I think of Paul.

Michael A. Harvey, PhD, is a clinical psychologist in private practice in Framingham, Mass, and adjunct faculty at Boston University and consultant faculty at Pennsylvania College of Optometry, School of Audiology. His most recent books are The Odyssey of Hearing Loss: Tales of Triumph and Listen with the Heart: Relationships and Hearing Loss. (Dawnsign Press, San Diego).

Correspondence can be addressed to HR or Michael A. Harvey, PhD, 14 Vernon Street, Ste. 304, Framingham, MA 01701; email: [email protected].

1. Miller WR & Rollnick S. Motivational Interviewing. New York: The Guilford Press; 1991.