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Preface                                                                          ix
Contributors                                                                     xi

PART I: The Nature of Aural Rehabilitation                                        1

  1    The Nature of Aural Rehabilitation                                         3
         Raymond H. Hull
  2    Introduction to the Handicap of Hearing Impairment:                       23
       Auditory Impairment versus Hearing Handicap
          Jack Katz and Thomas P. White
  3    The Psychosocial, Educational, and Occupational Impact of Impaired       45
       Hearing and the Vocational Rehabilitation Counseling Process
         R. Steven Ackley and Karen Dilka
  4    Introduction to Hearing Aids and Amplification Systems                    69
          Joseph J. Smaldino

PART II: Introduction to Aural Rehabilitation: Children With Impaired Hearing    87

  5    Family Involvement and Counseling in Serving Children Who Possess         89
       Impaired Hearing
         Dale V. Atkins
  6    Considerations and Strategies for Amplification for Children Who Are     111
       Hearing Impaired
         William R. Hodgson
  7    Development of Listening and Language Skills in Children Who Are         137
       Deaf or Hard of Hearing
         Arlene Stredler-Brown
  8    Speech Development for Children Who Are Hearing Impaired                 163
         Daniel Ling
  9    Cochlear Implantation in Children                                        189
         Thomas C. Kryzer
10     Educational Management of Children with Impaired Hearing                 207
         Molly Pottorf-Lyon

     PART III: Introduction to Aural Rehabilitation: Adults Who Are Hearing Impaired   223

     11     Aural Rehabilitation for Adults: Theory and Application                    225
              Raymond H. Hull
     12     Counseling Adults Who Possess Impaired Hearing                             247
              R. Steven Ackley
     13     Hearing Aid Orientation for Adults Who Possess Impaired Hearing            269
              Raymond H. Hull
     14     Non-Hearing Aid Assistive Hearing Technology for Adults with               289
            Impaired Hearing
              Joseph J. Smaldino

     PART IV: Considerations for Older Adults with Impaired Hearing                    309

     15     Influences of Aging on Older Adults                                        311
               Judah L. Ronch and Michael Novotny
     16     Auditory and Nonauditory Barriers to Communication in Older Adults         329
              Dawn Konrad-Martin and Gabrielle Saunders
     17     The Impact of Hearing Loss on Older Adults                                 347
              Raymond H. Hull
     18     Special Considerations for the Use of and Orientation to Hearing Aids      363
            for Older Adults
               Raymond H. Hull
     19     Techniques of Aural Rehabilitation for Older Adults with Impaired          377
              Raymond H. Hull
     20     Special Considerations in Aural Rehabilitation for Older Adults in         411
            Health Care Facilities
              Raymond H. Hull

     APPENDICES: Materials and Scales for Assessment of Communication for              435
     the Hearing Impaired
       Appendix A: CID Everyday Sentences                                              437
       Appendix B: The Denver Scale Quick Test                                         441
       Appendix C: The WSU Sentence Test of Speechreading Ability                      443
       Appendix D: Hearing-Handicap Scale                                              445
       Appendix E: The Denver Scale of Communication Function                          449
       Appendix F: Test of Actual Performance                                          455
       Appendix G: The Hearing Measurement Scale                                       457
                                                                       CONTENTS      vii

  Appendix H: Profile Questionnaire for Rating Communicative Performance       461
              in a Home and Social Environment
  Appendix I: The Denver Scale of Communication Function for Senior            467
              Citizens Living in Retirement Centers
  Appendix J: Wichita State University (WSU) Communication Appraisal and       471
              Priorities Profile (CAPP)
  Appendix K: The Hearing Handicap Inventory for the Elderly                   475
  Appendix L: The Communication Profile for the Hearing Impaired               479
  Appendix M: Communication Skill Scale                                        487
  Appendix N: The Shortened Hearing Aid Performance Inventory                  503
  Appendix O: Communication Scale for Older Adults (3-Point Response Format)   505

Index                                                                          515

The book that you have just purchased is an       dents to determine on their own whether
introductory book on the nature and pro-          they understood important points within
cess of aural rehabilitation. As an introduc-     each chapter.
tory look at the processes involved in this           This book is divided into four parts:
exciting aspect of our field, it covers a broad
range of topics considered to be the most         Part I: The Nature of Aural Rehabilitation
important in preparing future professionals       presents information that is fundamental to
to serve children and adults with impaired        the provision of services on behalf of all per-
hearing. It is a natural outgrowth of what        sons who possess impaired hearing, includ-
previously became a popular text entitled         ing an introduction to aural rehabilitation;
Aural Rehabilitation, written and edited          an introduction to the nature and potential
by this author, that resulted in four success-    impact of hearing impairment and related
ful editions over a span of over 20 years.        terminology; an introduction to hearing aids
One of the reasons that those previous books      and their components; and a psychosocial,
were so popular among professors and stu-         educational, and vocational profile of per-
dents was not only the logical sequence in        sons with impaired hearing.
which the information was presented, but
also the ease with which the book could be        Part II: Introduction to Aural Rehabilitation:
read. In other words, the book that you have      Children with Impaired Hearing concen-
purchased entitled, Introduction To Aural         trates on habilitative/rehabilitative services
Rehabilitation, retains the readability and       on behalf of children who possess impaired
ease of understanding that the previous           hearing. The information centers on the im-
books by this author have maintained over         portance of family and its involvement in
the years, but also provides comprehensive        serving children who are hearing impaired;
information on the nature and process of          considerations regarding amplification for
aural habilitation and rehabilitation on behalf   children; the development of auditory skills
of children and younger and older adults          in children who are hearing impaired; lan-
who possess impaired hearing. Therefore,          guage and speech development for children
the information is presented in a readable        with impaired hearing; their educational
fashion that has immediate theoretical and        management; and the issue of cochlear
practical application.                            implantation on behalf of children.
     The first page of each chapter provides
a brief outline of the chapter for a quick        Part III: Introduction to Aural Rehabilitation:
content overview. Further, the examinations       Adults Who Are Hearing Impaired concen-
and answer sheets found at the conclusion         trates on matters that affect services on behalf
of each chapter provide a ready-made oppor-       of adults with impaired hearing. Chapters
tunity for professors to quiz their students      in this section address the impact of hear-
on a periodic basis, or to simply allow stu-      ing impairment on adults, and procedures

    for counseling; hearing aid orientation;            countries were consulted about the topics
    assistive listening devices for adults who          they felt were important in preparing audi-
    are hearing impaired; and the history, the-         ologists and speech-language pathologists
    ory, and application of aural rehabilitation        to work with children and adults who pos-
    for adults.                                         sess impaired hearing, and further, if they
                                                        would prefer a term other than aural reha-
    Part IV: Considerations for Older Adults            bilitation in this book. When a general con-
    with Impaired Hearing addresses special con-        sensus was reached, this book was designed,
    siderations for services on behalf of older         written, and prepared for you.
    adults who possess impaired hearing. The                  As an introductory look at the processes
    chapters in this section present information        involved in aural rehabilitation, it covers a
    on psychosocial and physical factors of             broad range of topics considered to be the
    aging; the special nature of hearing loss in        most important in preparing future profes-
    older adulthood; the impact of hearing loss         sionals to serve children and adults with
    on older adults; counseling the older adult         impaired hearing. Therefore, a basic but
    who is hearing impaired; considerations for         diverse range of vocabulary and sophisti-
    hearing aid use for older adults; techniques        cation is acknowledged in regard to both
    of aural rehabilitation for all adults who are      the content of the chapters and the book’s
    hearing impaired; and programs for the              intended readership as an introductory book
    hearing impaired elderly in health care facil-      in this area of study. The book has been
    ity environments.                                   designed for use by a broad range of readers,
                                                        primarily upper-level undergraduate students
    Appendices: The Appendices of this book             and early graduate students in audiology and
    contain the most comprehensive compilation          speech-language pathology, and as a refer-
    of assessments of communicative function in         ence for professionals in audiology, speech-
    adults who possess impaired hearing found           language pathology, deaf education, and other
    in any text on the topic of aural rehabilitation.   fields that serve children and adults with
                                                        impaired hearing. Other interested readers
         The topics for this book were by no            include physicians, nurses, gerontologists,
    means arbitrary. University professors and          vocational rehabilitation counselors, teach-
    practitioners of audiology, speech-language         ers, psychologists, and sociologists.
    pathologists, deaf educators, rehabilitation              Preparing this text has been an enjoy-
    counselors, psychologists, otologists and oto-      able and rewarding experience. It will prove
    laryngologists, along with upper-level under-       to be a valuable source of information for
    graduate and graduate students across the           serving children and adults who possess
    United States, Canada, Europe, and other            impaired hearing. Enjoy!

