The Counseling Process: Before and After the Hearing Instrument Fitting

Research consistently shows counseling to be an essential factor in the acceptance of hearing loss, hearing instrument utilization, and satisfaction with hearing instruments. For example, Barrett¹ reported that hearing-impaired individuals who receive effective counseling:

• Wore the hearing instrument more often;
• Wore the hearing instrument for longer periods of time, and
• Reported a greater perceived reduction in hearing handicap.

Studies² have also shown that failure to provide effective counseling can be a significant contributor to patient dissatisfaction with hearing instruments. Given the relatively high level of user dissatisfaction with hearing instruments,³ it is critical to focus attention on the role of counseling in the practice of the hearing care professional.

Professional and Non-Professional Counseling
In the most fundamental sense, counseling occurs in any relationship where one person is helping another person to better understand and solve some problem. Counseling is also a professional service based on the well-patient model, whereby a professional provides personal assistance in exploring an individual’s attitudes, feelings, values, experiences, etc.⁴ In this context, counseling deals with the healthy adaptive capacities of psychologically “normal” individuals. Professional counseling also adopts a developmental view of psychopathology wherein problems are viewed as serving an adaptive and functional role for the client/patient.

As a sub-specialty (ie, along with clinical, school, and industrial/organizational psychology) of the general field of psychology, counseling psychology has its roots in vocational guidance and in the psychotherapeutic research into human behavior and interpersonal relationships, an area greatly influenced by Carl Rodgers. Unlike clinical psychology, which deals with the study, diagnosis, and treatment of abnormal behavior, counseling psychology generally focuses on the educational, social, and/or career adjustment problems that may be confronting an individual.

When one person counsels another from a perspective outside of the counseling profession (ie, without specific educational credentials in counseling psychology), that person is a “non-professional” counselor.⁵ Attorneys, physicians, and clergy, as well as hearing care professionals, can serve effectively as non-professional counselors provided they:

1. Have a basic understanding of the theoretical and experiential paradigms that counseling is based upon;
2. Are sensitive to the comprehensive needs and experiences of individuals; and,
3. Are willing to address concerns beyond the scope of their professional discipline.

The hearing care professional must be prepared for instances wherein the hearing-impaired individual presents “psychological problems” in the context of communication difficulties that the practitioner feels unqualified to address, and/or that require referral for professional treatment. Deciding when to refer an individual to a counseling professional for psychotherapy, however, is not easily learned in a textbook, nor have practitioner guidelines or rules been established. Learning how to deal with this type of situation will most likely be the result of what is discerned from listening and hearing about the deepest concerns/problems of the individual.⁶

For the hearing care professional, performance in the role of non-professional counselor means being able to provide ongoing and effective support to those requiring more than just technical education and training. Furthermore, the goal of the counseling effort is not to solve an individual’s problems relative to hearing loss per se, but to help the individual discover for themselves the nature of the problems they are confronting and to help clarify their thinking as to how to solve those problems.

Approaches to Counseling
Recognizing the importance of counseling is important to how the hearing care professional approaches the counseling process. For example, Sweetow⁴ suggests that there are two approaches to counseling that the dispensing professional can employ. These can be summarized as:

• Professional-centered: In this approach, the hearing care professional asks questions, makes the hearing-related diagnosis, and reaches conclusions. By adopting this behavior, the professional maintains complete control of the professional/patient interaction. Implicit in the professional-centered approach is the fact that the hearing care professional is responsible not only for all decisions regarding the needs of the patient, but also for the outcomes of those decisions;

• Client-centered: In this approach, the hearing-impaired individual is the central focus of the counseling effort. The hearing care professional attempts to draw answers from the hearing-impaired individual, rather than provide specific information. This is done most effectively through the process of “deep listening” to the client’s answers to open-ended questions.⁷ The objective of deep listening is to understand what the individual is saying and not saying. Through deep listening, the dispensing professional can develop insight regarding the individual’s needs, desires, and fears, then begin to understand the psychological barriers that may be keeping him/her from positively addressing the hearing loss.

In a similar model, Clark⁸ describes a dual approach to the counseling process through the use of terms “content counseling” and “support counseling.” The content counseling approach is defined as the transfer of information from the hearing care professional to the hearing-impaired individual. The information provided through content counseling can include the findings of the auditory assessment, possible rehabilitative alternatives, the performance aspects of various amplification technologies, and supplemental strategies for enhancing communication effectiveness.

