Dr. Ross on Hearing Loss
Tracking and Communication Repair Procedures
by Mark Ross, Ph.D.
Tracking procedures are a deceptively simple, but potentially potent, aural rehabilitation therapy practice. It requires no elaborate equipment or preparation just a patient and a therapist "talking" to one another. Because it simulates reality more than any other procedure, it is also the one with the greatest face validity. Many specific variations can be practiced within the same general framework. Similar procedures can be found in several books on conversational therapy authored by Norman Erber (Clovis Publications, Melbourne, Australia).
Initially, tracking procedures, as developed at the National Institute for the Deaf, emphasized only the visual modality. The procedure is more applicable, however, when performed audio/visually. The therapist sits facing a patient and using a soft, conversational level, utters the first sentence of a paragraph. The content and length of the paragraph depends upon the interests and capacities of the patient's. At first, relatively simple paragraphs should be chosen; later, more elaborate ones may be used. The patient's task is to repeat all of the words he/she understands. To make the task a bit more difficult and challenging, it is useful to produce competing sounds via an audio cassette machine playing one of the multi-voice babble signals often used for audiological purposed. The intention is to make the listening situation sufficiently challenging so that the patient will have difficulty in correctly repeating the entire sentence. When there are errors as there initially should be at first else the task is too easy - the therapist repeats the sentence verbatim. This gives the patient another opportunity to comprehend the entire spoken sentence.
If there are still errors, the therapist repeats the entire sentence again, this time stressing the words that the student missed. If errors continue, the therapist provides additional clues until the patient can repeat the entire sentence correctly. These additional clues include (1) precisely articulating the word or words that were missed, (2) slightly raising one's voice, (3) paraphrasing the sentence before going back to the original version, (4) spelling a missed key word, and, finally, (5) writing the word. Once the entire sentence is comprehended correctly, the therapist repeats the first sentence, but this time immediately follows it by the second sentence. This and subsequent sentences should be easier to comprehend correctly, since the patient can depend upon the information in the previous sentence(s) to make predictions of content.
The same process is followed until the student is able to understand the entire paragraph correctly. When a patient is able to track fairly rapidly and accurately, it is time to make the task a bit more difficult. This can be done by increasing the level of the noise, and/or slightly increasing the distance between the therapist and the patient.
In the original tracking procedure, the speed with which a patient could accurately track a complete paragraph was used a measurement of performance. The faster a patient could perform the task, the better. Of course, in order for this comparison to be made, it was necessary to have a number of equivalent paragraphs available. This proved to be difficult to arrange and the procedure, when it is actually practiced, is now limited to its role as a clinical training activity rather than as a measurement of communication performance.
In this original version of the procedure, the entire burden of making the adaptations necessary to ensure understanding fell upon the therapist. In the following version, the responsibility for ensuring comprehension of the spoken material is shared by both the therapist and the patient (as it would be in real-life). As before, the therapist reads the first sentence of the selected paragraph (which should still reflect a patient's interests and performance level). And as before, the patient repeats what he/she hears. But this time, rather than the therapist selecting the "communication repair" strategy, it is the responsibility of the patient to make this decision. It is the patient's task to determine exactly what words were missed, why they were missed, and what can be done about it.
It is at this point that the concept of "communication repair strategies" is introduced and explained to the patients. They are informed that their task in this communication exercise is not only to try to understand the spoken messages, but also to analyze the why "broke down", if indeed it did. As an example, a patient is told if he or she missed the last word in a sentence but understood the rest, all that is necessary is to ask the therapist to repeat just that word (or to spell it out if it is a particularly difficult word like a proper noun). Precisely what a therapist is instructed to do depends upon the nature of the verbal message and the precise reason the patient did not understand. These could include asking the therapist to:
The contributions of therapists are made by their creative introduction of various problems when they say the sentence. Thus, at various and unpredictable times, therapists may purposely cover their mouths, drop their voices, say the sentence to quickly, intentionally slur some words, or turn slightly away when talking. These problems should be in as natural a manner as possible, to try to simulate the kinds of problems a patient would face in real-life. The simulated problems should also reflect a patient's performance level. Fewer ones should be used for people who already have a great of difficulty in comprehending speech, while more problems may be introduced for those who need a greater challenge.
The reason the therapist asks the patient to repeat the sentences is to check his/her comprehension. In real-life people with hearing loss will often prefer to pretend to understand (to bluff, in other words) rather than assertively attempting to repair the communication breakdown. Or else, they may simply say "what" or "huh", which gives their communication partners no idea of how to actually modify their speech to ensure comprehension. This procedure is designed to teach patients about different communication repair strategies and practice in rapidly applying them. It is also a time in which patients can be encouraged to be more assertive in applying communication repair strategies in their everyday lives. Such encouragement is a key component of this therapy practice; "homework" may be assigned in which patients report on instances where they did and did not engage in appropriate "assertive" communication practices.
What can be particularly beneficial is to teach and apply communication repair strategies within the context of a group aural rehabilitation program (such as a group hearing aid orientation program). In this type of setting, the therapist should not be the only one talking; much of the value of a group setting occurs when patients share their experiences and problems with the other members of the group. Now it is unlikely that in any such group, that all the participants understood all the utterances made by other members of the group. In this situation, a skilled therapist can observe which participants appeared to miss some or all what someone says. These people (with everyone's permission, of course), can be queried as to the content of the other's person's utterance. When they report, as suspected, that they did not understand then they are asked what the speaker should do to clarify (or "repair") the utterance. This is when the concept of communication repair strategies is best explained, as they are practiced within the group setting. The goal is for the patient participants to take the initiative with one another, without the therapist acting as a mediator.
It will not be possible for most patients to achieve 100% understanding of every spoken message in every situation. Part of what a therapist must offer a patient is a realistic level of expectations. Some hearing losses and some situations will preclude perfection from occurring. But just about everybody with a hearing loss can improve their comprehension of spoken messages to some degree, given the proper use of communication repair strategies. This has to be our goal.