Download Working with post-lingually, severely deafened clients

Working with post-lingually, severely
deafened clients: Cultural vs. pathological
perspectives.
Part three: Practical strategies for the
clinician.
Graham Weir
M.A. (Counsl.)(Wash. D.C.) Cert. Audiom. (Syd.) FACAud
Audiometrist and Hearing Rehabilitation Specialist
This is the third and final installment of a three part article discussing a theoretical and practical
framework for working with clients with severe to profound hearing loss since their formative years.
The first installment identified eight cultural similarities with the pre-lingually deaf community. The
second installment discussed a practical framework for understanding the implications of these cultural
differences on communicative behaviour, and proposed a renewed focus on the impact of hearing loss
on expressive communication skills, as the most effective foundation for building a rehabilitation plan.
In this final installment, we revisit the eight cultural differences described in part one, and in the light
of the suggestions made in part two, suggest some practical working strategies that a clinician can
adopt when dealing with clients with severe / profound hearing loss acquired during their formative
years. Lastly, references to some useful treatment tools and further research are listed.
(1)
Reliance upon vision as a key communication conduit.
Both the pre-lingually deaf and the post-lingually deafened, or severely hearing impaired client are
vitally dependent upon a clear view of the face and lips of speakers during conversation. Since audible
signals for these levels of loss are incomplete and easily misunderstood, even with amplification, visual
signals from facial expressions and body language are far more critical for this group, than for people
with mild or moderate hearing impairment who, with amplification, may still be able to follow
conversation without necessarily seeing a speakers’ face.
STRATEGY:
All hearing services professionals should be fully aware of this need among all their clients. But
it can be easy to forget and mumble a few words while working with the computer. When
working with the severely hearing impaired, it can be critical to demonstrate understanding by
ALWAYS facing the client and speaking clearly, without exaggerating lip movements. Male
practitioners should be extra careful to be clean shaven, or at least ensure that the complete lips
are not obscured by hair. Especially the corners. It is amazing how many lip-reading cues can
be destroyed by this one factor. Also be careful to keep hands and objects away from your
mouth while speaking.
(2)
The use of sign language (either as a first or second language)
It is quiet common for many post-lingually deafened or severely hearing impaired people to have some
degree of fluency in sign language if their deafness occurred in childhood, usually because they have
been exposed to it at school or in social activities involving sign language users. There are some
notable exceptions to this, namely children who have been educated in a strict “oral” only
environment where any use of sign language was forbidden in the belief that exposure to signs would
somehow damage their language and speech development. For people suffering severe or profound
hearing loss later in life, this will rarely be the case. Frequently, the psycho-social impact of hearing
loss on this latter group is far more significant than it is for those who, although of the same age, may
have had the benefit of a lifetime of adaptation, and may be more likely to be able to utilise sign
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language as a secondary, supplementary language to maximise their communicative input, in difficult
listening environments.
STRATEGY:
A working knowledge of sign language can sometimes be helpful when working with
profoundly hearing impaired clients who are familiar and comfortable with using it as a
supplement to their audition. But it can be a very sensitive matter that must be approached with
great care. As a general rule, I will not use sign language unless it becomes obvious verbal
communication isn’t working, and then I will first ask in both sign and speech, if they
understand signs and would like me to use it to supplement my speech. A hint that sign
language might have been part of their cultural environment can be the presence of a typical
“deaf voice”, indicating long standing profound hearing loss. But this isn’t always a reliable
indicator. Some deafened people might have grown up in an “oral only” environment where the
use of sign language was forbidden and there will be a strong aversion to it’s use. There is a
complex and heated history behind the “Oral vs. Signs,” debate so it is wise to always respect
the client’s preferred method. If verbal communication methods simply don’t work and either or
both of you can’t use sign language, then the easiest thing to do could be to open up a blank
Word document on your computer screen and use this to type your questions / statements etc.
allowing the client to answer verbally.
(3)
Delays in educational development
Again, if the loss has occurred during childhood or very early adulthood, delays in educational
development can occur due to iniquities in access to classroom presentations and audio-visual
materials. This was very common as recently as 10—15 years ago, less so to-day with equal
opportunity / anti-discrimination legislation impacting educational institutions. The impact of these
delays can be profound, often producing a deep sense of injustice and resentment and even a fear of
further educational or learning experiences. This can translate to a low tolerance for ambiguity that, in
turn, can negatively impact social attitudes and interpersonal communication strategies.