When engaged in the support counseling approach, the hearing care professional is required to assume a “listening posture” and employ reflective questioning techniques that further develop the counseling information. Reflective listening and questioning will also suggest to the hearing-impaired individual that the interpersonal dynamic is based on a desire by the hearing care professional to achieve a “true empathetic understanding” of the individual’s hearing loss.

The Counseling Environment
Another significant aspect of the auditory rehabilitation process is the environment in which counseling transactions occur. The majority of hearing care professionals prefer to undertake the counseling process on a one-to-one basis in a clinic or office setting (sometimes referred to as the diagnostic service delivery model). This is most likely to be a “comfort zone” familiar to both the professional and the hearing-impaired individual.

The hearing care professional may also elect to undertake a portion of the auditory rehabilitation process in a group setting. The group rehabilitation/counseling process permits the hearing-impaired individual to have peer-interaction with others experiencing hearing loss. The environment in which group counseling transactions take place may or may not be the provider’s clinic or office setting. Participation in a group counseling/rehabilitation process can provide an opportunity for the individual to benefit from the experiences and insight of other participants (catharsis), as well as the counseling dynamics that are part of the hearing care professional’s rehabilitation program.

Additional benefits provided by group AR programs include⁹:

• Enabling the development of a support network during the period of adjustment to amplification. Many hearing-impaired individuals do not know anyone who has hearing loss or may have never spoken to anyone about hearing loss;
• Allowing the individual (via encouragement from others experiencing the same problems) to assume responsibility for managing their hearing loss and to identify realistic expectations for, as well as the limitations of, the use of hearing instruments. The responses of individuals involved in a group format have proven that, not only is this counseling method an efficient way of providing information regarding the impact and remediation of a hearing loss, it is also a way to support more assertive problem-solving behavior by everyone concerned¹⁰;
• Educating family members, friends, and caregivers about various strategies for coping with hearing loss and encourage them to be actively involved in, and supportive of, the individual’s adjustment to amplification¹¹; and,
• Cost effectiveness.

It has been found, however, that although the desirability of group AR programs has been well-documented, relatively few group programs take place.¹² There appear to be several reasons for this situation. First, when invited, the majority of hearing-impaired individuals decline the opportunity to participate in group programming. Second, group AR reduces the possibility for intimacy that takes place in the one-on-one transaction. The interactions between the hearing care professional or group facilitator and the members of the AR group never reach the same level of familiarity and openness that take place in the one-on-one setting.¹³ Third, because the group approach is seldom covered by health plans, many dispensing professionals believe they cannot incorporate group rehabilitation programs into their practice in an economical or cost-effective manner.

Whether the counseling process takes place on a one-to-one basis or in a group setting, the hearing-impaired individual needs to have confidence in three things about the hearing care professional: 1) The professional knows what they are talking about; 2) the professional cares about them as an individual; and, 3) the professional has their best interests at heart and will act accordingly.4 In addition, it is essential that the hearing care professional instill a sense of confidence in those being served, without compromising professional ethics, the facts, or the truth.¹⁴ Failure to establish these perceptions will all but eliminate the possibility of implementing an effective hearing instrument fitting and AR program.

This article was adapted from Chapter 10 of The Hearing Healthcare Practitioner’s Handbook: A Guide to the Successful Treatment of Hearing Loss with Auditory Prosthetics, published by the NAIAP. Correspondence can be addressed to HR or Paul Popp, PhD, 7771 O’Bryan Place, Centerville, OH 45459; email: [email protected].

References
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3. Kochkin s. MarkeTrak VI: On the issue of value: Hearing aid benefit, price satisfaction, and brand repurchase rates. Hearing Review. 2003;10(2):12-26.
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8. Carmen R. Profiles in aural rehabilitation: Richard Carmen interviews John Greer Clark. Hear Jour. 2000;53(9):28-33.
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11. Gitles T. Successful rehabilitation: Whose responsibility? Hear Review. 1994;1(1):22-24.
12. Ross M. When a hearing aid is not enough. Hearing Review. 2000; 7(9);26-30.
13. Greer JG. Hearing aid dispensing: Have we missed the point? Hear Jour. 2001;54(5):10-19.
14. Harford ER, Curran JR. Managing Patients with precipitous high frequency hearing loss. In: Kochkin S, Strom KE, eds. High Performance Hearing Solutions, Vol 1; Hearing Review. 1997; [Suppl] 1(1): 8-13.