R. Steven Ackley, PhD                      Touro Institute of Neurobehavioral Studies
Professor and Chair                        Prairie Village, Kansas
Hearing, Speech and Language Sciences      Chapter 2
Gallaudet University
Washington, DC                             Thomas C. Kryzer, MD
Chapters 3 and 12                          Wichita Ear Clinic
                                           Assistant Professor of Surgery and Family
Dale V. Atkins, MA, PhD                      Medicine
Psychologist, Author, Media Commentator    University of Kansas School of Medicine
Greenwich, Connecticut                     Wichita, Kansas
Chapter 5                                  Chapter 9

William R. Hodgson, PhD                    Dawn Konrad-Martin, PhD
Professor Emeritus                         Research Investigator
Department of Speech, Language, and        VA RR&D National Center for
  Hearing Sciences                           Rehabilitative Auditory Research
University of Arizona                        (NCRAR)
Tucson, Arizona                            Portland VA Medical Center
Chapter 6                                  Assistant Professor
                                           Department of Otolaryngology, Head and
Raymond H. Hull, PhD                         Neck Surgery
Professor of Communicative Disorders and   Oregon Health and Science University
  Sciences, Audiology/Neurosciences        Portland, Oregon
Coordinator—Doctor of Audiology            Chapter 16
  ProgramDepartment of Communication
  Sciences and Disorders                   Daniel Ling, PhD (Deceased)
College of Health Professions              Professor Emeritus
Wichita State University                   Faculty of Applied Health Sciences
Wichita, Kansas                            The University of Western Ontario
Chapters 1, 11, 13, 17, 18, 19, 20         London, Ontario, Canada
                                           Chapter 8
Jack Katz, PhD
Director                                   Michael R. Novotny, BA
Auditory Processing Service                The Ericksson School
Research Professor                         University of Maryland Baltimore County
University of Kansas Medical Center        Baltimore, Maryland
Clinical Professor                         Chapter 15

      Molly Pottorf-Lyon, AuD, CCCA/SP              Joseph J. Smaldino, PhD
      Adjunct Lecturer                              Professor and Chair
      Department of Communicative Sciences          Department of Communication Sciences
        and Disorders                                   and Disorders
      Wichita State University                      Illinois State University
      Wichita, Kansas                               Normal, Illinois
      Chapter 10                                    Chapters 4 and 14

      Judah L. Ronch, PhD                           Arlene Stredler-Brown, MA, CCC-SLP
      Professor and Undergraduate Academic          Adjunct Faculty
        Program Chair                               University of Colorado
      The Erickson School                           Adjunct Faculty
      University of Maryland Baltimore County       University of British Columbia
      Baltimore, Maryland                           Boulder, Colorado
      Chapter 15                                    Chapter 7

      Gabrielle H. Saunders, PhD                    Thomas P. White, MA, MBA
      Investigator and NCRAR Deputy Director        Professor Emeritus
         of Education Outreach and                  State University of New York at Buffalo
         Dissemination                              Director Emeritus
      National Center for Rehabilitative Auditory   Hearing Evaluation Services
         Research                                   Buffalo, New York
      and                                           Chapter 2
      Assistant Professor
      Department of Otolaryngology
      Oregon Health and Science University
      Portland, Oregon
      Chapter 16
       Techniques of Aural
        Rehabilitation for
        Older Adults with
        Impaired Hearing
                          RAYMOND H. HULL

                            Chapter Outline
Introduction                         The Process of Aural Rehabilitation
Individual versus Group Treatment      The Ongoing Aural Rehabilitation
                                       Program: Reasons for Successful and
  Individual Treatment
                                       Unsuccessful Treatment Programs
  Group Treatment
                                       Use of Residual Hearing with
Components of Aural Rehabilitation     Supplemental Visual Clues
Services for Older Patients
                                       Linguistic, Content, and
  Counseling                           Environmental Redundancies
  Hearing Aid Orientation              Reducing Auditory or Visual Confusions
  Adjusting or Manipulating the        Communicating under Adverse
  Listening Environment                Conditions
  Creating Positive Assertiveness      Other Approaches to Aural
                                       Rehabilitation Treatment
  Involvement of Family and
  Significant Others                 Summary

                  Introduction                            found in a probable combination of both
                                                          peripheral and central involvement.The audi-
                                                          ologist is, indeed, serving complex people
      The process of aural rehabilitation on behalf       who possess complex auditory disorders.
      of older patients is as exciting as it is
      rewarding. To be involved in the recovery
      of communication skills that may have pre-                 Individual versus
      viously caused an adult to withdraw from
      his communicating world is, indeed, gratify-
                                                                 Group Treatment
      ing. Both the patient and the audiologist
      can rejoice in the recovery of those skills.        Individual Treatment
      Some older patients recover skills that allow
      them to participate on a social basis once          Some individuals will require individual
      again, at least with a greater degree of effi-      aural rehabilitation treatment. In instances
      ciency. Others may simply regain the ability        in which patients are experiencing commu-
      to communicate with their family with               nicative difficulties that are not conducive
      greater ease. In light of those gains and, per-     to a group therapy environment because of
      haps, a step toward a reinstatement of com-         their individual or personal nature, individ-
      municative independence, a patient and his          ual sessions are warranted.
      audiologist have reason to rejoice.                       For example, a semiretired physician
            Clinicians cannot, under any circum-          came to this author with a desire for more
      stances, hope to benefit every older hearing        efficient communication within his office
      impaired person. But, in attempting to do           and examination room. The sessions cen-
      so, if some are helped who had previously           tered on the specific difficulties he was
      submitted to a self-imposed withdrawal              experiencing in that environment, and he
      from family and friends because of the              did not desire to open them up to group
      embarrassment from responding inappro-              aural rehabilitation sessions.
      priately to misunderstood messages, then                  Another patient’s concern was that her
      professionals can be satisfied that our work        granddaughter’s wedding was forthcoming,
      is worthwhile.                                      and she felt that she was not going to be able
            Because most older adults who have            to hear and understand what people were
      hearing impairment have experienced nor-            saying while she stood in the reception line.
      mal to near-normal auditory function during         Her request was to receive some hints on
      their younger years, and because they are           how to “not embarrass herself and her fam-
      generally fully aware of the communicative          ily” by responding inappropriately to what
      difficulties they face, it is important that our    people were saying to her in the reverber-
      services address their specific communicative       ant environment of their church fellowship
      needs. In light of the fact that it is being con-   hall. Her aural rehabilitation program was
      firmed that auditory disorders found in older       based on two sessions of problem solving
      adults are quite complex (see Chapter 16            and supportive and informational counsel-
      and Chapter 17), approaches to aural reha-          ing. After successfully working through the
      bilitation must accommodate the communi-            potential pitfalls of the communicative
      cation difficulties experienced as a result of      demands of her granddaughter’s wedding,
      compounding problems; many of these are             the woman returned to enter group therapy.

The sessions held for this woman were rather
personal in regard to the difficulties she was
                                                 Group Treatment
anticipating and, in that instance and at that
time, she felt that they were not conducive      Group aural rehabilitative treatment, as dis-
to a group therapy environment. So her           cussed later in this chapter, can be extremely
desire for individual sessions was fulfilled.    motivating for many older adults who are
     Other circumstances in which individ-       experiencing impaired hearing. Once the
ual treatment sessions would be appropri-        problems and difficulties that are specific to
ate include:                                     individual patients have been resolved to the
                                                 degree possible through work on an indi-
 1. The patient’s hearing impairment and         vidual basis, patients can move into group
    concomitant communicative difficulties       treatment, if group services are warranted
    are so severe that the patient requires      (Figure 19–1).
    concentrated effort to resolve them to             Individuals in group treatment find
    the greatest degree possible before          strength in hearing of others’ successes and
    entering a group environment.                failures in their own communicative envi-
 2. The patient’s emotional response to the      ronments. They gain insights through group
    auditory impairment and the resulting        discussions and problem solving into how
    communicative difficulties are such that     to best cope in spite of their hearing impair-
    group involvement, at that particular        ment. The camaraderie that develops can
    time, is contraindicated.                    be rewarding to group members as their

          Figure 19–1. Group aural rehabilitation treatment works to allow patients
          to share frustrations and triumphs.

      confidence grows in their ability to take          intolerant family member or roommate.
      charge of the difficulties that they have been     And it is trust that must develop between
      having in their own communicative worlds.          audiologist and patient. Counseling is the
                                                         discussion that develops when a patient
                                                         desires to talk about an incident in which he
         Components of Aural                             had particular difficulty understanding what
        Rehabilitation Services                          another person was saying, and also includes
                                                         the problem solving that can unravel the
          for Older Patients                             possible reasons for the difficulty.
                                                               This aspect of the process of aural reha-
      The following are important elements in            bilitation is, again for lack of a better term,
      aural rehabilitation service programs for          called counseling. But, whatever it is called,
      older adults that are applicable for either        it involves listening, talking, problem solv-
      the well adult in the community or those           ing, facilitating adjustment to a frustrating
      who are confined to a health care facility.        disability, and the development of trust
      They include:                                      between patient and audiologist.
                                                               When an audiologist encounters an
       1. Counseling                                     older adult who has impaired hearing who
       2. Hearing aid orientation                        says, “I do not desire to be helped. I am old
       3. Adjusting the listening environment            and I do not know how much longer I will
       4. Development of positive assertiveness          live,” the attitude of the person certainly
       5. Developing compensatory skills in the          will influence how much potential progress
          use of residual hearing and supplemen-         that he will make. This is particularly true if
          tal visual cues                                the person has isolated himself from the
       6. Involvement of family and significant          outside world and is resigned to not seek
          others                                         help because of advanced age.

