Go Figure: Deconstructing the Stages of Change Model of Behavior

Author: Brian Taylor, Au.D.

The treatment planning process, one of the essential duties on a clinical audiologist, is a series of clinical decisions that usually looks something like this: First, you convince a patient, who has often ignored their hearing difficulties for several years, to try hearing aids. Second, realistic goals and expectations are targeted, and finally the audiologist offers the patient some thoughts on the longterm success with hearing aids based on the information collected during the in-take appointment.

A big challenge for many audiolgists, however, is they rely on the pure tone audiogram to make these clinical decisions. Numerous studies have shown the audiogram to be a poor predictor of both hearing aid acceptance and long-term success with amplificaiton. If the audiogram is such a poor predictor, one best ignored after a medical disorder or ear disease has been ruled out, what other tools does the audiologist have available that helps them make better clinical decisions?

One possibility is the transtheoritical stages of change model of behavior or SOC. The SOC model describes an individual’s current attitude, motivations, behaviors and intentions to change by adopting and sustaining healthy behaviors. The SOC model can be applied to any chronic condition in which a person has a choice on getting help or changing an unhealthy behavior or lifestyle. For audiologists, the healthy behaviors we want patients to adopt and sustain revolve around active use of hearing aids.

The above Figure outlines the six stages of change. The arrow denotes the typical pathway in which these stages progress over time. We know, for example, that the average person with hearing loss takes about eight years to move from a point where others are noticing that person’s hearing difficulties (represented by the pre-contemplation stage) to the person with hearing loss acquiring hearing aids and actively wearing them (represented by the action stage). Individuals with hearing loss usually move from stage to stage in a fairly predictable manner, however, not everyone moves through the stages at the same pace. That is, some individuals may stay stuck in one stage for years, while others move from stage to stage quickly or even revert to a previous stage.

Understanding the SOC model is important for two reasons: 1.) Audiologists who ascertain the stage of change the person with hearing loss is in during their first clinical encounter can guide that patient into the action stage more effectively and avoid feeling like they are pressuring the patient to do something, and 2.) In collaboration with the patient, the audiologist devises a plan that moves the person with hearing loss into the action stage. The use of the SOC model is predicated on the belief that a patient will not become a successful hearing aid wearer until he moves into the action stage, and the role of the audiologist is to recognize what stage of change the patient is in today and craft a plan that moves them into the action stage, and eventually into the maintenance stage.

If you want to practice patient centered care, the SOC model is an essential building block of that clinical philosophy. Let’s look at how an audiologist can apply the SOC model in their daily practice. Remember, knowing the patient’s stage of change helps us devise a plan to move the patient to action sooner and will improve the probability of long-term results.
Table 1. Common Behaviors or Characteristics of Each Stage of Change
  • Unaware that problem exists
  • Reluctance to change (“I don’t know if I really need to change”)
  • Rebellion against outside pressures (“No one is going to make me change”)
  • Resignation (“I’m too old to change”)
  • Rationalization of the problem (“It’s not that bad”).
  • Aware that a hearing problem exists but…
  • Indifferent or ambivalent regarding the pros and cons of accepting recommendation for help
  • May lack confidence or determination to accept help at this time
  • Actively seeking advice or information on hearing loss or hearing aids
  • Expresses desire in simply getting a baseline hearing test
  • Propensity to compare hearing aid prices (doing their homework)
  • Comes to the clinic with a lot of information about hearing loss or hearing aids
  • Active participation and engagement in the treatment planning process
  • Expresses an interest in accepting your opinions and recommendations
  • Willing to accept your recommendation
  • Schedules and keeps routine follow-up appointments
  • Actively seeks information and advice on how to be a better hearing aid user
  • Participates in communication training or other rehabilitative activities
  • Stops wearing hearing aids
  • Stops participating in follow-up appointments
  • Resists recommendations to re-activate hearing aid use
A simple way to know what stage of change a patient is likely to be in is to simply ask them this question:

“Mr. Jones, which of the following statements best describes your attitude and motivations today?”

  1. I don’t think I have a hearing problem; therefore, I am not planning to do anything at this time.
  2. I think I have a hearing problem; however, I am not yet ready to do anything about it
  3. I think I have a hearing problem and I intend to act in the future, but not now.
  4. I think I have a hearing problem and I am ready to act now.
Here is a simple guide on next steps that correspond with each of the four possible responses.

Next Step for Response A
Following the hearing assessment, focus on educating the patient about the importance of hearing loss prevention and consequences of hearing loss

Next Step for Response B
After the hearing assessment, ask the patient to participate in long range exploring and planning. Send the patient home and ask that they begin the process of discovering where they are having difficulty and why it might be a good idea to seek treatment sooner.

Next Step for Response C
Similar to Response B, help the patient explore and plan why it is a good idea to seek treatment sooner. To speed the process, consider sending the patient home with a hearing aid demonstration unit.

Next Step for Response D
Immediately move into goal setting and treatment planning

Audiologists who work primarily with adults, spend most of their time selecting, fitting and maintaining hearing aids. Because the hearing aid is so central to patient success, it is easy to focus too much time and attention on the components of the hearing aid selection and fitting process. By using the stages of change model in the decision making process, audiologists can take some of the focus off hearing tests and hearing aids and place it squarely on the patient and what they need to do to be successful communicators.