Dr. Ross on Hearing Loss
Are Group Aural Rehabilitation (AR) Programs for Adults Effective?
by Mark Ross, Ph.D.
We seem to be hearing about more and more people who are undergoing surgery for hip, knee, shoulder, etc. replacement. Almost always (and I have never heard of an exception), this surgery is followed by a prescribed course of physical therapy. It is simply assumed that, post-surgery, the patient will need to be seen by a physical therapist for, at the least, a short regime of follow-up physical therapy. In other words, surgeons do not tell their patients that they’ve done all they could, schedule one or two future appointments, and then tell them to “call if there are any problems.” Rather, physical therapy is conceived as an integral component of the overall procedure, and the assumption is made that patients will follow through with the recommendation.
Now contrast this situation with the most common service delivery model for obtaining hearing aids. After the aids are selected, the clients are routinely scheduled for appointments within the thirty or sixty day trial period, to be followed (possibly) by one or two follow-up appointments within the first year. What they do not generally receive is anything remotely resembling the organized and scheduled follow-up program that people getting replacement body parts receive. Instead, they are given the admonition to “call if there are any problems.” This statement is not a substitute for an organized, coherent, and relevant post hearing aid fitting follow-up program.
Without minimizing the profound effect a physical condition will have on someone’s quality of life, nonetheless an uncorrected hearing loss can be every bit as debilitating, though different, than such a condition. Why, then, don’t people with hearing loss receive the same care and attention as do people requiring hip or knee surgery? We know that a hearing loss brings with it many issues and problems, and not just for the person directly affected but for family, friends, and co-workers as well. Why, then, isn’t the hearing aid selection process defined so that a short-term aural rehabilitation (AR) program is recognized as integral to the entire process., much as physical therapy is following restorative surgery? One fundamental reason seems to be that in our society, we tend to trivialize or misinterpret the impact of impaired hearing (except if you or a family member is the one affected!). In other words, it often remains the “invisible handicap” and is not generally taken very seriously. Another reason is that for many people, just using any sort of sound amplification device appears to significantly diminish the hearing loss handicap, often to the point where no further services are apparently required or desired.
In my view, this is a rather specious rationale for several reasons. First, for people who have never worn any sort of sound amplification device, just the experience of hearing sounds louder will often seem to be miraculous; the comparison effects are immediate and apparent and their hearing problems now seems to be “solved.” But this optimistic judgment soon fades as they confront the many and varied hearing difficulties in the real-world. To a lesser extent, this also applies to an experienced hearing aid user. What this person is doing is comparing the sounds perceive through their new (and expensive) instruments with their older ones, the very ones they are discarding because they are somehow dissatisfied with them. Of course, the newer instruments sound better, else why purchase them? But will their use be sufficient to resolve the hearing difficulties, to the point where the hearing loss no longer has any significant detrimental effect on their lives? Possibly, I would certainly hope so, but my impression is that too often people settle for less than is possible.
To be sure, I don’t want to minimize the positive impact that properly fitted hearing aids can have for hearing aid users. My point, rather, is that even given this fitting (something that cannot be taken for granted), the routine inclusion of a group AR program for adults can provide valuable information and assistance to a participant beyond that available from the hearing aids alone, no matter how well fit the aids may be. Right now the marketing and provision of hearing aids are focused primarily on the presumed power of the new technical developments that keep being introduced. The implicit message that this focus conveys is that a technical cure (i.e., the sophisticated features included in the newer model hearing aids) is now possible; all one has to do is purchase this or that product and “lo and behold” the problem is solved. I may be overstating somewhat, but as I peruse the many marketing appeals published by the various hearing aid companies, I don’t think I am overstating by much. Of course, hearing aids are the essential ingredient in reducing the overall impact of a hearing loss, no argument with that, but still that’s not all there is.
It should be apparent that the more we know about a condition, particularly one that affects how we interact with others in our society, the better able we’ll be to deal with the inevitable consequences of that condition. And we can learn how to do this not only from professionals but from people who experience a similar condition. And that is why I stress a group AR program, one that routinely includes a significant other (SO). The necessity to include SOs rests on the observation that while the affected person will have the hearing loss, it is really the entire family that has the hearing problem (i.e., that also has to deal with the consequences of the condition). These are not exactly new or revolutionary recommendations; twelve years ago the HLAA passed a position paper on this very topic. Unfortunately, it hasn’t gotten much traction, which it surely deserves.
