From Ambivalence to Action: Rethinking Patient Counseling in Hearing Care

Speaker 1: Hello, and welcome to another episode of This Week in Hearing. I’m your host, Brian Taylor, and I’m so pleased this week that our topic is motivational interviewing and counseling. And here to discuss this important topic is Bobbi-Jo Marlatt. Bobbiejo, welcome to the episode. We’re really pleased to have you here.

Speaker 2: Thank you so much, Brian. I’m very excited to be here.

Speaker 1: Well, I have to say that when I saw that your book was published at Plural, I was really excited to see it. I think this is a very important topic. I’ve actually written a little bit on it myself, but, but by no means am I an expert. So before we talk about the topic of motivational interviewing, I thought it would be helpful to our audience if you could tell us a little bit about yourself and maybe what motivated you to write this book.

Speaker 2: Yeah. Absolutely. And, you know, I said I’m happy to be here. I, I really mean it. When I was at ASHA about two weeks ago in Washington, DC the book was there on a table, and it was right beside your book. And I was… I actually snapped a picture of it because I couldn’t believe I was on the same table as you. So I was very honored when you reached out to me. A little bit about me. I actually started out in psychology. I did my undergrad and a thesis in children’s memory, and after five, six years of being a student when I lost my hearing aids and I didn’t have enough money for new ones, I decided I would go back to work for a bit. So I applied at one of the hearing aid manufacturers in production to just get a job and get a paycheck for a while and hopefully some new hearing aids. And here we are, 14, 15 years later, I’m still there. I just… I fell in love with the industry the people the clinicians that I was helping. I also I love the hearing aid technology, which is why your book was one of my favorites. Fitting hearing aids, everything about them. Yeah. So regarding the book I think I probably started writing it in 2021, but I didn’t know that’s what I was doing. I took a 14-week motivational interviewing course at Western, and every two, three weeks, we had to do these reflections. And I just kept tying what I was learning into hearing care every week, and by the end of the course, I had five or six papers that had completely convinced myself that this needed to be the cornerstone, the cornerstone of our counseling in hearing care. I had no idea what to do with that though, so I just moved on with my life. And about six months later, we were building the hearing instrument specialist program at Humber College in Toronto, Canada, and I came across the patient counseling course. And we were looking at all the counseling material out there, and I saw the word motivational interviewing a few times here and there, and I just became obsessed with the idea that what if we built the entire patient counseling approach around this way of being with people? What if that was not a chapter, it wasn’t an article, it wasn’t a page at the end? What if the whole counseling course was based around that? So I started looking for resources on motivational interviewing in hearing care, and there was stuff out there, good stuff, but it was short and sweet. And you know, lots of great articles Douglas Beck and Michael Harvey, but they weren’t complete how-tos from beginning to end. So literally, that’s why I wrote the book, because I couldn’t find what I was looking for the students. So I thought, “Well, I’ll just take a stab at it.” I mean, at no point did I feel like I was a motivational interviewing expert. It was just, I have the time to pull together these resources, and maybe, maybe somebody else would be interested. So yeah. That’s where, where was born.

Speaker 1: Let me tell you, here’s a copy of the book right here for those of you that want to know what it looks like. It’s very, you know, approachable. It’s not super thick. You accomplished your goal, BobbieJo. I, I think it’s an outstanding book. I think it speaks to your practical experience. I think it’s, I think it’s just so cool that you’re not a traditional academic, that you’ve kind of learned this stuff in the real world. And it definitely shows in just how accessible the material is. So the book, I can’t, recommend it enough. I think it’s really outstanding. So we’re gonna, we’re gonna kind of dive into some of the different things that I think are that are most relevant for our little show here. But before we get into all the details I think it’d be helpful if you could kind of tell our audience what is motivational interviewing?

Speaker 2: Mm. So hard for me to summarize. I think that the way I see it is a way of talking about change and making change with individuals that’s going to be much more likely to result in them wanting to make that change. That’s what it boils down to, is, is just having the tools to talk about making change without talking them out of it in the process.