STRATEGY:
Clients who have suffered educational delays due to their hearing loss, may benefit from some
specialised vocational guidance assistance. Expressing an interest in their overall welfare by asking
questions about how their hearing loss impacts their family and work life can often bring any unmet
needs to the surface. Particularly in regard to the need for technological assistance in the workplace or
classroom. Older clients who may have missed out on the current benefits of equal opportunity
legislation in educational settings, and are interested enough to explore opportunities again, might
benefit from a referral to a specialised disability counsellor at a nearby further education facility.
Making contact with the counsellor on behalf of the client and offering your expertise to help ensure
technological interface needs can be met by the facility, can go an extra mile that can make an
enormous difference to your client’s rehabilitation potential.
(4)
Delays to social development
In the normal hearing population, where a mild or moderate hearing loss may be suffered later in life,
it is usually the impact of hearing loss on social function that prompts the sufferer to seek professional
help. These barriers to social function are far more severe and significant for those with severe or
profound hearing loss, particularly post– lingual, total deafness. An inability to fully participate in
social function, especially during developmental years, has a dramatic effect on perception,
personality and social engagement, particularly if the sufferer is living among a group of normal
hearing people. 2 This is not dissimilar to the social isolation experienced by a non-English speaking
new Australian. Surprisingly, this is much less a problem among a community of deaf sign language
users, for the simple reason that there is usually only minimal language diss-fluency or impoverished
communication diet among them. Social isolation only becomes a problem for sign language users
when dealing with “outsiders” in the hearing world who cannot sign fluently.
STRATEGY:
The audiologist can be instrumental in identifying the need for remediation by using the
questionnaire previously illustrated in table 1. If satisfactory change doesn’t occur at post-fitting
follow-up sessions, that is a good indicator that more extensive communication skills training
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will be needed, both on an individual and group basis. If specialised professional assistance is
not available, a self-help group such as S.H.H.H. or Better Hearing may be the best resource to
use. Often, even if they don’t conduct formal courses in effective communication, members of
these organizations can be highly effective change agents by being role models of
communicative behaviours, thus helping the client unconsciously develop adaptive strategies
that work best for them. Here, they can learn while also having a good time in a less threatening
environment, with people who understand and accommodate their communicative needs.
Helping clients to improve their communication diet doesn’t always need to involve formal
sessions with a specialised trainer. Association with effective and understanding role models can
sometimes be all that is needed to achieve a satisfactory transfer of skills.
(5)
The importance of spatial orientation in communication interaction.
Unlike the normal hearing or mildly hearing impaired population, who can usually communicate in a
variety of spatial arrangements without the need to change layouts to see speakers faces and minimise
acoustic interference, people who have become severely or profoundly hearing-impaired, pre or postlingually, have a critical need to maximise their receptive communication skills by organising the
spatial layout of room furniture and controlling acoustics to minimise environmental negatives, even if
they are wearing hearing technology. However, many will not be aware of this need ,or may feel
powerless to change their environments as needed. A culture of “learned helplessness” from years of
passive compensation strategies, can inhibit the development of the necessary levels of confidence and
assertiveness to change environmental negatives.
STRATEGY:
Again, there isn’t much an audiologist can do about this need in the clinical setting, other than
counsel the client about how to change room acoustics for optimal benefit. The difficulty
usually isn’t that the client doesn’t know how room acoustics affect their hearing ability. They
may just not know what to change or how to change it in social situations. Again, involvement
with a self-help group may give the best opportunity to learn effective coping strategies.
Practical demonstrations can save many words.
(6)
Barriers to conventional use of media and communication devices.
We live in an increasingly media dominated world. In particular, ability to utilise audio based
telecommunication devices is critical to employment and social engagement. But in spite of
technological breakthroughs in hearing instruments that enable improved access for the mainstream of
hearing aid users, access to these technologies is still largely very difficult for both of the groups under
discussion here. Even as access to telecommunication audio signals does improve, there is still the
insurmountable barrier, that with such severe levels of hearing loss, only part of the audible spectrum
can be improved with hearing aids. A degree of residual disability (albeit a lesser one) still remains
that demands a visually based, technological solution. (e.g. S.M.S.; Email etc.)
STRATEGY:
This is one area where the skill and knowledge of the audiologist can be vitally important to
successful hearing rehabilitation. The need for interface with audio based media and
communication devices should be part of every client’s initial history questionnaire and
recommended technology must be selected with these needs foremost in mind. Never make
assumptions about this. Always ask about their current experiences and needs and demonstrate
the benefits during the fitting process. In my clinic, we have an audio loop and an infra-red TV
listening system plus a telephone with very good inductive coupling in the handset. Every client
experiences the use of the phone via their hearing aid’s telephone program as well as the
television interface as part of their routine fitting experience. In some cases, specialised business
phone or classroom interface devices need to be sourced. This requires a professional interest in
ALD hardware and a commitment to ensure these vital needs are not allowed to fall through
cracks in the hearing rehabilitation program just because of neglect to equip a clinic effectively
for financial reasons. Investments of time and money in this area will reap immeasurable
benefits for the client and their commitment to you as their preferred practitioner.
