Dr. Ross on Hearing Loss
When a Hearing Aid is Not Enough
by Mark Ross, Ph.D.
As we've heard and seen these past few days, there have been marvelous strides in hearing aid technology in recent years. I don't think there is any question but that these impressive developments can and do offer improved listening advantages to hard of hearing people. And as we've also learned during this time, these advances in technology are being accompanied by an increased sensitivity on the part of the professional community to the psychosocial consequences of a hearing loss. Evidence is now being accumulated that demonstrates, both objectively and subjectively, the positive impact that personal amplification can have on a person's adjustment and quality of life. Of course, this is not a finding that would surprise those of us wearing hearing aids! All of these are positive trends, one that I'm certain will continue to engage professionals into the new millennium.
But even as we acknowledge these positive trends, I do not believe that they fully respond to the total impact that a hearing loss can have upon the life and well-being of the affected individual. Too often hearing aids are presented - or understood - as panaceas, as devices that "restore" a person's hearing capacities comparable to that enjoyed by a normally hearing person. What this belief implies is that the provision of hearing aids alone is a sufficient response to the full consequences of a hearing loss in the life of an individual. That is, that since hearing is "restored" no further efforts are required.
On the contrary I think it important to stress that hearing aids are just one component, albeit arguably the most important one, of what should be construed as a rehabilitative "process", one that includes, or should include, other components as well. I certainly do not mean to minimize the value of hearing aids; as someone who has worn aids for nearly fifty years, I can personally testify to their value and absolute necessity. I shudder to think what my life would be like without them. But it's important for all of us to recognize that hearing aids alone do not, and cannot, address all the difficulties that are experienced by someone with a hearing loss.
I would contend, and there is evidence to support this contention, that it's possible to further reduce the handicapping effects of a hearing impairment beyond that occurring with the provision of hearing aids. This can be done by ensuring that hearing-impaired people are provided with the full range of rehabilitative services, as well as hearing assistance devices other than hearing aids.
Let's consider the typical prospective hearing aid user. I doubt that very many relish the thought of having to wear these things in their ears. Most such people have either been dragged or nagged into hearing centers or have experienced such evident hearing difficulties that they feel that they have no choice but to succumb and "get a hearing aid". We know that, on the average, people with adult-onset -hearing loss have been experiencing hearing-related communication problems for about 5 years or more before they seek help.
Think about those years. Think about the effects these hearing problems may have had upon the person's family, social circle, and employment situation. Consider the psychosocial problems, the stress, anxieties, and conflicts associated with frequent and erratic communication breakdowns. Most prospective hearing aid users must have experienced such problems or they wouldn't be seeking help (or others wouldn't be seeking help for them!). We trivialize the sense of hearing and the role that audition plays in our lives if we believe that hearing aids in themselves can enable people resolve the problems wrought by years of poor hearing and an unacknowledged or untreated hearing loss.
No matter how advanced and well-fit the hearing aids, they cannot retroactively help people understand how the hearing impairment has affected their current behaviors and relationships. Wearing the aids will not immediately overcome the maladaptive habits formed in those twilight years. We cannot effectively "treat" the person with the hearing loss separate from the very real fact that it's the entire family that has the "hearing problem". By focusing on the hearing aid as the sole "prescription" for the hearing impairment, we are overlooking the total impact that a hearing loss can have upon the life of the affected person.
What I am suggesting is that the hearing aid fitting procedure be defined in a way that it routinely incorporates a group hearing aid orientation program as an integral part of the entire process. Rather than focus on just the selection and follow-up of the hearing aid itself, the process would incorporate information, group interactions, communication strategies, and evaluation and selection of hearing assistance technologies other than hearing aids.
I recognize that the provision of an organized, group follow-up post-hearing aid fitting program is not an original suggestion (see Abrahamson l997 for extended references). It has been recommended and offered often, at various times in different places. I don't know precisely what sort of programs are offered in other countries, but I do know that currently, in the United States, in spite of the many references on the desirability of such programs, in actuality very few are offered or take place.
It's not as if there are serious questions regarding their effectiveness. I would venture that most professionals accept their value, though not necessarily their being coupled to the hearing aid fitting process. Mainly, it seems to me that group follow-up programs are not now being provided because (1) dispensers do not feel that they can be incorporated in their practice in an economical manner, and (2) even when they are offered, many if not most new hearing aid users fail to take advantage of the opportunity. I think both of these assertions are rather simplistic. But let me first respond to the effectiveness question.
The overall research on this topic seems fairly unambiguous. While the details of the programs vary somewhat in the various studies, there is convincing evidence that those people who receive enriched counseling services show a greater reduction in the hearing handicap than those who received less such services.
Twenty years ago, Brooks (l979) examined the extent of handicap reduction and hearing aid usage in two groups of patients, one which received extensive counseling and one which did not. His conclusions: "although the provision of a hearing aid alone produces some reduction in the handicap, a much greater reduction appears to be achieved by providing some measure of counseling to the hearing-impaired subjects".