Speaker 1: Yeah. I mean, I think that makes… that’s a really great definition. I mean, I guess it’s the it’s, it’s You can’t tell people what to do. And I think anybody that’s spent even a few days in a clinic knows that when somebody comes in with age-related hearing loss or some variety of that, at least. It’s counterproductive to try to tell them what to do when they’ve often lived with this condition for years. So I think your definition or your explanation of what motivational interviewing is great. I guess the next question I would have is you know, clinicians out there often are pressed for time. It’s hard to incorporate new ideas or new programs into their clinical practice. So maybe high level, what are one or two motivational interviewing strategies that you would say have the biggest impact in a typical hearing care appointment?

Speaker 2: Absolutely, yeah. I get this question a lot. I think everyone’s looking for quick fix. They’re looking for something immediate. And I do feel like a lot of people think their scheduling is limiting them from experimenting in their practice. I do wanna say that I think if you look at your appointment structure and your blocking, a lot of businesses, when they’re figuring out how many new patients they need to see in a month, are expecting 30, 40, 50% of those new patients to walk out without purchasing. Right? They’re expecting them to walk out. So I mean, yes, we all feel like we don’t have enough time, but part of that is because we’re, we’re expecting people not to listen to us. So I think that a little bit of one and the other. So I think if I had to say two things that would be the most impactful, it’s probably delaying giving your solutions. Hold back on giving them education and advice. That’s probably the most key thing, and then the other one would be asking more open-ended questions instead. I think a lot of the time, we take indecision for asking for advice on how to proceed, and we need to just be okay with indecision and sit with it and explore it. And instead of giving that advice, people, when they catch themselves about to give advice, the next step is, “Okay, what do I say instead?” And just asking questions, just holding back on the advice and asking questions things like, “How does that affect your relationship? What would happen if you continue down this path?” Or, “How would your life improve if you could hear better?”

Speaker 1: Yeah, I mean, that makes a lot of sense. I think all of us that are, in the helping professions have It’s really difficult to us to resist the urge, the reflex almost, to offer advice and you know, spew out all the ways that we can help somebody. And I think that a lot of motivational interviewing is just learning how to resist those temptations and kind of sit back for a moment and let the patient. Give them time and space to reflect. And your book is full of tools on, on how to do that. What do you see as some of the more common mistakes that when somebody’s first learning how to to try motivational interviewing in in their practices, what are some of the more common mistakes? And how can you help them overcome those?

Speaker 2: I think a lot of the time they confuse sympathy with empathy right? Exploring somebody’s issues versus feeling bad for them or sorry for them or sympathizing, and I I think it’s hard because a lot of the training I do is with students, and on one hand, they’re learning everything they need to know about being a clinician . It’s kind of like riding a bike. You’re thinking about everything you’re doing so hard, and then I say, “You know the one thing that you thought you already knew, how to talk to people? I want you to throw that out the window too.” It’s almost like I want you to ride a bike and juggle at the same time. So I think one of the best tools I’ve had for the students is when you’re learning MI for the very first time, you don’t have to go through those growing pains in clinic. You can do MI with anyone. So why don’t you practice it socially first? Why don’t you practice it when you’re not doing 10 other things for the first time as well? Go sit down with your sister and talk about her new job. Go sit down with your friend and talk about how they wanna start going to the gym. Practice MI in your everyday life, and then when you feel a little more confident, bring it into the clinic. But again, with the students, a little bit of juggling. I don’t want them… I want that habit of using MI right there at at the beginning of their career, so I definitely encourage them to start practicing right away when they start in the program.

Speaker 1: Yeah, that’s good advice, and I have to say, speaking from my own experience at work, MI works really well with teenage children. So

Speaker 2: I have a 17-year-old. I haven’t used it on him yet.

Speaker 1: It works pretty well. It’s better than kind of hammering them with ways they can improve or do things differently and just trying to make them do things. So MI really does work in a lot of different cases. I wanted to ask you I think we all know that hearing care often involves many patients that I would say are probably more ambivalent than they are resistant. So could you tell us how motivational interviewing might help clinicians reframe those people that are noncompliant or ambivalent? Especially maybe in cases where you know, they’re reluctant to accept your recommendation or they’re not compliant around using their hearing aids?

