One of the most useful ideas surrounding the concept of the “Continuum of Denial” is how it requires the provider to listen deeply. In a two-day seminar I took on Motivational Interviewing several years ago, the facilitator was ever exhorting participants to “listen deeply”. My question was, “OK, that sounds great. So how do I do that?” The answer is not mystical or touch-feely. It simply requires that we remain in the moment with our patient and listen past their words to their meaning.
To “listen deeply” means to use inductive and deductive skills to untangle what our patient is not saying, or at least not saying directly, but is implying by his or her words. To do that we must try to understand beyond the words. This we should always be doing when we listen to our patients, but the continuum of denial is a particularly clear example.
Within the statements representing the levels of the continuum of denial are implications for which we must be vigilant in order to really understand our patient’s current state of mind and motivations. Let’s look at them closely.
Level 1 – I don’t have a problem, they do!
OK – not much to work with here, except the idea that the problem is solely the responsibility of others, not of the patient. Here is something we can challenge, with the hope that we can change this perception.
Since we are hearing professionals with a “dog in the fight”, so to speak, our arguments may not be very persuasive.
Particularly ineffective is waving the audiogram in front of our patient (Look at those X’s and O’s, will you!) It is my experience that very few people have obtained hearing aids because of the audiogram.
But your patient’s primary communication partner (PCP) can be your (and your patient’s) best friend. Not by teaming up to wrestle our patient to the ground and forcing hearing aids in their ears (I have tried it on occasion – something I am not proud of, by the way – and it inevitably results in return-with-bag-in-hand syndrome).
Rather, we can facilitate a conversation in which the PCP relates to the patient how their loved one’s hearing loss affects them (this was discussed in depth in a previous article). Listening deeply means to not simply accept your patient’s views at face value. If s/he is wrong, the belief should be challenged in a positive, non-confrontational way that leaves the patient’s autonomy intact.
Level 2 – It’s not that bad.
The implications here are 1) “I have hearing loss” and 2) “It is not yet bad enough to do anything about it.”
This gives us a couple routes for further examination:
- “So, you do realize that you have a hearing loss, then. Can you tell me in what kinds of situations it is noticeable?”
- “How bad do you think it should get before you do anything about it?” (This would be a good time to reinforce the consequences of untreated hearing loss, unless it has not been brought up before. If this is the first time it is being addressed with your patient, it will be seen as a sales tactic [“You’re trying to scare me into buying hearing aids!”] and your credibility and the patient’s trust in you will suffer.)
Level 3 – I know I have a problem, but I am not getting hearing aids.
Again, we have here acknowledgement of the problem. Further probing such as that described above is in order. But now the issue of hearing aids has entered the conversation. The implication is that your patient has misgivings about hearing aids themselves.
A hearing aid demonstration can go a long way in dispelling many of these objections and misconceptions. It would first be helpful to find out what this patient’s specific qualms might be:
- What is it about hearing aids that you object to?
- Is there anything that you think hearing aids might be able to do for you?
- Nobody here is going to force hearing aids into your ears, but you should know that they will (assumptive language) be able to….. (here enumerate the specific difficult listening situations – preferably situations already enumerated by your patient – s/he will be able to better navigate with use of hearing aids).
Level 4 – I know hearing aids can help me, but I am going to wait.
There is a lot implied by this sentence:
- I do understand I have a problem.
- I realize that I would do better with hearing aids.
- There is some reason that waiting seems to me a better idea than doing something about my hearing.
The principles of Motivational Interviewing tell us that it is more profitable to concentrate on our patient’s motivation to change than to confront their bias to maintain the status quo.
More probing of difficult listening situations is certainly in order. And the more specific, the better.
- “Can you tell me about a time recently when you encountered difficulty hearing in noise?” (a recent event will be fresh in mind, including details and any emotional response it may have elicited).
- “What was going through your mind when that was happening?” (ask your patient to confront the emotional aspect of the incident)
- “If I could offer you something that would help assure that kind of situation would be much less likely to occur, would that interest you?” (ask for incremental agreement to a solution).
The final implication (waiting is a good idea) is not positive but should be challenged, nonetheless. Ask the patient to justify his/her choice to delay a decision that even s/he admits would be a positive one. “Tell me, why is it you think that waiting is better for you (and your family) than getting the help you need today?” This could well uncover an objection that you can address immediately and possibly move your patient to action.
Level 5 – I think I may be ready.
We are oh-so-close, but still not quite there. The most important notion implied here is willingness to proceed. Willingness is a small step toward a decision to move forward that provides a modicum of momentum toward such a decision.
Bring to bear all the arguments you have employed thus far to propel your patient to a decision everyone (including your patient) now agrees will greatly benefit them and their family.
At any point during the continuum there is potential for your patient to catapult over the upcoming levels to agreement to invest in hearing instruments – but none more so than now.
Level 6 – Today is the day!!!!!
Cue the Hallelujah Chorus!! No more convincing is required. Your patient is telling you that s/he trusts you with their hearing care and is willing to invest in hearing instruments at your recommendation. What is required of you at this point is to reassure your patient that they have made a good choice for themselves and their family and that you will do everything in your power to assure that they will be successful.
Listening deeply is not something to be initiated only when confronted with a patient in denial. There are many other situations in which it can be useful. The key is to be in the moment with your patient and to open your mind to the implications of what they are telling you.
There are many potential obstacles that can prevent this kind of insightful conversation from occurring:
- Multitasking while interviewing your patient
- Being distracted by personal or workplace issues
- Being overly reliant on a presentation “script” (actual or habitual)
- Thinking about your next question before you have listened to the answer to the last question
- Being more interested in impressing the patient with what you know rather than with what you need to find out about them
All these things detach us from the moment. Be in the moment with your patient. And listen deeply.
Paul U. Teie, MS, has been an audiologist since 1991. He has spent much of his career in direct clinical care but has filled other roles in the hearing care industry as sales representative of a special instrument dealer and a hearing instrument manufacturer. Since 2007 he has provided sales and clinical training for large hearing care networks and currently trains for HearUSA/HearCanada.
**featured image courtesy consumer reports