                                                         The Audiologist as Counselor
                                                         If there are no other significant contraindi-
      As this author teaches his students about          cating factors that would hinder respon-
      aural rehabilitation services for older adults,    siveness to aural rehabilitation services, the
      it is emphasized that counseling, for lack of      audiologist is in a position to serve in a coun-
      a better term, is one of the most important        seling role. It is possible that this patient
      aspects and is intertwined throughout the          has said what was said because he has been
      process of aural rehabilitation. It is not some-   told by others that “you are too old.” A well-
      thing that occurs alone or out of context. It      meaning physician may have said, “You
      is an integral part of everything an audiolo-      know you’re no spring chicken any more.”
      gist does when working with his patients.          Or a child may have said unthinkingly,
      It is talking. It is instilling confidence in a    “Mom, you know you can’t care for yourself
      patient who has become discouraged when            as well as you used to, so we should start
      he did not do as well as expected in a given       thinking about moving you to a care facil-
      communicative environment. It is listening         ity,” not realizing that the older adult is con-
      to the feelings a patient reveals about him-       vinced that placement in a “care facility”
      self, or that person’s relationship with an        will be terminal. Such statements, even said

in a well-meaning way, are understandably         aural rehabilitative services or the progress
unsettling to an older adult.                     they may be capable of. They are, further,
      One of this author’s patients, a woman      those to which the audiologist must respond.
of 89 years, told me that her 50-year-old         The following are a few of those statements,
daughter told her they should sell her house      out of context, recorded by this author:
and she should then move into an efficiency
apartment. She was so hurt and angry that         ■ “I feel that I’m on trial, becoming
she could not think of anything to say. She           incompetent.”
felt convinced that if her mature daughter        ■ “My son is right behind me. He comes
felt that she could not care for her house,           down to see me as often as he can, but
then she must be doing a worse job than               he has a lot of business to handle there.
she thought. I asked her what she would               I don’t see him very often anymore.”
have said if her daughter had suggested that      ■   “I can’t hear and my eyes bother me.
to her when she was 45 years old and her              Surgery won’t help my ears or my eyes.
daughter was 15. She said she would have              I’m told that I’m too old.”
asked her why she would say such a thing,         ■   “My arthritis bothers me all over,
but she said, “But when you are 89 years              especially with the weather. I used to
old, perhaps it is not worth it.”                     walk a lot. I can’t hear now. I’m too
      If the medical records of an individual         old.”
indicate satisfactory health, and there appears   ■   “I fear being alone—being melancholy
to be nothing that would contraindicate the           —with no future to look forward to.
provision of aural rehabilitative services,           I need to find some way to be useful.
then the self-defeating attitude of the poten-        But I can stand a lot. I’m still sturdy.”
tial patient may be the only thing that stands    ■   “I would like, more than anything, to be
between the provision of services and rea-            able to get out, to socialize, but I can’t
sonable progress in aural rehabilitation treat-       hear very well. I would like to go to
ment. Although the person’s realistic view            church, but the children don’t come on
of becoming older may be a healthy one,               Sundays and there is no one to take me.”
long-term mourning because of age and the
possibility of death is not. The audiologist           One statement stands out from all of
can be a positive catalyst in moving beyond       the rest. It is a statement by a physically
aging, particularly for those who are barred      strong and mentally alert 82-year-old man
from social interaction as a result of their      who possesses impaired hearing and who
auditory deficit.                                 is torn between giving up and submitting
                                                  to the opportunity to improve his ability to
Feelings to Which the Audiologist                 function communicatively through an audi-
Must Respond                                      ologist’s services. The statement is, “I’d like
                                                  to put a younger person on my shoulders to
Phrases exemplifying attitudes typical of         function intellectually on my behalf and
many older adults who have hearing impair-        hear for me, and to go on from there. I sup-
ment have been recorded by this author            pose I need to learn to rely on myself . . .
during initial aural rehabilitation interviews    relationships with people are important,
with hundreds of older patients. The feelings     but do I have the potential?”
that prompted these revealing statements               The above statements are representative
are those that can and do stifle the desire for   of those heard by audiologists who accept

      the opportunity to provide a significant
      rehabilitative service on behalf of adults
      who have impaired hearing. These people,
      in many ways, wish to be recognized not
      simply as older persons, but as adults who
      have grown older, who have something to
      offer, and who do not want to be left alone.
      Their resolution to “not be a bother” and
      their resignation to “being old” is, in some
      cases, the most logical choice in their minds
      for lack of alternatives. The audiologist can
      be a catalyst in developing a desire for self-
            The audiologist must not be afraid to
      work with these patients in a close profes-
      sional manner. He must not be hesitant to
      intervene in a counseling role, but must be
      cognizant of those instances when a patient’s     Figure 19–2. Assertiveness training brings
      emotional problems are beyond the scope           out strengths patients may not realize they
      of the audiologist’s service. For those per-      possess.
      sons, it is the responsibility of the audiolo-
      gist to refer the individual to other appro-
      priate counseling professionals. Above all,
      the patient must be confident in the audiol-      —counsel—listen—ask questions—expect
      ogist who is providing the aural rehabilita-      answers—listen—provide guidance. Then,
      tion service. The patient must be aware that      add an appropriate amount of inspiration
      the audiologist understands the commu-            for what may be the key to successful moti-
      nicative impact of presbycusis through his        vational counseling. Counseling as a part of
      experience in working with other patients.        the aural rehabilitation process is presented
      The patient must know that the audiologist        later in this chapter under The Process of
      feels that he can, indeed, be helped to com-      Aural Rehabilitation.
      municate more efficiently through aural
      rehabilitative services, and that feeling has
      justification on the basis of evaluation, not     Hearing Aid Orientation
      sympathy. A feeling of justified trust is the
      true key to motivational counseling. The          Information in Chapter 18 deals with con-
      patient pictured in Figure 19–2 trusts that       siderations for hearing aid orientation on
      the audiologist understands the frustrations      behalf of older adults. As stated in that chap-
      that he has experienced, and that what the        ter, the process of adjustment to the use of
      audiologist is saying will assist him in learn-   hearing aids and orientation to their efficient
      ing to cope in his otherwise difficult com-       use can be facilitated with greater ease for
      municative environments.                          some older patients than others; this depends
            Listen-talk-empathize-listen—encour-        on prior exposure to and knowledge of the
      age where appropriate—remember the sta-           use of hearing aids and factors of memory,
      tus and age of the patient—provide support        manual dexterity, and others. The process of

adjustment to hearing aids and orientation          situations in which they desire to function
to their use can be logically carried into          more efficiently. After this is completed, they
daily or weekly aural rehabilitation treat-         are asked to choose one or two in which
ment sessions, as can the trial use of various      they most desire to learn to communicate
assisting listening devices.                        more efficiently. They are, of course, re-
      Through carryover of hearing aid orien-       quested to be reasonable in their selections.
tation into the aural rehabilitation treatment      In this way, the aural rehabilitation treat-
program, slight adjustments to the hearing          ment program can be designed to meet their
aids can, for example, be made to alleviate         specific communication needs. In instances
communicative problems encountered dur-             in which a patient’s auditory difficulties are
ing the previous week. Questions can be             so severe that group sessions are not prac-
answered regarding their use, and discus-           tical or cannot be tolerated by the patient,
sions regarding certain difficult listening         individual treatment is scheduled.
environments can be entertained that may                  The goal, however, is to integrate the
benefit not only that individual patient, but       patient into a group situation as soon as
others in a group session. More experienced         possible, if at all possible. Another situation
hearing aid users can be an important cata-         in which it is desirable that individual treat-
lyst in a new user’s successful adjustment to       ment be instituted is in the case of a patient
amplification. Further, experimental adjust-        whose priority communication environment
ments in hearing aid gain and frequency             is so different as to warrant individual work.
response can be made in accordance with             A situation in point is a patient who was
the activities in various treatment sessions.       provided services individually by this author.
      Carryover of the hearing aid orienta-         His most difficult communication environ-
tion process into aural rehabilitation treat-       ment as a teacher in a middle school was his
ment sessions can be as important as the            classroom. His treatment sessions, therefore,
orientation process itself, and is a logical        centered on physical/environmental adjust-
extension. The consistency of patient con-          ments in that specific room. The author
tact is a valuable asset in facilitating adjust-    worked with him individually on redesign-
ment to amplification. In group treatment           ing his classroom, which was specific to his
sessions, the catharsis and camaraderie that        difficulties and strategies for communication
arise as various patients describe their own        in that environment. He had little difficulty
difficulties experienced during the initial         in other more social environments.
adjustment period is a healthy environment
for efficient adjustment to hearing aid use.        Patient Discussions of Problem
Procedures for hearing aid orientation appli-       Environments
cable for older adults are outlined in Chap-
ters 13 and 18 in this text.                        Problem solving of difficult listening envi-
                                                    ronments can be extremely productive.
                                                    Those sessions center on discussions of the
Adjusting or Manipulating the                       patients’ chosen prioritized communication
Listening Environment                               environments. Priority environments most
                                                    frequently center on church (understand-
As is noted in The Process of Aural Rehabil-        ing the minister or Sunday school teacher,
itation section of this chapter, elderly patients   or participating in church committee meet-
are initially asked to establish priorities for     ings), other social environments in which