Speaker 2: So for me, if a patient doesn’t seem receptive of my recommendation, then that’s on me. I wonder when were they ready to it? You know a I think a lot of the time, I’m not saying that we can’t give advice. It’s just the timing of it. I think if you ask sometimes questions like, “What do you think would help?” or, “What would you like to do?” or, “Is there anything you would like to know from me?” Or, “How would you like to use the rest of our time together?” A lot of the time they’re gonna ask for information and they’re also gonna ask for advice. And then you can say the same thing you were about to say one minute before. But they’re gonna be that much more open to it. So, I think a lot of the the resistance that we talk about is really just perhaps advice they weren’t ready to hear. And I also just on the idea you said of non-compliance, I think about a lot of the people using MI to address people not wearing their hearing aids. And I just wanted to say I think that sort of misses the bigger picture where when they own the decision to get them, that wouldn’t really so much be a problem, right?

Speaker 1: Mm-hmm. Yeah. I think that’s well said. When you’re in it together, so to speak, and not telling somebody what to do, it’s not really a compliance issue. It’s more of a I don’t know, discovery of trying to figure out why somebody is not doing something that would be in their best interest, I guess. Anyway, I… Maybe it would be helpful if you could share an example of where motivational interviewing may have changed the patient’s outcome or influenced the decision-making process.

Speaker 2: So, I don’t work in clinic. I don’t have a hearing care example right now that from my day-to-day life, but, you know, I was thinking about an example of where MI would’ve been helpful. So a few years ago, the doctor told me that my teenage son had one weak eye and he had to wear some glasses to strengthen it. And for me, it was similar to the attitude in hearing care. You have a hearing loss, you need hearing aids, end of story. You need glasses, end of story. I went and I bought top of the line glasses and he had to wear them every single day. I wasn’t budging. He fought me every day. And he eventually would hide them and whatever. So, after a couple of months, we gave up and we moved on with our life. A year later, he read that blue light glasses would help him sleep better at night. He bought a pair of $11 Amazon blue light glasses and he wears them every day by choice. And at the beginning, I was like, okay, he’s not ready. He doesn’t like glasses. He’s worried about, you know, the stigma of wearing them. He’s worried he’ll be made fun of. And then I found out none of those things applied. He just didn’t see a value for himself. The decision of wearing them wasn’t one that he made, that he owned. It was something I imposed on him. And then here we are a year later where he saw a benefit that meant something to him and he was wearing glasses every day. Just it was an example to me of where I excused away his non-compliance when I think that if I had just had a better conversation with him, it would’ve gone differently.

Speaker 1: Yeah. I mean, I It’s well said. I like the way you used the word impose. I think that too often when we don’t use motivational interviewing, it feels like we’re imposing some… we’re being, we’re imposing our recommendations on somebody whereas we really need to kind of have them come to that decision on their own, I guess, is maybe a way to put it. Another question I have for you, Bobbi Jo, is, you know, in my experience when I’ve worked with professionals trying to you know, help them with open-ended questions or scaling questions which come out of the whole motivational interviewing playbook one of some of the pushback I get is around those questions feeling scripted or artificial. Do you have any recommendations as far as how you might integrate motivational interviewing into clinical protocol so it doesn’t feel so scripted or artificial?

Speaker 2: I don’t have strong recommendations yet. Like I said, I’m doing my PhD research at Western and we are looking directly at motivational interviewing for hearing care. And I’m hoping some of the things to come out of that will be training, what it should look like, measuring competency, but also feasibility and what it’s gonna look like integrated with best practices. But I can say I think it feels scripted when we are not confident in ourselves, which is why I think measuring competency needs to be part of it. We have to have that I know I’m good at this, I can trust myself, and it’s hard to do that. And then I also think that practice. Like I said, a lot of people when you’re in your counseling room, you’re alone with the patient. Nobody else can see or hear what you’re doing, and you don’t have that gauge of, am I doing this properly? And with MI, there’s so many different things you could say. It’s not really a script. It’s you you could say 10 different things that would all be MI consistent, right? So there’s so much variability that it’s hard to be sure in yourself, so I do think that group practice sessions where other people can give you feedback is important. And then also using MI in your personal life, like I said before, to practice. Get the growing pains out of the way. I think that’s a good And also businesses making sure that they create those opportunities. Regular training. I do believe that there’s some potential for businesses to create sort of KPIs that are more MI friendly as well so that people can see, hey, I am doing this.I’m doing it properly, and I’m being rewarded for it as well.