Also about twenty years ago, a study was conducted which compared hearing aid usage in patients receiving a two week residential program at Walter Reed Hospital to a group that received a traditional 2 hour follow-up program (Surr, Schuchman, & Montgomery l978). Their conclusions were similar to those reported by Brooks. (Parenthetically, when I received my hearing aids at Walter Reed Hospital nearly fifty years ago, it was coupled to a two months aural rehabilitation program! And I can personally testify how effective it was.)
Ten years later, Smaldino and Smaldino (l988) essentially reached the same conclusion. All four of their experimental groups who received hearing aids displayed demonstrable help from the aids - as I've already noted, of course hearing aids by themselves do help - but they also found that the handicap of hearing loss was further reduced by the group receiving a month long aural rehabilitation program
And in a 1992 study by Abrams, et al (Abrams, Hnath-Chisolm, Guerreiro & Riterman, l992) again we find that while the conventional method of fitting hearing aids does indeed reduce the handicap of a hearing loss, that the handicap can be further reduced when the selection process includes a short term aural rehabilitation program.
Finally, I should point out that just two days ago, Dr. Kochkin in his presentation showed that patient satisfaction increases as counseling is increased. Considering also his findings that over 16 percent of people receiving hearing aids have completely rejected them, and that only 60 percent of hearing aid recipients are satisfied with their aids, quite evidently there are shortcomings in current model of hearing aid dispensing that have to be addressed.
How about the argument that clients do not desire such programs or take advantage of them when offered? While true for some people, this argument has been overdone. For example, in a l997 survey conducted by the American Academy of Audiology, it was found that almost half the people desired more information about other rehabilitation options. Moreover, I would argue that the overwhelming majority of new hearing aid users are simply unaware of the full range of available services that can be helpful to them.
Generally, at this stage people don't even know enough to ask the right questions. They do not know, for example, of the existence of hearing assistance devices other than hearing aids or how to effectively use communication and repair strategies. And, if this type of information is not communicated during the hearing aid selection process, it's unlikely that it will ever be known. It's at this time, when people have acknowledged that they need hearing assistance, and when they are seeing a professional who has the information that they require, that they will be most receptive to learning about other ways to further reduce the problems caused by a hearing loss.
In this time of financial constraints and rising health costs, the budgetary argument would appear to be particularly salient. If an aural rehabilitation program is joined to the hearing aid selection procedure, then superficially it does appear that costs will increase. Not necessarily, however. Several studies have shown that people who receive an expanded educational/counseling program return their aids much less often than those who have not received such a program (DiSarno, l997; Northern, l999). This certainly would be a cost saving for the hearing aid dispenser.
We should not be surprised at this finding, nor the likelihood that the need for individual follow-ups will diminish when people are enrolled in a group program. Professionals in private practice will find that the group setting enhances patient satisfaction, which translates into more "word-of-mouth" referrals, possibly the best source of new patient contacts there is. When I've conducted such programs, I've often found that many monaural hearing aid users decide to accept binaural amplification, not necessarily because of anything I say, but because other members of the group come out strongly in favor of binaural amplification. And finally, in an organized group follow-up program, there would be time to evaluate, select, and dispense other types of hearing assistance technologies. All of these factors have potentially positive economic consequences.
Let me now review some of the needs that hard of hearing people have that can be met most effectively in a group setting.
They need general information about the causes and treatment of hearing loss. People can deal with a problem much more effectively when they have greater understanding of the nature of the problem. Many people come to clinics wanting to be "fixed" with a medical or surgical procedure; they have to understand why some types of hearing losses cannot be "fixed" medically, and that the best "treatment" is often a well-functioning hearing aid.
They need information about the listening implications of their own hearing loss, explained in a way that they can understand (for example, why people seem to be "mumbling", or why they can "hear" speech but not understand what is being spoken).
Furthermore, a person's spouse or adult children must understand the communicative implications of their loved one's hearing loss. One technique I often use in a group setting is to play filtered speech to these people. Often their responses are amazement and mortification: "Is that what she has been hearing!" I never knew! This simple step can decrease tensions and stress within the family.
They need an opportunity to review and share their listening experiences with the clinician and other group members. We've all seen examples of how reluctant users experiencing problems with their first hearing aid want to discard the aids as "being too much trouble". The best way to encourage these people to continue their hearing aid trial, and to work through their problems, is for them to share their experiences with the group, many of whom have experienced similar problems and overcome them.
The group setting lends itself to help people develop realistic expectations of what a hearing aid can and cannot do for them. Some people's expectations may be unrealistically high, while others set their standards too low. A group follow-up program, that takes their individual hearing losses into account, can help them calibrate their expectations to a realistic and appropriate level.
