Download Working with post-lingually, severely deafened clients: Cultural vs

Working with post-lingually severely
deafened clients: Cultural vs. pathological
perspectives.
Part two: Developing a working framework
Graham Weir
M.A. (Counsl.)(Wash. D.C.) Cert. Audiom. (Syd.) FACAud
Audiometrist and Hearing Rehabilitation Specialist
Discussions on how best to work with people with hearing loss usually revolve around clinical issues,
or more specifically, how to optimise the benefits of technology to help people hear better. While this
focus is vitally important and must not be ignored, this paper proposes that in the case of severe to
profound losses, it is also helpful to evaluate the possible impact of the cultural differences mentioned
in part one of this article, upon interpersonal communication behaviour. The simple reason for this
approach is that communication behaviour, whether we hear well or not, has a much more decisive
influence upon success or failure in social integration, than does simple ability to hear. In other words,
how we respond to what we hear or perceive is the only criteria other people can use to determine how
to interact with us. Therefore, a focus on cultural shapers of communication behaviour, rather than
pathological or psychological explanations of disability, may be more enlightening and helpful as a
framework for developing a hearing rehabilitation program for people who have acquired severe to
profound hearing loss during their formative years.
“An inability to hear a conversation clearly isn’t much different from being able to hear it clearly,
but not understand it…”
Hearing loss is after all, a common part of the human condition and the communication behaviours that
result from it are normal for anyone facing communicative barriers, no matter what causative factors
are involved. For example, we wouldn’t dream of regarding the communication difficulties experienced
by a non-English speaking immigrant as a “psychological disorder”. Therefore since an inability to
hear a conversation clearly isn’t much different from being able to hear it clearly, but not understand it,
then it will be much more helpful to the task of rebuilding a client’s communicative confidence if we
focus on culturally based communication modifications, rather than any attempt to treat negative
communication behaviours that are supposedly “psychological” in origin. This addition to traditional
clinical perspectives does not deny the fact that failure to address the residual communication barriers
resulting from long term severe hearing loss can certainly result in mental health problems. It simply
tries to make the point that the best perspective for teaching remedial strategies is a cultural approach,
rather than a psychological disorder approach.
“An effective framework for hearing rehabilitation must consider the impact of hearing loss on both
components of communication, not just one.”
The act of communication involves two components - reception and expression. We receive
environmental sounds and interpersonal communication through our ears and eyes and we respond to
these stimuli. These responses express our feelings and thoughts and convey messages to others. The
resulting interactions determine our effectiveness in interpersonal engagement and therefore social
survival. Any impedance to the frequency, quantity or quality of our social engagement with our fellow
beings will have a significant impact on our “communication diet” and if left untreated long enough,
our mental health. It doesn’t matter what form the impedance takes, whether it is hearing loss, speech
impediment, language barriers, anti-social behaviour or careless and destructive communication tactics,
the result will be the same—a negative impact on our ability to engage productively and in healthful
ways with the people of our society.
1
Traditional treatment approaches to hearing rehabilitation tend to be framed around a clinical
perspective of hearing loss - or how to optimise the remaining receptive capacity of the ear. Most of
the clinical research and technological advances that have been developed since the inception of
hearing science have been framed around this perspective. This view while perfectly valid and
absolutely vital, is still incomplete because it limits consideration of the impact of hearing loss only to
the receptive elements of communication, but this is only half of the total picture. The communication
deprivation caused by hearing loss not only impacts upon communication reception, but also—and
perhaps much more significantly—upon a client’s expressive communication skills.
