Dr. Ross on Hearing Loss
Aural Rehabilitation in Australia
by Mark Ross, Ph.D.
Recently, on a grant from the World Rehabilitation Fund, I visited Australia to observe aural rehabilitation (A/R) programs in that country. In this paper, I will comment on three of these programs: conversational therapy, audio-cassette auditory training and a nursing home program. While, conceptually, none of these approaches is unique to Australia, they have generally been systematically organized and elaborated there, and they reflect a thorough grounding in basic therapeutic principles and the world literature on the topic.
Several years ago, Erber (1988) wrote a book outlining the theoretical framework and procedures for what he terms "Communication Therapy." In the book, Erber develops and expands on the therapeutic possibilities inherent in normal conversations. For a person with a hearing loss, comprehending a conversation represents the peak of a communication pyramid, one resting on a foundation of appropriate amplification systems; visual cues; assistive devices; linguistic, contextual, and world knowledge; and a host of coping behaviors (e.g.: assertiveness, anticipatory and environmental strategies, etc.). All this may seem obvious, but it is a concept not often adequately developed in clinical A/R practice.
All the participants in a conversation have an investment in its ease and accuracy. It follows, then, that some of the burden for an effective communication exchange be assumed by the normal-hearing communication partners. This is a liberating idea for many hearing-impaired people, who have traditionally always blamed themselves for all communication breakdown. (Yes, sometimes people do talk as if they "had mud in their mouths.")
A great many conversations take place with another person or a small group, such as a family member, a friend, co-worker, neighbors and store clerks. If the person with the hearing loss does not indicate when he/she doesn't understand, the conversational partner(s) will not know when a breakdown has occurred and/or how to repair it. (People with hearing losses often nod or say "uh-uh" even when they don't understand.) One goal of conversational therapy is to point but the self-defeating aspects of this behavior. It is the responsibility of the person with the hearing loss to recognize when breakdowns have occurred and to suggest specific remediating measures. The beauty of this approach is that lessons practiced in therapy are directly transferable to "real-life" outside of the clinic.
As practiced in a clinic, the sessions can be structured, semi-structured, or completely unstructured, depending on the interests and sophistication of the person with the hearing loss. The therapeutic principles are the same, regardless of how therapy is conducted. Erber (1988) describes a procedure he terms "Questar," which consists of 20 general, sequenced questions on any topic selected by the client or the clinician. Examples of questions are: "Why did you go there?" "What happened?" "What else did you do?" The questions are given to the client to read, and it is the clinician who answers them.
When answering the questions, the clinician deliberately induces communication breakdowns. This may be accomplished by talking too softly, quickly, articulating poorly, covering his/her mouth, digressing or randomly switching topics, turning up the volume on a TV or radio, orienting the light on the speaker's face, and so on. Of course, in addition to these created situations, many breakdowns naturally occur because of the nature of the person's hearing loss.
The clinician should periodically verify comprehension because people with hearing losses frequently have difficulty in acknowledging that they have not understood all or part of the utterance. Many are so accustomed to imperfect communication that their expectations are limited: incomplete comprehension of a conversation is perfectly normal for them. They must be helped to identify communication breakdowns more assertively.
When breakdowns occur, the therapist points out the most effective way to repair them. Repeatedly saying "what?" or "huh?" does not give a talker enough information. Repairing a communication breakdown may require a specific request: to repeat all or a portion of the utterance, to talk slower or slightly louder, to articulate a little more clearly, to stress a particular word or element, to rephrase the missed portion or the entire utterance, to ask specific questions (Did you say "soccer" or "hockey?" "four people" or "fourteen people?"), to provide a key word or context, to spell the misunderstood word (such as a person's name--"s" as in Sam or "f" as in Frank, etc.), or to write a key word down. Training continues until the person with the hearing loss is able to apply the appropriate repair strategy quickly, comfortably, and automatically.
I do not want to give the impression that this procedure is a panacea. No A/R therapy will eliminate all conversational breakdowns, no matter how skillfully it is conducted. We have not, after all, "cured" the hearing loss. What this therapy can realistically achieve is some significant improvement in comprehending face-to-face conversations--but only if the lessons are applied outside of the clinic. A prerequisite condition is the necessity for the hearing-impaired person to assert his or her communication rights. Most normal-hearing conversational partners will be willing to modify their utterances to enhance the communication exchange if they know what to do. No one else but the hearing-impaired person can give them this information.