People need information on how to troubleshoot their hearing aids, how to take care of their earmolds, and how and when to change batteries. They need to know why one type of hearing aid was selected rather than another. Certainly all of this information is ordinarily conveyed in the usual delivery model, but, from the perspective of the user, so much is happening that much of what they are told may be forgotten when they leave the room. It takes time and repetition for people to absorb new information. This indeed may be one of the key advantages of an organized follow-up program: it provides the time for important information and experiences to be conveyed and assimilated.
If we accept the notion that our focus is on the needs of the individual, and not on hearing aids, per se, then people require information about other kinds of hearing assistance technologies. Let me give several examples to illustrate what I mean. A hearing aid will not wake me up when I'm sleeping. For that I need a vibratory or light signal. To ensure that I can understand on the telephone, I find an in-line amplifier very helpful. Sometimes I use one that permits me to employ a neck loop so that I can listen with both ears. Other people with different degrees of hearing loss need other kinds of telephone assistance, of which there are innumerable possibilities.
There are many other devices that can be useful for some people in some circumstances, such as TV listening devices, conference microphones, personal FM systems, doorbell and telephone signal lights, and large-area listening systems, much like the inductive loop system being used in this auditorium.
When I'm in a hotel, I usually bring a door-knock sensor with me so that I can be sure to be awakened in the event of an emergency. As a matter of fact, at the last convention of Self Help for Hard of Hearing people in Boston, I and about four or five hundred other SHHH members could have used such a device, or better yet, a visual smoke alarm. There was a fire alarm in the hotel late at night which we didn't hear and which we didn't find out about until the next morning! People were actually being evacuated from the hotel while the fire department searched for the site of the fire.
Fortunately, it was a false alarm, but can you imagine what kind of disaster could have occurred if there had really been a fire! This is clearly a rather dramatic example, and one that demonstrates the need for the routine inclusion of visual rather than just auditory smoke alarms in public places. In my judgment, perhaps the biggest weakness in the typical hearing aid delivery model is the lack of attention paid to the need for and potential usefulness of other types of hearing assistance technologies. Where better place for people to learn about these products than from the person who is fitting them with hearing aids?
Most people with hearing loss can benefit from information about various kinds of communication and repair strategies than can be used to enhance interpersonal communication. The basic principles of speech reading are important for people with hearing loss to know about. With a little practice and focus on the lips, it's possible to increase a hearing-impaired person's communication competencies. By learning to be more "assertive" in their communication practices, hard of hearing people can be more effective communicators - but they have to know what to do and when to do it.
What I've outlined above is only some of the major, general needs of hard of hearing people. It takes time to deal with the communicative as well as the psychosocial implications of a hearing loss; it takes time to evaluate the need for and to provide other types of hearing assistance technologies; it takes time to help patients and family members understand the implications of a partial hearing loss; and it takes time, particularly for older people, to work through the fitting procedures until they reach the point that they are content with and are receiving the full benefits of hearing aid amplification. The key notion here is time, time which would be available if the hearing aid selection procedure were to be defined in a way that includes the routine inclusion of a group post hearing aid fitting program.
Of course hearing aids are marvelous and indispensable devices; even more, for many IFHOH members including me, they are of immense value. They make it possible for us to more fully participate in the social, cultural, and economic activities of our societies. Without them, our lives would be very different, certainly more constricted and limited. But to realize their full value, and to go beyond what they themselves can offer, people with hearing loss need and can benefit from a more comprehensive type of aural rehabilitation program. In brief, a Hearing aid by itself is often not enough. As we move into the 21st century we should set our sights a bit higher.
Abrams, H. B., Hnath-Chisolm, T., Guerreiro, S.M. & Ritterman, S. I. (l992). The effects of intervention strategy on self-perception of hearing handicap. Ear and Hearing, 13(5) 371-377.
Abrahamson, J. (1997). Patient education & peer interaction facilitate hearing aid adjustment, Hearing Review Supplement, 19-22.
Brooks, D. N. (1979). Hearing aid use and the effects of counseling. Australian J. of Audiology, 1(1), 1-6.
DiSarno, N. (1997). Informing the older consumer - a model. The Hearing Journal, 50(10). 49-52.
Northern, J. & Meadows-Beyer, C. (1999). Reducing hearing aid returns through patient education. Audiology Today, 11(2), 10-13.
Smaldino, S. E. & Smaldino, J.J. (1988). The influence of aural rehabilitation and cognitive style discourse on the perception of hearing handicap. Journal of the American Academy of Rehabilitative Audiology, 21, 57-64.
Surr, R. K. , Schuchman, G. I. & Montgomery, A. A. (1978). Factors influencing use of hearing aids. Archives of Otolaryngology, 104, 732-736.
This paper was supported by Grant # H133E9800010 from the US Department of Education, NIDRR, to the Lexington Center.