      groups of people meet, understanding what         patient joins the group discussion by ex-
      women or children are saying, or under-           panding on the explanation of the difficult
      standing what people are saying in environ-       environment and as questions or possible
      mentally distracting environments such as         solutions are made, ways in which he may
      on the street corner, in a restaurant, or at      have been able to change the listening envi-
      the theater. The inevitable commonality of        ronment or those within it to his benefit
      their choices allows for group sessions that      become clearer. Others in the group also
      are beneficial for everyone, as the majority      benefit because they may have found them-
      of patients can enter into the discussions as     selves in a similar environment or may in
      they relate to them.                              the future.
            A problem specific to a certain envi-
      ronment, for example, is brought before the
      group by one of the therapy group mem-            Creating Positive Assertiveness
      bers. The patient who presented the com-
      munication problem is asked to describe           A trait that appears to become more typical
      it in detail by giving examples of instances      as some people grow older is to become less
      when it has occurred and the physical envi-       assertive. This is particularly true of older
      ronment of each. As the physical environ-         adults who have been placed in a health
      ment is described, the audiologist or the         care facility, or who have moved from their
      patient diagrams it on the chalkboard as          home to a retirement complex not of their
      accurately as possible. The room or other         own will, or who are trying to maintain
      physical environment is drawn on the chalk-       their independence by remaining at home.
      board or flip chart (including windows,           Some may seem “stubborn,” but those re-
      doors, partitions, furniture, and so on). The     sponses may be out of self-defense, perhaps
      remainder of the group is then asked to           because they may not have heard or under-
      give suggestions, as they see it, about how       stood what was expected of them, or they
      the patient may have adjusted to that com-        may suspect that they are being imposed
      munication environment by changing it,            upon rather than being allowed to make
      making physical adjustments, or their opin-       independent decisions about their life.
      ion of making requests of the speaker to                Then, in all too many instances, older
      resolve the patient’s difficulty understand-      persons in health care facilities are not told
      ing what was being said.                          what is going to be done to them, and they
            As those suggestions are made, the          find that things are being done to them rather
      audiologist lists suggestions and makes the       than for them. Rather than continuing to
      suggested adjustments on the diagram, for         react against the health care facility person-
      example, (a) moving the patient’s chair into      nel and, thus, being listed as “uncooperative,”
      a better situation for listening, (b) changing    such patients may become more passive.
      position away from a window, (c) moving                 Whether an older person is residing in
      closer to a public address system speaker,        a health care facility or in the community, it
      (d) asking the person being conversed with        regrettably becomes more common for dra-
      to move closer, (e) walking out into a hall-      matic and sometimes unpleasant things to
      way where it is quieter, (f) asking the speaker   occur in that person’s life. In light of the
      to move closer to the microphone, and so on.      unexpected occurrences that may occur, it
            Participation in this type of treatment     becomes easier to remain passive and wait
      activity can be extremely motivating. As the      rather than to become assertive and say

“No,” as one may feel forced to do some-             The patient said that she hardly under-
thing anyway. “Dad is getting stubborn in       stood a word the speaker said throughout
his old age,” may be the label placed on the    the next hour, but she was too embarrassed
older person. Many older persons feel pow-      to leave the auditorium. When I asked her
erless because of a lack of independence. It    why she did not say, “Please use the micro-
is difficult to respond to a rapidly changing   phone; we are having difficulties hearing
world when one does not possess the             you,” when the speaker moved away from it,
finances, transportation, physical mobility,    her reply was that she just could not bring
quickness of analytical thought, or strength    herself to do it. She wanted to, but was too
to manipulate one’s environment.                embarrassed. “Besides,” she said, “maybe
                                                I was the only person there who couldn’t
Examples of Passive Behavior                    hear her.” When I asked her if she was
                                                important enough to warrant that speaker’s
One of this author’s patients, a 78-year-old    consideration, this patient’s response was
man, was asked to chair a committee in his      simply, “I hope so.” I said, “Don’t you think
church because of his knowledge of reli-        that the microphone was placed there for a
gion. He was flattered to be asked to accept    purpose? A public address system generally
that position, but then shortly resigned        helps everyone to hear more comfortably.
because he could not understand what his        If you would have said something, I am sure
committee members were saying. When             that others in the audience would have been
I asked him why he did not ask the mem-         pleased that the presenter had returned to
bers to speak up, he said that he did once.     the podium and used the microphone.” Her
He further stated that it worked for a short    reply was that she had not thought of that.
time, but then they returned to their previ-    “But still,” she said, “I didn’t want to make
ous manner of speaking. When I asked him        a nuisance of myself. I’m just an old woman
why he did not change the room arrange-         who can’t hear very well.” One of the audi-
ments so he could place himself in a more       ologist’s challenges is to change that atti-
advantageous position for communication,        tude of self-depreciation.
he said that the room had been in that same
arrangement for years, and he did not want      Learning to Help Themselves
to disrupt it. Those attitudes can defeat an
otherwise potentially productive person.        The attitude just described is one that must
     Another example that illustrates the       be altered, if possible, if persons who pos-
feelings of older adults who have hearing       sess impaired hearing are to learn to cope
impairment is one that involved a 72-year-      and function more efficiently in their com-
old female patient who had just returned        municative worlds. In light of the fact that
from a lecture on Southeast Asia that she had   some people are simply not willing to ac-
been looking forward to attending for some      commodate older adults who have hearing
time. She explained that the lecturer, a        impairment or, perhaps, are not aware of
woman who had a rather soft voice, began        what accommodations can be made to facil-
talking to the audience, and then walked        itate communication, older persons must
away from the public address system micro-      be taught ways to become assertive enough
phone and sat down in front of the podium       to manipulate their communication envi-
with the statement, “I’m sure that you can      ronments and those with whom they desire
all hear me without the microphone.”            to communicate.

      Altering Passive Behaviors                        these treatment sessions are, “If those with
                                                        whom we desire to or must communicate
      As stated earlier, one way to alter passivity     do not seem to be accommodating, then
      is by asking individual patients to describe      we must assert ourselves by showing them
      difficult communication situations in which       how they can best communicate with us!”
      they have found themselves during the past        Suggestions or adjustments must be made
      week or month. The situation in which the         without hesitation. To do otherwise is to
      72-year-old woman found herself, as described     “place ourselves back where we started.”
      above, is a prime example of the problems         These are powerful treatment sessions that
      that are brought to the treatment sessions.       instill confidence in patients who may not
      Suggestions by group members are brought          have had confidence for some time.
      forth after individual questions by the
      group members and the audiologist have
      been satisfied. When other group members          Involvement of Family and
      courageously state what they would have           Significant Others
      done in that situation (e.g., told the woman
      speaker, “I would appreciate it if you would      The patient’s family and significant others
      use the microphone.”) in front of the audi-       in the patient’s life are critical elements for
      ence, they are asked if they really would         a successful aural rehabilitation treatment
      have done it. If they hold fast to their com-     program.This is particularly true if a patient’s
      mitment, they are challenged to do it at the      significant other is willing to become in-
      next lecture they attend when the speaker         volved in the aural rehabilitation process.
      hesitates to use the microphone. Occasion-        This includes attending individual or group
      ally, a group member returns after such           treatment sessions and participating in
      an experience and triumphantly proclaims,         follow-up assignments.
      “I did it!” On occasion, another member of              A significant other’s involvement in
      the aural rehabilitation treatment group who      the aural rehabilitation treatment process
      may have been in attendance at that meet-         provides that person with a better under-
      ing will confirm that the individual did a        standing of the difficulties and frustrations
      very nice job in changing a poor listening        with which the friend, spouse, or family
      situation to a more pleasant one. Also, others    member undergoing treatment is faced, par-
      at the meeting may have thanked our patient       ticularly if he can attend the first sessions
      for asking the speaker to use the micro-          when discussions of hearing loss and difficult
      phone by saying, “We just did not have the        communication situations are emphasized.
      courage to speak up like that!” The triumph       It further aids the patient’s significant other
      is great and does much toward encouraging         to understand the commonality of commu-
      the other group members to also become            nication difficulties when other patients
      more assertive.                                   discuss similar problems. The involvement
            Other difficult situations brought before   prompts a realization that the communica-
      the groups may include family dinners,            tion difficulties that have arisen because of
      going to a noisy restaurant, talking to timid     the auditory deficit are not limited only to
      grandchildren, talking to one’s attorney with     his spouse, family member, or friend, but
      other members of the family in attendance,        are found in others as well. That enhanced
      following more than one request in a              understanding hopefully can be passed on
      sequence, and many others. The bywords in         to others who are close to the patient.