“Modified expressive communication strategies can be powerful tools in hearing rehabilitation…”
To repeat our earlier statement, how we respond to what we hear or perceive, has a far more significant
impact upon our success or failure in social engagement, than does simple ability to hear. Helen Keller
was one of the best examples of that. More recently, Rocky Stone, the American based founder of the
“Self Help for Hard of Hearing” (SHHH) organization, although profoundly deaf, was a master at
confidently “working a room”. Rocky had developed the amazing skill of “confirmatory questioning”
to build on the limited auditory information he received from his hearing aids and was remarkably
successful in social engagement. Most people if faced with Rocky’s level of hearing loss would be
forced to learn sign language to maintain their communication diet. His adaptive skills were an
excellent example of how modified expressive communication strategies can be powerful tools in
hearing rehabilitation, in spite of severe auditory impairment. His example has always been a powerful
role model for myself as I learned to develop a set of coping strategies for my own profound hearing
loss.
Fortunately for most of the cases of mild to moderate losses we see in hearing clinics, technology
solutions alone do such a good job of restoring receptive capacity to near “normal” levels that any
negative impact on expressive communication behaviours mostly just disappears. But we can never
make the presumption that we don’t need to objectively measure if this has actually occurred,
particularly when we are dealing with post lingual, severe or profound losses that have been part of a
client’s experience since childhood. Technology solutions for these degrees of loss, usually only
succeed in shifting the loss from profound back to moderate, so a residual level of impairment is still
present and can only be treated with other methods. Being told to “learn to live with it” is an
unsatisfactory answer and a most diss-heartening experience for the client, especially if they are given
no clue how to “live with it”.
In designing an effective hearing rehabilitation plan, careful efforts should be made to identify any
potentially destructive expressive communication behaviours the client may be using and then measure
the impact of technological solutions on those behaviours during follow-up sessions. Table 1 lists five
typical questions and a follow-up ranking scale that can be administered pre and post fitting. Targeted
questions like these can easily be incorporated into any initial assessment questionnaire and completed
by the client in the waiting room. A quick review of answers serves to flag key communication
behaviours to be measured for change during post fitting follow-up sessions. Little or no change
identifies a need for training in expressive communication skills targeting the identified negative
behaviour. Such a carefully targeted and measurable approach will be much more effective than
involving the client in broadly focused, individual or group counselling sessions on “hearing tactics”
that risk providing a lot of generic information without meeting the client’s specific need.
2
Table 1: Suggested questionnaire design for identifying potentially destructive,
expressive communication behaviors.
Tick one or more boxes that describe typical conversation breakdowns
caused by your hearing problems and how you deal with them.
Never
Rarely Occasionally
Almost
always
Always
Follow up after hearing instrument fitting
How often do these problems occur now?
Never
Rarely
Occasionally
Almost
always
Always
1 My family / friends tend to leave
me out of detailed discussions
because of my difficulty keeping
up with conversation flow
2 I tend to avoid group gatherings,
or if I must go, I tend to say as
little as possible because of the
risk of embarrassing myself and
others with inappropriate
responses due to my poor
hearing.
3 When I do get involved in a
group discussion, I find myself
trying to avoid the
embarrassment of miss-hearing
by doing most of the talking and
I seldom allow other people to
take control, or steer the
direction of the conversation.
4 When I do get involved in a
group discussion, I find myself
making mostly non-committal
or neutral responses, and I
seldom take the initiative to
steer the discussion, due to fear
of embarrassment from not
hearing clearly.
5 When a conversation in which I
am involved in appears to break
down due to my hearing
difficulties, my attempts to
repair the situation usually fail.
Question 1 targets the degree of social isolation experienced; Question 2 targets the extent of passive
communicative behaviors; Question 3 targets the extent of aggressive communicative behaviors;
Question 4 targets the extent of neutral or non-committal behaviors and Question 5 targets the degree
of success with present conversational repair strategies. Minimal change in any of these areas
following technology solutions identifies the specific type of unhelpful communication behavior to be
targeted by communication skills training.
The “Communication Diet” model.
Communication behaviours are culturally derived, or learned from the family and social environments
we grow up in. Severely impaired hearing during formative years impedes ability to adopt the
communicative norms of our community. We will understand these impacts better if we consider some
fundamental attributes of communication and how severe hearing loss affects these attributes.