Audio-cassette Auditory Training
Although rarely described in the literature, the use of audio-cassettes for a home auditory (and language) training program is a familiar therapy technique, albeit one rarely used here. The tapes developed in Australia by Keith McRitchie, a cochlear implant recipient, for Better Hearing Australia demonstrate that the potential value of this technique has been overlooked. The Australian tape was developed to give new cochlear implant users practice in listening skills; the same logic applies to any hearing-impaired person with poor speech perception capabilities.
Traditionally, the prepared auditory stimuli are delivered through the loudspeaker of the audio-cassette player. I would suggest that the output of the tape player to be directed to a neck loop rather than to the internal loudspeakers. This permits the use of a relatively inexpensive tape player and direct electrical coupling between the tape player and the loop, which produces better fidelity than acoustic coupling, less possibility of hearing aid feedback, and a happier family (since there is no need for them to be bombarded for hours by the training tapes). This arrangement requires hearing aids with telephone ("T") coils to pick up the magnetic signals from the neck loop or, better yet, an "M/T" switch, since for some home auditory training exercises it is desirable for the trainee to repeat the stimuli as they are heard. The Australian tapes come with a written script which includes the directions for the task. There are three tapes, providing approximately four hours of listening time and, of course, the trainee can listen to any section as often as desired. A unique feature of the Australian tape is the fact that the stimuli were recorded by 27 different male and female talkers, representing different articulatory proficiencies, ages, and dialects. This provides a more valid listening experience than recordings by professional announcers.
The first lessons are easy, requiring only tracking the written script. This is followed by tasks identifying sentences out of order, in different intonation and stress patterns ("CLOSE the door" versus "Close the DOOR"), sentences and questions with the last word omitted, and omission of one or more words from different parts of the sentence. The difficulty increases as the tape progresses, culminating in the discrimination and identification of similar words and sentences. The developer of the tapes made an extra effort to make the task challenging and interesting. Every once in a while, there was a musical interlude (including Eddie Cantor, whom I haven't heard for many years). Many of the identification tasks illustrated the contribution of linguistic and contextual cues (given a key word, such as "dinner" or "vacation" and then selecting such spoken words from a number of others which fit the different key categories). Other, more difficult tasks require identifying words omitted from the written script, using less and less contextual support as more and more words are omitted. The beauty of the technique is that audio-cassettes can be individually "tailored" to fit the speech perception needs of specific people.
Given listening problems at work, for example, a tape can be recorded in which work-related vocabulary and topics are the main theme. Identification can be required in different closed- and open-set conditions, with and without other linguistic and contextual cues, and omitting progressively more material from work-related documents. Tapes focusing on other interests and needs can be similarly developed. Material can also be obtained from a number of different resources, including reading material for the blind (the written scripts would have to be obtained) and tape recordings made for learners of English as a second language. This latter material may be particularly useful, since much of it is ordered in difficulty and the written scripts are generally available.
The therapist who spends his/her time in developing home auditory training audio-cassettes, monitoring a particular client's progress, and providing support and motivation is utilizing limited clinical time to the greatest advantage. The client can take the tapes home and spend many hours in listening practice. All that is required is knowledge of the person's listening skills, some creativity in editing the script, a tape recorder, and a neck loop (for most clients). As a matter of fact, therapists need not be involved at all for some people. With a little initial help and occasional consultation, many people with hearing losses are perfectly able to develop their own "Home Auditory Training Program." It is even possible to develop a "lending library" of audio cassette tapes for home auditory training purposes for people with roughly similar listening needs.
Nursing Home Program
One of my observations took place at Montefiore Nursing Home in Melbourne. A/R therapy in nursing homes in the U.S. (when available) generally focuses on direct services to clients. The approach in Melbourne, conducted by Dr. Erber's speech therapy students, is quite different. There were 800 residents in the nursing home I visited. Considering normal demographic factors, we can assume that a large percentage had hearing losses of sufficient magnitude to disrupt normal communication interactions. Rather than dilute the limited clinical services available by providing a few people with a few hours a week of therapy, Erber's approach focuses on in-service training to all professional and paraprofessional staff. The in-service training program centers around the needs of particular clients based upon the results of a rapid but effective communication screening program.