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(7) The communication diet may be severely impoverished.
Mental health is significantly impacted by the frequency, quantity and quality of communication
interchanges with significant others in relationships. No relationship can survive on a diet of
superficial communication most of the time. There must be sufficient meaningful, personal interaction
on a regular basis. This is easy enough among families or groups with normal hearing. Untreated
hearing impairment directly affects these variables in much the same way as inequality in language
fluency, (e.g. non-English speakers in Australian society.) For the severely or profoundly deafened
individual however, where hearing technology cannot fully restore receptive hearing ability, significant
challenges to fluent and easy communication still exist. Frequently, this impacts negatively on the
individuals’ communication diet and can result in compensative communication behaviours that may
be seen by un-impaired individuals, as unusual, inappropriate or even aggressive.
STRATEGY:
The presence of an impoverished communication diet will not always be evident without
targeted questioning. Again, the questionnaire in table 1. can be helpful in flagging this need,
especially if technology solutions don’t produce much change in the five critical questions at
post-fitting follow-up sessions. With severely impaired clients, hearing aids alone are unlikely to
entirely solve their speech-in-noise problems. FM technology will usually be needed to optimise
their performance in difficult listening environments. Identification of the listening
environments critical to their lifestyle or culture is a vitally important component of an initial
questionnaire. Especially if the audiologist is able to establish which environments cause the
difficulties recorded in table 1. Perhaps the best time to explore the health of the client’s
communication diet is during discussion of their responses on the initial questionnaire. Then
bring the subject up again during the follow-up interview if it becomes obvious little change has
occurred in the five questions in table 1.
(8) The use of interpreters or advocates to assist articulation of needs or ideas.
In the non-English speaking community and also the Australian Sign Language community, the use of
advocates or professional interpreters in important communicative situations is an accepted norm. And
at least where sign language is involved, will be a government funded service in some, if not all
situations.
Unfortunately, no formal interpreting assistance structure yet exists in Australia for a person with
profound hearing loss who is not a sign language user. In Australia the National Association for the
Accreditation of Translators and Interpreters (N.A.A.T.I.) does not formally recognise “Oral
interpreting” as a legitimate translation as lip-speaking is not a “language”. In contrast, the USA’s
interpreting assistance programs allow for “lip-speakers” or “oral interpreters” as an alternative to
sign language interpreters, if needed.
There is some debate however, that with the current effectiveness of cochlear implant technology in
combating profound post-lingual deafness, it is very rare nowadays to encounter a situation in an
audiological setting where a formal, professional “lip-speaker” would be needed. Instead, the
attending Audiologist, as the recognised hearing professional, would be expected to speak with
sufficient clarity or simply write things down.
However, although the need for a formal interpreter service is not really a shared cultural attribute
with the pre-lingually deaf, sign language using community, the need for advocacy assistance can be
much more frequently observed when a severely hearing-impaired client attends an audiological
consultation with a family member or friend who may act as un unofficial spokesperson for the client.
STRATEGY:
Most practitioners have been in the situation where a severely hearing impaired client attends
with a family member or friend. The need for the assistance of the advocate quickly becomes
apparent when we observe the client looking at them instead of us in answer to our questions. It
is easy to then address the advocate instead of the client, but this is an ethical error that must be
avoided. Don’t be perturbed, just continue addressing the client, but keep eye contact with both
parties, to ensure neither feels marginalised or overlooked. If you can use signs fluently, ask the
client in sign and speech if they would like you to sign or arrange an interpreter for another visit.
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If the client doesn’t exhibit much comprehension, try opening a blank document on the
computer and type your statements on the screen in print large enough for both to see it and try
and encourage the client to be the one making the decisions. Clients in this category are often
likely to benefit the most from specialised communication strategy training, but it isn’t wise to
bring that possibility up unless they express a need or until it can be demonstrated from the
client’s follow-up responses on the questionnaire in table 1. If the client has suffered severely
from educational deprivation and is unable to complete the questionnaire due to literacy
limitations, then that alone may be sufficient reason to explore further educational potentials.
Helpful resources and references for further research.