Hearing is a fundamental part of communication, therefore loss of hearing results in communication
deprivation. Since communication is often called “food for the mind”, taking a closer look at what
happens to the human body when it is deprived of food, might help us to understand what happens to
the mind when it is deprived of some of the essential “nutrients” of normal, unhindered
communication.
Communication is just as necessary to mental health as food is to our physical health. If we neglect to
eat an adequate quantity of nutritious food regularly, our bodies soon become physically sick and will
eventually die unless a correct balance of these three essential elements is restored. Equally, inability
3
or neglect to “feed” the mind with an adequate quantity of “nutritious” communication at regular
intervals, will trigger various symptoms of mental health problems, such as loneliness, depression,
anxiety state, withdrawal, aggression, etc. In the extreme, anti-social attention-getting behaviours
and/or suicide can occur. A poor communication diet resulting from relationship tensions caused by
untreated hearing loss is often the un-named culprit in numerous divorce cases. Symptoms of an
impoverished communication diet within a relationship begin to emerge when just one of the three
essential elements, (frequency, quantity, or quality), are depleted for an unacceptable length of time.
Consider the following example:
Table 2.
Example of an impoverished communication diet.
Inadequate Frequency
Son or daughter only phone home
once every six months
Inadequate Quantity
When they do call, they only talk for
five minutes
Inadequate Quality
They always talk superficially, or just
about themselves, never meaningfully
or with any interest in your welfare
As anyone who has ever experienced this kind of communication behaviour knows, it usually spells
disaster for a relationship. This is true with or without the presence of a hearing loss. A person with a
severe hearing loss is far more likely to be on the receiving end of such destructive communicative
behaviour simply because of the impact of their hearing loss upon others. This becomes particularly
evident when we consider the element of “nutrition” in the communication diet. Let’s explore this by
examining what “nutrition” means in a normal food diet.
If we are suffering from a nutritional disorder, our doctor may refer us to a Dietician whose job is to
examine our diet, determine what is out of balance - quantity of food; frequency of meals; or
nutritional balance of routine food items. And then recommend remedial action to restore the mix of
these three elements back to a correct balance. In accomplishing this task, the Dietician can do a
detailed analysis of our meal plans and even each individual food item and then recommend exactly
how to change our eating habits to restore balance to our diet.
Unfortunately, this level of detailed research in the field of human communication, if it has ever been
done at all, isn’t generally well known in the field of audiology. It would be of enormous value to
hearing rehabilitation science if we could numerically define the “nutritional values” of various
combinations of words and sentences in relationship development, and use this as a means of
identifying and correcting destructive communicative behaviours, especially those that are common
among people suffering from untreated hearing loss. By way of example the following table attempts
to describe three possible levels of communicative nutrition:
4
Table 3. Three possible levels of communicative “nutrition”.
1
2
3
Superficial level
“Hi! How are you today? Well that’s
great. Good to see you. Bye!”
Information sharing level
“Jim! Last week Joe Bloggs came in to
discuss plans for the new building. When
can I discuss this with you?”
Meaningful level
“Jim! I appreciate your perceptive
insights and if you’re agreeable, I’d like
to share some private ideas with you
about how best to deal with this situation
the family is in, and get your feedback?”
It is on the third level that one obtains the most communicative “nutrition”. Only on this level is it
possible to express the deepest emotions and obtain the reinforcement and motivation necessary to
determine attitudes and feelings in relationships. Indeed, relationships cannot proceed to develop
beyond superficial or merely acquaintance level, into long-term, closely bonded partnerships unless all
parties frequently engage in a significant quantity of meaningful (“nutritious”) communication.
Conversely, failure to continuously feed a relationship in this way, will ultimately result in failure of
that relationship. Such a relationship breakdown will be preceded, (as in the case of an impoverished
food diet) by symptoms of communication starvation. And starving people will do desperate things.—
the partner who feels neglected will seek meaningful, nutritious communication in other relationships.