In addition to the usual audiometric tests (including hearing aid status when pertinent) and case history, three other evaluations are conducted. The first evaluates the resident's ability to understand ten simple sentences as more auditory and visual information is given (repeating the sentence verbatim, emphasizing a key part of the sentence, and permitting speechreading). The results indicate the modifications that the staff must make in order to effectively communicate to a specific client.
The second procedure evaluates functional vision. Clearly, the contribution of visual cues to the communication process is going to be affected by poor vision. This test evaluates such simple dimensions as the ability to discriminate different mouth shapes and the maintaining of eye contact. The results are also communicated to the staff (with a recommendation that an optometric examination be conducted, when necessary).
In the third procedure, the residents are engaged in two conversations, one with and one without an assistive listening device (ALD). This device looks like a Walkman but functions like a body hearing aid with headphones. The resident's comprehension ability in the two conditions is rated on a five point scale, from #1, indicating no useful understanding of speech, to #5, denoting complete comprehension. The difference between the two conditions reflects the possible benefits of amplification. For residents who do possess hearing aids, the comparison is between their aids and the ALD. Most residents do better with the ALD, which proves the value of locating a microphone close to a speaker's lips (thus eliminating the effects of reverberation and background noises).
The results of this evaluation demonstrate the potential value of amplification to both the staff and the residents. Its importance was shown by an elderly lady with very little vision and a severe hearing loss who spent her time simply sitting or sleeping. While she received good physical care, the staff evidently believed that she "wasn't all there." With the ALD, she became alert, animated, and was able to engage in a relevant conversation with the student clinician. But when the system was removed, she reverted to her previous condition. Hopefully, a device will be obtained for her now that its value has been demonstrated. (The Australian government supplies hearing aids free to pensioners, to children under age 21,and to a few other special groups.)
While communicating the results of the screening program, the clinicians also use the opportunity to provide the staff with information about:
Sensitizing the staff in a nursing home to the problems posed by a hearing loss and instructing them how best to reduce these problems for specific clients personalizes the in-service training approach.
In the U.S., in spite of the importance of staff in-service training, only direct A/R services in a nursing home are supported by third-party payers. A/R services are usually more or less patterned on traditional speechreading and auditory training lessons, services which can be quantified to prove the effectiveness of therapy as demanded by funding agencies. Hearing aids and other assistive devices (such as ALDs, TV listening devices, and amplified telephones) are not covered by Medicare. (Medicaid may occasionally provide hearing aids for some elderly people.) In-service training to the staff is not a refundable activity, yet it is probably the most cost effective method of ensuring appropriate management to the majority of elderly nursing home residents.
Persons interested in providing in-service training in nursing homes (or any health-related Facility or senior center) should avail themselves of the curriculum developed for SHHH Australia by Dr. Jenny Rosen (SHHH Australia, 1334 Pacific Highway, Turramurra NSW 2074, Australia). The curriculum comes with a videotape which dramatically portrays the problems and potential solutions covered in the lessons. It is the most comprehensive, organized, illustrated, and informative in-service training package I have yet seen. Learning of the existence of this program was one of the valuable pieces of information I took with me from Australia. The section concerning additional resources for hearing-impaired people in Australia can be substituted by comparable information for the U.S.
Some Concluding Remarks
In some respects, all the services described above have already been conducted by programs in this country (e.g. League for the Hard of Hearing in N.Y.). Some of the activities practiced in Australia (e.g., the free week-long A/R program sponsored by the National Acoustic Laboratories) cannot be transplanted here because of the different nature of our health delivery systems. Other programs and/or specific techniques and material can usefully be adopted here. The Australians I met were just as interested in learning what we did as I was in learning what they did. We taught each other and, hopefully, we influenced each other to all our (and our clients') mutual benefit.
Erber, N. P. (1988). Communication Therapy for Hearing-Impaired Adults. Melbourne: Clavis Publishing.