There are many texts and resources on Aural Rehabilitation, but only a very few contain tools and
strategies for dealing with the impact of hearing loss on expressive communication skills as
recommended in this series of articles. Some of the best resources available are those of Dr Norman
Erber of Melbourne. Some these materials are listed below. See his website for further resources and
ordering information. www.hearingvision.com.au
QUEST?AR Communication Practice. Melbourne: Clavis
A rehabilitation procedure that is easy to use. The client asks conversational
questions, and attempts to understand the partner’s answers. The clinician selects
vocabulary and language to match the client’s interests and abilities. Both
participants apply clarification strategies. Suitable for age 7 through adult. Includes
booklet, topics, clarification strategies, and instructions
Erber, N.P. (1996) Communication Therapy for Adults with Sensory Loss.
Melbourne. Clavis. ISBN 0646 30061 X 261 Pages 53 tables 363 references
Revised and expanded., this popular university text and clinical sourcebook will
guide you through an innovative approach to the assessment and rehabilitation of
adults with acquired hearing and vision impairments - and their communication
partners. Throughout this thought provoking book you will discover a wide range of
conversation based therapeutic methods that promote self-help, problem solving, and
behavioural change.
Erber, N.P. (1993) Communication and Adult Hearing Loss.
Melbourne. Clavis. ISBN 0646 14156 2 148 Pages 12 tables 133 references
This practical book is appropriate for anyone who wants to communicate more
effectively with a hearing-impaired person – including friends, relatives and healthcare providers. You will learn how hearing loss impairs communication, and how to
resolve or avoid difficulties through clear speech and management of situations.
Samples of everyday conversation illustrate the methods.
Recommended for families of new hearing aid users.
For a good general overview of Aural Rehabilitation with some attention given to
expressive communication skill training see Tye-Murray, N. Foundations of
Aural Rehabilitation: Children, Adults and Their Family Members, 2 nd Edition
(2004) Delmar Learning, NY) www.delmarlearning.com
Also, for some excellent, simple games that anyone can use at home to develop their
expressive communication skills see www.conversation-matters.com/products)
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Also see Hickson, L., Worrall, L., & Scarinci, N. (2007). Active Communication Education
(ACE): A program for older people with hearing impairment. London: Speechmark.
It is available in Australia from a company called Double F [email protected]
SUMMARY:
Hearing rehabilitation isn’t just about the restoration of hearing, It is about the restoration of
communication function. Communication function involves two parts: (1) Receiving information and
(2) Expressing information. The prime purpose of hearing, apart from awareness of our environment, is
to obtain the information we need to express ourselves with a reasonable degree of confidence and
relevance. Anything that impedes this will affect our ability to feel integrated with the community we
live in. It doesn’t matter if the barrier is an inability to speak the language, a speech impediment, or a
hearing loss. Nowhere is the damage to communication function more evident than when we see clients
with post-lingual severe to profound hearing losses since their formative years. Although this client
group represents only a minority of the routine caseload seen in the average hearing services clinic,
their needs can painfully underscore the limitations of our professional tools and skill sets.
Unfortunately, the majority of hearing science research and rehabilitation product development
addresses only the first part of the communication paradigm. Much more research and product
development can and should be done on helping our clients repair the damage defective hearing has
done to their expressive communication abilities. This series of three articles suggests that the
traditional view of approaching the problem of hearing loss from a pathological or technological
perspective needs to be supplemented with an examination of the impact of cultural shapers of
communicative behavior in the client’s life experiences. Targeting culturally learned, communicative
behaviors that are hindering social integration is more likely to lead to success than any attempt to
regard or treat disabling communicative behaviors as some kind of psychological disorder.
A comparison of eight culturally derived communicative behaviors that are common to both the prelingually, profoundly deaf and the post-lingually severely hearing-impaired, serves as a vehicle to
illustrate how communicative behaviors are learned from life experiences and how we can successfully
utilize our knowledge of these factors, to assist our severely hearing-impaired clients to optimize their
communicative function and restore balance to their communication diets.
References:
Johnston, T. “Auslan Dictionary: Deafness Resources Australia, 1989.
Weir, G. “Hearing Loss Survival Kit” Self Publication, Mandurah, Western Australia 2007.
Graham Weir has had a severe to profound bilateral hearing loss since a nearfatal attack of meningitis at the age of eight. He majored in psychology at the
University of Queensland and completed a Masters degree in counseling of the
hearing-impaired at Gallaudet University, Washington D.C. USA (1980). He has
had a varied career in deaf welfare and as a Rehabilitation Counselor and staff
trainer for the Commonwealth Rehabilitation Service. He has been a practicing
Audiometrist since 1994. Email comments are welcome to [email protected]
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