For a relationship to develop from the superficial, all the way to closely bonded, long term status, all
parties must continuously demonstrate appropriate listening and responding skills. Normally, a
relationship will start at the first level and will proceed smoothly to the third level, before matters of
deep personal importance and sensitivity can be openly discussed. If any party makes an unacceptable
number of inappropriate responses at any level, the communicative relationship will start to break
down. Inappropriate responses can take many forms and be verbal or non-verbal, e.g.: failure to display
interest by not paying attention; making comments un-related to the speakers’ statements, etc. Overall,
the net effect will be to send out conflicting messages where words say one thing, but body language or
facial expressions may say something entirely different. If this kind of communicative behaviour is
repeatedly exhibited in a relationship, then it will prevent development to a higher more personal level
where the greatest communication “nutrition” and bonding can be obtained. Thus a deteriorating
relationship can be “stuck” at the superficial or information exchange level.
Implications for people with severe hearing loss
People with severe hearing loss are just as subject to these principles of communication as anyone else.
However, they will be much more likely to repeatedly make inappropriate responses, simply because
they cannot hear well or have not learned to master the art of confirmatory questioning, such as made
people like Rocky Stone so successful in social engagement. Subsequently it can be much more
difficult for them to maintain a healthy communication diet with their significant peers and families.
Particularly if the communicative culture of the people around them tends to exhibit a low tolerance for
the hearing loss e.g.: failing to speak clearly; saying “Oh! It doesn’t matter!” when asked to repeat; not
looking at the hearing impaired person when speaking, etc. Unless technological or remedial
communication strategies to change the cultural environment into a more accommodating one are
somehow learned and implemented, relationships will inevitably become strained, sometimes to
breaking point with painful consequences for everyone involved.
5
As was previously pointed out, technological solutions to hearing loss can only focus on the reception
element of the communication paradigm, while they completely ignore the impact on the expression
element. In the case of severe hearing losses, technology solutions only provide partial answers to the
overarching problem of communication deprivation. It therefore remains critical to include in the
hearing rehabilitation plan, a formula for identifying unhelpful expressive communicative strategies
that may have been culturally learned, and to teach remedial strategies aimed at restoring a healthy
balance to the client’s communication diet. In some cases an entirely new communicative “modus
operandi” or “culture” will need to be learned by the client. This will require a co-operative agreement
with the treating practitioner, to identify negative communication strategies that caused social isolation
in the past, and develop new strategies that are more successful at helping the client maintain a
comfortable level of social engagement. Teaching these new skills can be as simple as suggesting and
practicing alternative approaches during individual counseling sessions or involving the client in group
sessions where participants help one another to analyze and role play effective conversational repair
strategies that are more likely to maintain social engagement.
More research and product development is needed to give practitioners effective tools to help them
complete client’s rehabilitative needs when technology solutions have reached their limits.
While foundational textbooks on aural rehabilitation are available and do cover conversational repair
strategies for the hearing-impaired, (e.g. see Tye-Murray, N. Foundations of Aural Rehabilitation:
Children, Adults and Their Family Members, 2nd Edition (2004) Delmar Learning, NY)
www.delmarlearning.com their application among practitioners does not appear to be widespread.
Simple kits, card games and booklets to help anyone improve conversational skills may be more
readily useful in designing appropriate intervention strategies.
(eg: see www.conversation-matters.com/products)
With the foregoing foundations in mind, the third and final installment of this article revisits the eight
points of cultural differences outlined in the first installment and suggests some specific professional
approaches that reflect not only an understanding of the cultural variables impacting clients with severe
/ profound hearing loss, but also a practical working knowledge of how to help these clients restore a
healthy balance to their communication diet. Which is after all, what a hearing rehabilitation program
should be all about.
Graham Weir has a severe to profound bilateral hearing loss since a near-fatal attack of meningitis
at the age of eight. His undergraduate coursework was in psychology at the University of
Queensland and he completed a Masters degree in counseling of the hearing-impaired at Gallaudet
University, Washington D.C. USA in 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 [email protected]
6