The very first and most significant advantage a group AR program offers is intrinsic to the format itself. We have in our society thousands of various kinds of support groups, one for every ailment and condition extant it seems, and their very prevalence offers convincing evidence for their effectiveness. The essence of any group program is listening to and sharing feelings and experiences with people who are in the same boat. For people with hearing loss, this sharing will aid them in acknowledging the reality of their condition, an acknowledgement that is a prerequisite in helping them help themselves. It may seem counterintuitive but because a hearing loss, particularly among older folks, is such a common occurrence in our society, its consequences tend to be underestimated or ascribed to other causes (such as the beginning of dementia, for example). The group format is designed to bring home the important message: You are not alone and you’re not going crazy!
Two kinds of evidence have been offered to support the notion and effectiveness of group AR programs. Support for the first type of evidence is inherent in the content of the typical group AR program; sometimes this is labeled “face validity” but I prefer to call it “common sense” (which may not be all that “common”). Consider this brief outline of a fairly typical group four-session AR program:
Most people who take this kind of program report that it is helpful. In one survey conducted at the Mayo Clinic Jacksonville, 307 patients were asked to rate the helpfulness of the program (from 1, “not helpful,” to 6 “very helpful”); the average rating was 5.8 with 97% of the patients giving a score of 5 or 6. Another survey, conducted at a multi-center dispensing practice, found that hearing aid return rates were reduced from 9% to 3% for the people who had completed the program, compared to those who had not. While these surveys may not meet a strict definition of research, they clearly indicate that these AR programs have been helpful to lots of hearing aid users and their SOs. Certainly, this has been my experience when I conducted such programs myself.
What does count as research are the studies reviewed by Dr. David Hawkins in the Journal of the Academy of Audiology several years ago. After an intensive search of the literature, he found just twelve that met the criteria of a properly conducted research study. These were studies that employed both appropriate research conditions and recognized outcome measures. The typical program was conducted over a four week period and usually compared the performance of subjects who received a hearing aid but no AR to a group that received a hearing aid plus a short-term group AR program. It should be noted that these were counseling based studies, unlike those that focus directly on communication skills (such as speechreading and auditory training).
After carefully examining all of these studies, Hawkins concludes that there is “reasonably” good evidence that these programs will provide for, at the least, a short-term reduction in the self-perception of a hearing handicap as well as better use of communication strategies and hearing aids. As such, from a research perspective these programs are clearly worth doing. Even so, there is still some question whether these benefits persist over time, as well as whether or not the right kinds of “outcome” measures were employed. In my judgment people who take such a program can benefit from an occasional “booster” shot, whether in the form of another “review” short-term AR program, or perhaps by just being an active member of a Hearing Loss Association of America chapter. In short, in the same way we get booster shots to protect us against the flu each year, an occasional AR boost can also be beneficial.
The most recent research study (2009) on the effects of a short-term AR program, conducted by Drs. Jill Preminger and Suzanne Meeks, has an interesting twist. They provided an identical program to two groups, an experimental one in which their significant others were also provided with a separate AR program and a control group whose SOs received no such program (later rectified). Previous research had shown that the inclusion of SOs in the same classes as the persons with a hearing loss was beneficial to both parties. The researchers took this concept one step further, providing group classes designed specifically for SOs, in recognition of the fact that they also have a hearing “problem,” just by living with someone with a hearing loss.
The basic question that the investigators asked was: Would the person with a hearing loss and the SO both judge the impact of the hearing loss on their quality of life (stress, affect, mood, marital communication, etc.) similarly after the SOs separate program compared to their previous pre-treatment ratings. It is surely a recipe for a tension filled marriage if the two parties see the impact of the hearing loss very differently. Pre-treatment, both groups of hearing-impaired subjects and their SOs were administered identical quality of life rating scales. Only about 50% of the couples, in both groups, rated the impact of the hearing loss similarly (termed “congruence”). For half the couples, then, there were significant differences in their perception of how the hearing loss affected their lives. Usually, it was the person with a hearing loss who felt the hearing loss had a greater effect than the SO. Obviously, it is not exactly a good omen for marital comity when couples have such disparate views of a condition that affects both their lives. After the study, however, the congruence score increased to 72% for the partners in the experimental group. Not perfect by any means, but clearly superior to the lack of congruence prior to the group program for SOs. No congruence change was noted for the control group, which remained at 50%.
As we consider, then, both the research literature and common sense, it is clear that there is value in a post-hearing aid fitting short-term AR program. Not as an add-on, but as an integral component of the hearing aid selection process. It should be routinely included in the hearing aid fitting process in much the same way that physical therapy is included following many surgical procedures. I can hear the many objections now (and have heard them repeatedly over the years), and some do have merit. But the basic question to ask is whether these group programs can be helpful, and the answer in my view, is an unambiguous yes. Given this observation, then, the challenge is how best to respond to these objections rather than offering excuses why AR follow-up can’t be done. As it happens, it has and is being done is a few exemplary programs – but these are exceptions when they should be the rule.