      This author frequently requests that         can be stressful even with normal hearing.
those who attend the treatment sessions            Even if grown children live in the same com-
with individual patients be fit with earplugs      munity, their desire for involvement with
to at least experience to some degree what         their parent on a social basis may be lacking,
depressed hearing “sounds like.” Some of           let alone a desire to become an important
the communicative frustrations revealed by         part of their mother’s or father’s rehabilita-
the patients are often felt by the significant     tion program. The excuse is generally, “We
others at least during that brief period of        just don’t have time.” In this remarkably
time. It is explained to them, however, that       advanced society, it is sad that we lose sight
earplugs do not replicate the speech recog-        of the needs of our family. But it seems to
nition problems being encountered by the           be the case, and alternative means for car-
person with whom they are attending the            ryover support for older patients must, in
sessions, but simply demonstrate a moder-          many cases, be sought.
ate loss of hearing acuity. Still, their use may         As stated earlier, a patient’s spouse can
enhance a feeling of empathy for the frus-         be the most effective significant other, if the
trations the hearing impaired person must          spouse is emotionally supportive of his or
feel. One important byproduct of encourag-         her husband or wife. If the spouse is not
ing the involvement of a significant other in      willing or capable of aiding in the support
the aural rehabilitation treatment program         or carryover process, then a friend is appro-
is that carryover of the treatment process         priate and can be a most effective partner
into the everyday life of a patient can be         in the aural rehabilitation process. In fact, at
greatly enhanced. If, for example, an older        times it is common for people to discuss
patient asserts himself before the remainder       feelings with supportive friends prior to
of the family by suggesting certain adjust-        bringing them before a spouse or other
ments regarding seating arrangements for           family members. In any event, a close friend
Thanksgiving dinner so that he can become          can be a very significant other.
involved in the conversation with greater                A case to illustrate this point is that of
efficiency, the significant other can reinforce    a 70-year-old male patient who was pro-
and strengthen that positive step.                 vided aural rehabilitation services by this
      It is, further, not as much fun to go to     author. He had been a widower for 4 years.
a restaurant or the movie by oneself. The          On the first day of his group aural rehabili-
significant other will not only strengthen and     tation program, he brought a female com-
encourage carryover, but also make some            panion. Both loved to fish and were almost
potentially apprehensive situations more           inseparable. They both enjoyed attending
enjoyable. It helps to have someone there          social gatherings together, but the patient
to back you up when the going gets rough!          was experiencing great difficulty hearing
      One of the most discouraging aspects         and, in particular, understanding what was
of the provision of any rehabilitative service     being said in those environments. His
to elderly patients is the lack of family          female companion was willing to explain
involvement. In many instances, if a spouse        what was being said, but was becoming
has passed away, the remainder of the family       frustrated at the consistency with which
may live quite a distance from the patient.        she had to function in the capacity of inter-
Children may visit only once a year if the         preter. In this instance, she attended all treat-
distance is great, and that may be for only a      ment sessions with the patient, she wearing
few days around a principal holiday, which         her earplugs and he his hearing aids. A great

      deal of warmth and understanding devel-             5. Learning to become positively assertive;
      oped between them. And his ability to func-         6. Throughout everything listed, learning
      tion communicatively increased, as did her             to use one’s residual hearing and sup-
      willingness to aid in the treatment process            plemental visual cues to enhance com-
      through carryover. The assignments, which              prehension of verbal messages.
      included experimentation at social gather-
      ings, were carried out in an excellent man-             To put all of this together into a mean-
      ner. Problem situations that were to be dis-       ingful aural rehabilitation treatment program
      cussed during treatment sessions lessened          for an older adult is not really difficult. As a
      and, likewise, his dependence on his female        matter of fact, the process becomes quite
      companion for communicative support                logical once a number of older patients
      became less frequent.                              have critiqued your approach in relation to
            The support and carryover by this signif-    its meaningfulness and benefit to them.
      icant other was instrumental in the patient’s           The following is an example of an ap-
      achievements in learning to use his residual       proach to aural rehabilitation treatment for
      hearing with greater efficiency, to use sup-       elderly adult patients, employing and inter-
      plemental visual clues, and to change his most     mingling the six listed areas. This process
      difficult listening environments in construc-      has been found effective for use with both
      tive ways. Without such support and assis-         confined and community-based older adults.
      tance, an audiologist will have great difficulty
      facilitating such improvements. In the end,
      he may never be able to assist the patient in
      making such significant and positive strides       The Ongoing Aural
      as will the significant other.                     Rehabilitation Program:
                                                         Reasons for Successful and
                                                         Unsuccessful Treatment
          The Process of Aural                           Programs
                                                         Some structure in the treatment process is
                                                         desired by the majority of older patients. But,
      The aural rehabilitation program for an            on the other hand, overly structured sessions
      older adult patient can include:                   can be counterproductive. For example, it
                                                         is sadly not uncommon for audiologists who
       1. Knowledge of the patient’s desires and         utilize traditional speechreading (lipreading)
          needs for communication through set-           approaches that emphasize a progression
          ting priorities that are those of the          from phoneme analysis to syllables, words,
          patient, not the audiologist;                  phrases, sentences, and stories (which, for
       2. Ongoing motivational counseling as an          example, stress several like phonemes) to
          integral part of the process;                  begin to realize in a fairly short time that
       3. Carryover of hearing aid orientation,          the patients who seemed motivated initially
          at least for those who seem to benefit         are attending speechreading sessions with
          from amplification;                            less regularity. Soon they may cease attend-
       4. Learning how to manipulate one’s envi-         ing altogether. Excuses generally range from
          ronment and the speakers in those envi-        “My family is coming to visit and I will be
          ronments to enhance communication;             spending time with them,” to “We have sev-

eral church suppers coming up, and I have         based on a treatment plan designed around
to help with them.” It is embarrassing to see     the assessed needs of each patient. Why,
such persons downtown later with appar-           then, are some audiologists still opening
ently nothing to do. They may further call        their lipreading lesson book and beginning
to tell your secretary that they really do not    at page 1 to provide services to patients who
feel the need to come to “class” anymore,         have varied and individual communication
even though the audiologist knows that they       deficits and needs? Those speechreading
have made little or no progress in treatment.     books too often are used as “hymnals,” and
     Those patients are telling us something      the session begins with the audiologist say-
that we should receive loudly and clearly.        ing, “And for the next session we will turn
That is, if they felt that aural rehabilitation   to page 15.” That is not treatment.
services were benefitting them, they proba-
bly would still be attending, as they evidently   Individualizing the Approach
were motivated when they began.
     If the aural rehabilitation treatment        How does one develop a meaningful ap-
program had been geared to the specific           proach to aural rehabilitation treatment for
needs of those patients, they would proba-        the older patient? More than 30 years ago
bly be taking advantage of the audiologist’s      Hardick (1977) described the basic charac-
services. But, for those reasons, and because     teristics of a successful aural rehabilitation
the audiologist may have begun the first          program for older adults. They are well
session from a predetermined approach to          defined and provide comprehensive guid-
speechreading, the patients were not inter-       ance for those who intend to provide serv-
ested in receiving those services any more.       ices for older patients and in many ways are
A few faithful patients might continue to         still current. Those characteristics are:
attend, but they probably will leave the final
session as able or unable to communicate           1. The program must be patient centered.
with others they were in the beginning.            2. The program must revolve around ampli-
The audiologist may wonder why these oth-             fication and/or modifying a patient’s
erwise apparently alert older adults have             communication environment.
not improved, even though they may say,            3. All programs consist of individual ther-
“I enjoyed your class,” and pat the audiolo-          apy, with some group sessions when
gist on the shoulder. Further, why does this          necessary.
audiologist have to coerce patients in health      4. The session must contain normally hear-
care facilities to attend aural rehabilitation        ing friends or relatives of the person
treatment sessions or have to depend on a             who has hearing impairment.
gracious activity director to bring them from      5. Aural rehabilitation programs are short-
their rooms to attend sessions that should            term.
be helping them cope in the everyday world         6. The program is consumer oriented.
more efficiently? Again, it may be because         7. Aural rehabilitation programs and their
the audiologist has lost sight of the fact that       potential benefits need to be promoted
the treatment must be designed with the               to colleagues and other professionals.
needs of the patients in mind. Other treat-        8. “Successful graduates” should be used
ment procedures used by speech-language               as resource people in therapy activities
pathologists, occupational therapists, phys-          whenever possible (Hardick, 1977, pp.
ical therapists, physicians, and others are           60–62).