Speaker 1: I’m curious you mentioned that you’re getting your PhD at Western University in Canada. Tell us, if you could, a little bit about how your… What, what aspects of motivational interviewing are you studying? Or what’s part of your thesis, I guess?

Speaker 2: Yeah. So I mean, that’s really the question is, what aspects of MI need to be there, right? I think to start, we have to include as many aspects as possible and to look for a treatment effect to make sure it’s there. And then the next step would be to start pulling things out to see what really needs to be there. But until… There’s, there really isn’t a study right now that looks at motivational interviewing for hearing aid adoption. And, and I think that it just, just like the book, someone just needs to do it. It doesn’t have to

Speaker 1: Exactly.

Speaker 2: It doesn’t have to be perfect but somebody needs to open the door and do it first, and then everyone can give their feedback, their criticism, whatever it is, but it, we just need to start somewhere.

Speaker 1: Well, that’s what I love about your book is that, like you mentioned, there are these papers, you know, you mentioned Beck and a few others that have done some work in this area. Dave Citron, I know is an audiologist, a private practice out on the East Coast, retired now, that’s done some work in motivational interviewing. One of the founding founders of AAA. Anyway, what I love about your book is you’re kind of taking all these different things and you’re putting it all under one roof, and I think that’s really helpful and beneficial to not only students, but experienced clinicians who want to you know, maybe add a few wrinkles to their repertoire. I guess my final question for you, Bobbi Jo, is just looking ahead how do you see motivational interviewing shaping the future of hearing care education and also patient-centered practice?

Speaker 2: I’m hoping that motivational interviewing will be the cornerstone of patient counseling. Not the only thing, but, I mean, the idea that if they can’t solve their ambivalence, they’re not going to move ahead is a pretty big one. So I would love to see it be a central part of the education in this industry. And at the end of the day, I think that we all wanna help people. We wanna help people. And in a lot of cases, hearing aids and accepting treatment is a big part of that. And I think that if we potentially, I mean, I sound, sounds a little bit like a dreamer, but we could treat hearing loss systematically sooner if we all had the tools to help people resolve their ambivalence sooner. Right? We all say, “Oh, 7 to 10 years, people wait. 7 to 10 years, people wait.” I refuse to accept that as a fact. And I think that if we had effective conversations at the three-year, five-year mark potentially on a big enough scale, we could help the aging population age healthier. And I think that in the end of the day, this would be a little bit more of a rewarding career if we were helping a few more people every day, right? If we’re having a few more productive conversations, if patients were happy, were happier with their hearing aids, they were wearing them more often, I just, I don’t… I think there’s so many great, wonderful things in our future if we can incorporate this into our education and our best practices.

Speaker 1: Yeah, I couldn’t agree more. I think you look at how sophisticated hearing aids are, you look at the range of technology that’s available, you know, with Bluetooth streaming, with some of the things with AI-based noise reduction, over-the-counter hearing aids, I mean, it’s a real shame that ambivalence, reluctance, those things get in the way. And to me, motivational interviewing is sort of the, the, the technique that you use to like you said get people into the treatment pipeline at a younger age when maybe we can make a bigger difference over a longer period of time and just simply telling people, “This is the best, this is what’s for you,” I think most of us know that that doesn’t work and it can lead to a lot of frustration, both frustration on the part of the clinician, but also frustration, from the patient. So these guiding principles around motivational interviewing are incredibly powerful and beneficial to everybody in the profession. So kudos to you for taking the time to write this book. I know that writing a book is a huge endeavor. People do these things with a lot of other you know, with a full-time job and with families and things like that. So before I let you go, any final words of wisdom that you have for our audience?

Speaker 2: I think that there’s gonna be a few growing pains. I just want… I really genuinely hope that you can read the book or, or don’t read the book, attend a talk, read one of the other resources out there, fall in love with motivational interviewing the way I did, and, and commit. You know, if you can get past the growing pains, I think that it will be a wonderful addition to your practice and your career.

Speaker 1: I think that’s a good way to end things. Here’s the book, Motivational Interviewing for Hearing Care Providers. You can find this at the Plural Publishing website. Bobbi-Jo Marlatt, the author of the book, thank you so much for taking time out of your busy schedule to be with us. We really appreciate it.

Speaker 2: No problem. Thank you, Brian.