            These characteristics are extremely        otherwise distracting environments. The
      important for consideration prior to the ini-    level of terminology is determined by the
      tiation of aural rehabilitation programs for     individual or group in question. The audiol-
      older adults. They go far beyond the more        ogist is cautioned never to speak down to
      traditional lipreading procedures that con-      patients. It is important to use the correct
      tinue to be employed by some. Even though        technical terminology, but immediately ex-
      Hardick (1977) and others recommended            plain it at the level of the persons involved.
      group treatment for older patients, some         Clinicians must always remember that the
      will require individual services. However, as    audience is adult, no matter what their edu-
      has been noted by this author, there is a ten-   cational level or age. They deserve to be
      dency among some to hesitate or refuse to        treated as such.
      participate in individual treatment unless             Charts need to be used in such discus-
      they themselves have requested it.               sions, perhaps along with a 35-mm slide
            Other early patient-centered approaches    or PowerPoint presentation on the ear. If
      to aural rehabilitation are discussed by Al-     individuals in the group are severely hard
      piner (1963), Alpiner and McCarthy (1987),       of hearing, projected slides should be used
      Colton (1977), Colton and O’Neill (1976),        only if enough light can remain in the room
      Giolas (1994), Hull (1982, 1992, 1997, 2001,     to facilitate the use of visual clues. Charts,
      2007), McCarthy and Alpiner (1978), M.           diagrams, slides, and chalkboard drawings
      Miller and Ort (1965), O’Neill and Oyer          are used for these discussions, including
      (1981), Sanders (1982, 1993), and others.        presentations on (a) the aging ear, (b) uses,
      The aspect stressed by these authors is that     benefits, and limitations of hearing aids,
      older adult patients possess needs that are      (c) environmental factors that affect com-
      specific to them and each patient’s aural        munication, (d) poor speakers versus good
      rehabilitation program must be centered          speakers and their makeup, and (e) a gen-
      on his needs and priorities.                     eral discussion of the aging process.
            If the ingredients presented on the pre-         The basis for the first session (or ses-
      vious pages are combined properly, a possible    sions) is to facilitate a basis of understand-
      sequence of services emerges. An example         ing for the remainder of the treatment pro-
      of such a sequence is provided below.            gram, to develop a better understanding
                                                       among the patients of what has occurred to
      Awareness of Reasons for                         them, and to assure them that in all proba-
      Auditory Dysfunction                             bility they can improve, at least to some
                                                       degree. Most persons leave such session or
      Understanding Hearing Loss. Facilitat-           sessions with a better understanding and
      ing an awareness of the reason for auditory      greater acceptance of what is occurring to
      communication difficulties through an un-        them and a desire to participate in the aural
      derstanding of the process of aging and its      rehabilitation treatment program.
      effect on the auditory mechanism is an                 It cannot be emphasized enough that
      important part of the aural rehabilitation       a significant other in each patient’s life
      process. Included is a discussion of the cen-    should be encouraged to attend these ses-
      tral processing of auditory-linguistic infor-    sions (Figure 19–3). Whether it is a spouse
      mation and the effect of aging on the speed      or a family member such as a child or a
      and precision of that important component        friend, he will gain much greater insight
      in communication, particularly in noisy or       into the auditory or communication prob-

          Figure 19–3. A spouse, family member, or significant other can reinforce
          the aural rehabilitation process.

lems with which the person is attempting          asked, of course, to be realistic in their final
to cope.                                          choices. For some, the choice is a simple
                                                  one. For others, it is more difficult. It is
Prioritized Communicative Needs. The              important to note, however, that if gains are
second step in the aural rehabilitation treat-    made in one category, there is the probabil-
ment programs is, as stated earlier, to ask       ity that patients will observe improvement
each patient to list those difficulties in com-   in others.
munication that most affect him.The Wichita             They are asked to discuss their choices,
State University Communication Appraisal          present a situation in which they had diffi-
and Priorities Profile (CAPP), as presented       culty, and explain what prompted them to
in Figure 19–4, can be used in this process.      make those choices. Particularly in a group
They may include specific communication           situation, it is interesting to note the general
environments, such as a meeting room,             consistency of priority areas that emerge.
church, certain restaurant, table arrangement     The patients generally appreciate the cama-
at their child’s home, and so on. They also       raderie that develops out of this discussion.
may list certain individuals who they have        For the first time, many of them realize that
difficulty understanding.                         they are not the only ones who have diffi-
      The next step is for patients to set pri-   culty in certain environments.
orities for these situations or persons, from           In many instances, patients put part of
most important to least important and, if         the blame for their auditory/communica-
they had their choice, in which of those          tive difficulties on others who display poor
would they most like to improve. They are         speech habits. That is acknowledged and

               Figure 19–4. The WSU Communication Appraisal and Priorities Pro-
               file (CAPP).

      discussed. The discussion centers on the fact   the habits that interfere with efficient com-
      that there are, indeed, many poor speakers      munication is appropriate. Patients generally
      in this world. A demonstration of some of       immediately recognize poor speaking habits.

Even though there are many poor speakers,         and the accompanying significant other, if
persons with impaired hearing must develop        he was involved). Suggestions regarding pos-
ways to cope in those communication envi-         sible ways the patient might have manipu-
ronments. The encouraging acknowledg-             lated the communication environment to
ment that they can, in many instances,            his best advantage, including the physical
manipulate such difficult situations to func-     environment or the speaker, are made by the
tion more efficiently in them, and that they      group under the guidance of the audiolo-
will be working on those situations, ends         gist and are accepted as viable or discarded.
the discussion on a positive note.                       As stated by this author previously (Hull,
      These items generally do not consume        2007), insights into ways of manipulating
more than 1 or 2 full-hour sessions. The          the communication environment to the best
discussions of priority difficulties and cir-     advantage, along with methods of coping
cumstances that interfere with efficient          with and adjusting to frustrating situations,
communication should not be curtailed,            are in turn developed among patients under
however, because the airing of frustrations       the guidance of the audiologist. This form
and concerns will greatly facilitate future       of self- and group analysis is an extremely
progress. For many, this may be the first         important part of the aural rehabilitation
time those concerns have been discussed.          program. Patients, then, are helped to develop
To prematurely conclude such a discussion         their own insights into methods of adjust-
simply on the basis of a rigid schedule can       ing to situations where communication is
stifle the airing of emotions and adjustment      difficult. If, for some reason, they find that
that may otherwise not be made.                   it is impossible for them to make the neces-
                                                  sary adjustments, perhaps they can, in a
On Becoming Assertive. Weekly assign-             positive, supportive, and assertive manner,
ments for each patient are made and include       ease their difficulty by requesting that oth-
noting a communication situation in which         ers make certain adjustments. Perhaps they
they had particular difficulty that, in the       could request that the physical environ-
end, interfered with communication. As dis-       ment be adjusted so that they can function
cussed earlier, they write about situations       more efficiently in it or they can make
and diagram the physical environment if           adjustments on their own.
necessary (or simply recall it as accurately             It becomes difficult for some older
as possible). In any event, patients are to       patients to develop even mildly assertive
bring the specifics of the situation to the       behaviors. They do not want to be noticed
next treatment session for presentation and       as a demanding older person. Many do feel
discussion. Each patient (or in the case of       rather vulnerable, perhaps feeling that the
individual treatment, the patient) presents       people who invited them to a party did so
his difficult situation, if one has been noted.   more out of obligation than desire. They
It is imperative that the patient who was         may feel that if they request those seeking
involved in the situation be the one who          conversation change positions by moving
presents it and not the significant other         to a quieter place to talk, or request that
who may accompany the patient.                    someone change the position of his chair to
      After a thorough presentation, with dia-    be in a better position to talk then, perhaps,
grams if desired, the situation is discussed      the hosts will feel that it is more trouble
by the group (or in the event of individual       than it is worth to invite them again. In light
treatment, by the patient, the audiologist,       of such fears, it becomes quite logical to

      avoid that possibility by simply remaining         that if she wants to talk to you, to take her
      quiet and being fearful that if asked a ques-      gum out of her mouth!” to a timid, “If you
      tion, he might be embarrassed by answering         value your friendship, maybe it is best to say
      inappropriately. Those fears are occasion-         nothing and simply tolerate the situation.”
      ally brought forth by patients and should be       The latter suggestion was discarded. The ulti-
      discussed as they arise.                           mate conclusion was to simply tell the truth.
            Examples of those discussions include              It was the consensus of the group that
      one that was initiated by one of this author’s     they would respect their own friend more
      patients who was being seen on a group             if he would say something like, “You know,
      basis.The woman in question was discussing         we’ve been friends for a long time. You real-
      a situation involving another woman with           ize, as I do, that I have some difficulty hear-
      whom she had morning coffee on almost              ing what people say to me. I have particular
      a daily basis for a number of years. The           difficulty with men who wear mustaches or
      patient’s complaint was that her friend was        beards, people who do not move their lips
      an incessant gum chewer, and as she chewed         enough, or people who talk with their hand
      as she talked, it interfered with precise artic-   near their mouth, as I depend upon seeing
      ulation and two-way conversation. Her friend       the face of persons with whom I am talk-
      interpreted the patient’s inability to under-      ing. You know, I have difficulty understand-
      stand what she was saying to be the result of      ing what you say sometimes and I think that
      the hearing impairment, not her imprecise          I may have discovered why. I know that you
      manner of speaking from her enthusiastic           like to chew gum a great deal and, like me,
      gum chewing, compounded by the patient’s           it helps my mouth not to become so dry.
      hearing loss. This apparent interpretation of      I do think, however, that because you—
      the situation infuriated my patient. But she       probably not realizing it—chew your gum
      continued the morning coffee time, because         while we are talking, it doesn’t allow me to
      there were few other women her age in that         see your lips move properly and, besides,
      geographic area and, besides, they had been        you aren’t able to talk as plainly when you
      friends since childhood.                           chew it so hard. I just bet that if you don’t
            This woman’s major concern was how           chew gum while we are having our coffee,
      to tell her friend that her manner of speak-       I will be able to understand you better and
      ing and gum chewing had, for several years,        we’ll have a nicer time talking. Do you want
      interfered with her ability to understand          to give it a try?” Positive assertiveness are
      what she was saying and, in the end, made          the two key words in this instance. For that
      what might have been a pleasant conversa-          patient, the strategy she and the remainder
      tion a difficult one. She was particularly         of the group determined as most effective
      afraid to say anything because of the embar-       did prove to be successful. She maintained
      rassment her friend might feel because the         the friendship.
      situation had been going on for so long and
      nothing had previously been said. “Almost          Other Topics to Facilitate Communica-
      like,” as the patient said, “being associated      tion. Other topics for discussion and for the
      with a person for a long time and never            development of communicative strategies
      knowing her name. As time passes, you              may include (a) weekly socials at private
      become increasingly embarrassed about ask-         homes where the furniture arrangements in-
      ing her name, particularly when she knows          terfere with efficient communication. Some,
      yours.” The suggestions that came from the         as experienced through this author’s work
      group varied from an enthusiastic, “Tell her       with older patients, involve (b) the table

arrangement at one patient’s son’s home           aural rehabilitation program, sessions should
where they usually had Thanksgiving din-          also emphasize those aspects of commu-
ner, (c) the television set at a male patient’s   nication. Again, it is suggested that strict
friend’s home, (d) the seating arrangement        approaches to speechreading and auditory
and acoustics at a church meeting room,           training not be emphasized. Rather, the fact
and others. Even though the discussions and       that the majority of older patients possess
thought-provoking suggestions generally           normal to near-normal language function
aid the individual whose situation is being       should be capitalized on to encourage the
discussed, they also provide insights for the     use of innovative and useful approaches
remainder of the group on how they, too,          toward increased efficiency in the use of
may be able to manipulate similar commu-          a very natural complement to communica-
nicative environments.                            tion, that is, the complement of vision to
      These assertiveness sessions can be ex-     audition.
tremely stimulating for the patients involved          The premise on which these sessions are
and for their significant others in attendance.   based is that speech (including the phone-
Patients have told this author that those ses-    mic patterns of words in the English lan-
sions are probably the most valuable for          guage, the use of gestures, inflectional clues,
them, particularly because we are working         and the English language itself) is generally
and sharing about their problems in com-          quite predictable, although, understandably,
munication. As patients identify with other       there are differences among individual’s
patients’ difficult communication situations      speech patterns, use of gestures, words, and
and relate to solutions as they see them,         so on. A further premise is that the average
insights into solutions for their own difficult   listener has been taking advantage of the
situations emerge and are strengthened.           redundancies inherent in American English
      Self-confidence reawakens when pa-          speech and language patterns to aid in verbal
tients return to state that the solution con-     comprehension for the majority of his life.
trived during the last session did not work       When hearing declines with age, along with
as planned, but with a few adjustments devel-     the precision and speed of the processing
oped by him, it did. Most older patients,         of phonemic verbal and linguistic elements of
no matter the level of hearing impairment         speech, it becomes more difficult to com-
or how distraught they may be as a result of      prehend what others are saying. This is par-
their inability to communicate, can benefit       ticularly true in environmentally distracting
from these assertiveness sessions. The top-       or otherwise difficult listening situations.
ics of self-worth and “I’m important too”              The purpose of these sessions, there-
that become a part of the discussions are an      fore, is to remind patients of what they have
extremely important part of the total aural       been doing for years at an almost subliminal
rehabilitation program.                           level—that is, using important parts of audi-
                                                  tory/verbal messages, when heard, and sup-
                                                  plementing what was not heard with visual
Use of Residual Hearing with                      clues. By visual clues, this author means the
Supplemental Visual Clues                         face of the speaker, including lip, tongue,
                                                  and mandibular movements, gestures, facial
Even though the use of visual clues and           expression, shoulder movements, and so
every possible bit of residual hearing indi-      on used to “fill in the gaps” between what
vidual patients can muster is discussed and       was heard, what was not heard, and what
practiced throughout all aspects of the           was observed visually.

           A further purpose of these sessions is        surprised, in fact, to find that their “edu-
      to discuss the redundancies of the phone-          cated” guesses are often extremely close,
      mic and linguistic aspects of spoken Amer-         if not correct. Guesses in this instance may,
      ican English and to encourage patients to          for example, range from “The man was walk-
      take advantage of them when they are com-          ing down the street,” to “The stoplight fell
      municating with others. This aspect of the         into the street.” They are, however, encour-
      aural rehabilitation treatment program is          aged to be rational in their decisions. The
      called, for lack of a better descriptive title,    question may appropriately be asked, “How
      “A Linguistic Approach to the Teaching of          many times have you heard someone say,
      Speechreading” described by this author            ‘The stoplight fell into the street?’ Probably
      over 30 years ago (Hull, 1976). It essentially     not frequently. The word ‘street’ as the last
      depends on patients possessing normal              word in a sentence tells you what? It tells
      language function. Further, a great deal           you, generally, that something is happening.
      of time is spent using the chalkboard. If,         If the word came as the second word in a
      however, a patient has visual impairment,          sentence, maybe after the word ‘the,’ I may
      these sessions help to enhance auditory            have been describing the street, such as,
      closure. The term closure is the byword            ‘The street was very bumpy.’ But, because it
      during these sessions, as the reader soon          is located at the end of the sentence, we
      will realize.                                      know that something is probably happen-
                                                         ing either on or to the street.
      Linguistic Closure                                       “Now, let’s set the stage for an example
                                                         of this activity. Let us say that your neigh-
      As the reader will observe in this section,        bor’s child, Billy, has run away. You and other
      patients are asked to determine the correct        people from around the neighborhood are
      information within sentences from the least        searching for him. Suddenly, someone runs
      number of words provided. Patients are             to you and says something about, “_____
      asked to imagine that the word or words            _____ _____ _____ _____ _____ street!” You
      written on the chalkboard are those that           observed that the speaker had obviously
      were heard. Blanks are placed between              been running, and was pointing up the street
      words, representing those not heard or not         as he was talking. Now, what do you imag-
      heard well. Patients are, first of all, asked to   ine the speaker was telling you?” Because
      tell the audiologist what the sentence is          the audiologist has now set the stage for the
      about (out of context), when perhaps only          patients, their guesses will probably be
      one word is provided out of a total of seven,      quite close to what he had intended.
      with six blanks indicating those words that              The audiologist’s next step is to say,
      were not heard.                                    “Now I am going to allow you to fill in the
            Patients are encouraged to venture           gaps by observing my face and gestures as
      guesses as to what the sentence might be.          I take the place of the excited neighbor who
      Let us say, for example, that the word pre-        is talking to you. I will be using the chalk-
      sented is street, located as the last word         board (or flip chart) as you fill in the gaps.”
      in the sentence. The patients are asked to         The audiologist then presents the sentence
      let their minds wander: “Take a guess.” As         in a slightly audible manner and with full
      patients accept that encouragement and             visible face and gestures. If patients are not
      begin to guess, the fear of being wrong            able to “make closure,” then another word
      appears to decrease. Many are genuinely            is added to the blanks on the chalkboard,

and the patients are allowed to try again. An
example of the sequence of presentation, if
                                                  Linguistic, Content, and
additional words are required, is presented       Environmental Redundancies
                                                  Formal usage of American English is redun-
 1. _____ _____ _____ _____ _____ _____           dant in the position of various parts of
    street!                                       speech. In other words, the positions of prin-
 2. I _____ _____ _____ _____ _____ street!       cipal words, such as nouns, pronouns, and
 3. I _____ _____ _____ _____ our street!         direct objects, are generally constant, as are
 4. I saw _____ _____ _____ our street!           function words, descriptors such as adjec-
 5. I saw _____ _____ down our street!            tives and adverbs, and action words such as
 6. I saw _____ running down our street!          verbs. Some dialects within the United States
 7. I saw Billy running down our street!          do, however, deviate from those standard
                                                  rules. During these sessions, although the
      As patients become aware of what the        technical names of the parts of speech are
message contains, the audiologist continues       not stressed, the importance of those words
by discussing (a) the importance of the           that fall within various positions in verbal
position of each word within the sentence         messages are discussed as they relate to
that was required before they were able to        deriving the meaning of those messages.
determine its content, (b) their linguistic             This aspect of treatment capitalizes on
value in terms of the probability of situations   the fact that most older patients who have
in the meaning of the sentence, (c) the           hearing impairment will possess at least
importance of the environmental clues that        near-normal language function. It stresses
were available to them, and (d) the supple-       that as people listen to others, they zero in
mental use of visual clues.                       on words within conversations that permit
      An important element involved in any        them to at least derive the thought of what
of these sessions is the audiologist’s enthu-     is being said, so that the conversation can
siasm for the fact that, perhaps, the patients    be followed. In some distracting environ-
needed only to “hear” one or two words out        ments, less of the message may actually be
of the sentence to make closure and grasp         heard, but most persons can still maintain
the meaning of the sentence. It is encour-        the content or intent of what is being said.
aging for older patients to understand that,      It is normal in those circumstances to ask a
with their knowledge of the English lan-          speaker to repeat a word, if one was missed,
guage and their successful use of visual and      because it appeared to be an important one
auditory clues, they were able to determine       regarding the content of the statement.
what a message was.                                     The point that is stressed to the patients
      On more difficult sentences and more        is that the reason a listener was able to
complex contrived situations, patients may        determine that the word was an important
require more heard words to be provided           one in following the conversation is that
via the chalkboard. Nevertheless, they are        most listeners have an almost innate knowl-
being reminded that with a relatively small       edge of the structure of the American English
amount of visual, auditory, and environmen-       language that has progressively expanded
tal information, they are generally able to       since early childhood. This provides the lis-
determine at least the thought of what is         tener with a distinct advantage even in light
being said.                                       of a loss of hearing.

           The treatment sessions that stress this           An awareness of the predictability, or
      important aspect of efficient listening revolve   redundancy, of people and what they will
      around bringing that functional language          say within known environments is some-
      capability to a more conscious level. Occa-       times surprising to older adults who have
      sionally, patients have become so despon-         hearing impairment. If it is surprising, it is
      dent over an inability to communicate with        generally because they had not really thought
      others that such otherwise natural compen-        about it prior to that time. If nurtured, how-
      satory skills have become repressed.              ever, this awareness can facilitate increased
                                                        efficiency in communication.
      Content and Environmental
                                                        Reducing Auditory or
      These discussions stress that, as we observe      Visual Confusions
      human behavior, it is discovered that not only
      do the same people generally say similar          Other activities that, by necessity, are impor-
      things on similar occasions, but they also        tant for adults may include sharing infor-
      say them in similar places. In other words,       mation on why certain confusions of words
      in a given environment, depending on who          occur in conversations. This particularly con-
      the person is with whom one will be speak-        cerns older adults, because word confusions
      ing, what the listener knows about him, and       may occur with some frequency. These dis-
      if the listener is aware of those influences,     cussions not only mention the fact that the
      the general content of some conversations         nature of the majority of auditory disorders
      can be predicted with reasonable accuracy.        that older adults face enhances the proba-
            Patients are asked to describe the envi-    bility of auditory confusions, but also that
      ronments they frequent. In all probability        the nature of certain sound and visual ele-
      they will be those that were set as priorities    ments within many words enhances the
      earlier. They are also asked to describe those    probability of confusions because they either
      persons who are generally there, including        sound like or look like other words. When
      their speaking habits, their facial character-    words are confused with others, the meaning
      istics, and their known interests. During         of a sentence or conversation may appear
      these treatment sessions, the patients also       to be different than what was intended.
      are asked to write down the most frequent         Words used as examples of homophenous
      topics of conversations that are observed         (visually similar) and potentially confusing
      among those whom they have described.             words include, for example:
      These not only include frequent topics, but
      also words and phrases that those people           1.   found-vowed
      may use habitually. They are asked to keep         2.   purred-bird
      those lists and add to them as they remem-         3.   head-hen
      ber additional items or as they find out more      4.   vine-fried
      about the person after speaking with him.          5.   geese-keys
      Patients also are asked to begin new lists as      6.   neck-deck
      they meet new people. The more one knows
      and remembers about a person, the more                An example of an activity that can
      communication is enhanced.                        bring about an awareness of how these

confusions can occur is based on typed lists      been to complete the thought of the conver-
of sentences or sentences written on the          sation, then they again are asked to attempt
chalkboard. It is generally best to use those     to determine what the confusion was.
sentences that contain visually or auditorily          An example of the type of brief con-
confusing words within mock conversations         versation and stimulus sentence used in
to exemplify most accurately the patients’        this exercise is:
real-world difficulties. In this instance, the
first sentence on the patients’ list may be        1. Stimulus sentence: “She bought a new
presented by the audiologist within a short           coat.”
“conversation.” The conversation is presented      2. Stimulus conversation: “Alice came over
with voice, but as close to the patients’             yesterday to see me, and had some news
auditory thresholds as possible. Full-face            to share. She said that she now has a new
observations and gestures are used.                   friend who is soft, black and white, and
      When the sentence within the conver-            weighs about 1 pound. Well, she bought
sation is presented, the patients are asked           a new coat. She named him Mike.”
to determine if the sentence the audiologist
said was the same as or different from the             In this stimulus conversation, the pos-
one on their list. If they determine that there   sible visual confusion occurs with the word
was, indeed, a word that was different than       coat, which was given to the patients within
observed in the sentence on their list, then      the stimulus sentence they were expecting
they are asked to explain why they felt that      from their list of sentences. Again, if patients
there were differences. On the other hand,        in this instance determine that the word in
if they felt that the sentence presented by       the sentence they were expecting did not
the audiologist was the same as the one on        make sense within the context of the con-
their sheet or on the chalkboard, they also       versation, they are asked to explain why that
are asked to explain why.                         word seemed to be misplaced, and what the
      If in the context of the short conver-      word should have been. Further, the visual
sation the patients determine what word           and auditory similarities and differences be-
or words in that sentence “threw them off         tween the word they were expecting and
course,” they are asked not only to analyze       the one they saw and heard are discussed.
those confusing words, but attempt to deter-           These exercises should progress toward
mine why they were confusing.They also are        truly homophenous (visually similar) and
asked, in light of what they derived from the     homophonous (acoustically similar) words
remainder of the conversation, to determine       within sentences. The “mental gymnastics”
the words (or the thought) that the sentence      required during these sessions allows for
should have contained so that it makes sense.     practice in making on-the-spot decisions
When that analysis is completed, the patients     regarding misunderstood messages by deter-
again are asked to listen to and observe the      mining why a sentence within a conversa-
conversation and the possibly confusing           tion was visually or auditorily confusing, or
sentence to determine if it then appears to       otherwise did not make sense. The process
be what they thought it should have been          generally involves:
within the context of the intended message.
If the word or words within the sentence still     1. Analyzing the information derived from
do not appear to be what they should have             the previous portions of a conversation;

       2. Determining that a confusing word has         Because situations include social events,
          been received that may change the con-        meetings, the theater, church, and other de-
          tent of what is being said;                   sirable environments, the decision to avoid
       3. Sifting mentally through other words          them can be self-defeating. The torment of
          that look or sound like one that would        those with hearing impairment may con-
          make more sense in light of the previ-        tinue, as they still want to function commu-
          ous portions of the conversations;            nicatively in those environments and are
       4. Simultaneously projecting what that           torn between making another attempt at
          word should have been from the ongo-          coping and giving up altogether.
          ing conversation.                                   In an attempt to ease such communica-
                                                        tion problems, treatment sessions need not
                                                        only be designed to aid patients in the
      Communicating under Adverse                       development of skills for communicating in
      Conditions                                        those distracting environments, but also to
                                                        develop coping strategies. The terms desen-
      One of the most frequent communication            sitization, reciprocal inhibition, and others
      problems that older adult patients view           may be appropriate to use here, but coping
      as their most difficult is communication in       behaviors stands as the most meaningful
      noisy environments, including social events       for this discussion.
      and meetings. Many patients’ primary com-               Within this framework, patients again
      plaint, after finding themselves in an adverse    choose as priorities those environments in
      listening environment, is that the noise and      which they have most difficulty or those
      the resulting difficulties they experience in     within which they most desire to function
      attempting to sort out the primary message        with greater efficiently. Those situations are
      from the chatter of other voices makes            recreated within the treatment room as
      them tense and nervous. They describe the         accurately as possible, based on individual
      nervousness as perhaps the greatest detri-        patients’ description of their chosen difficult
      ment to their ability to manage a conversa-       environments. It is stressed that in the treat-
      tion successfully in those environments.          ment environment, no one can fail but can
      They tell this author that as they begin to       feel free to discuss his concerns or frustra-
      experience difficulty within a noisy com-         tions as they arise. Use of the language-based
      municative environment, they begin to feel        speechreading instruction previously dis-
      nervous. The nervousness, as they describe        cussed is further emphasized during these
      it, results in a further deterioration of their   sessions.The areas stressed in the discussions
      ability to cope in that environment and,          during these noise exercises are outlined in
      thus, their ability to sort the primary mes-      Table 19–1, but not in order of importance.
      sage from the noise.                                    These sessions are used as the culmi-
            For many, the only alternative that ap-     nating treatment experience. Patients are
      pears to be available is to excuse themselves     asked to take everything that they have
      from the situation by ceasing the con-            gained from the previous sessions and put
      versation. By submitting to that less-than-       it to use here. Some may never learn to
      satisfactory option, however, they generally      cope in environmentally distracting situa-
      feel some embarrassment. Unless they are          tions. Others develop such self-confidence
      quite resilient, many will simply avoid those     that they feel more comfortable in the most
      situations in which they consistently fail.       adverse environments.

TABLE 19–1. Topics for Discussion Stressed during Treatment Sessions
• Relaxation under stressful conditions.
• Confidence that clients can piece together the thought of the verbal message, even
  though not all of it was heard.
• Remembering that, because of their normal language function and their knowledge of
  the predictability of American English, they can determine what is being said if
  supplemental visual cues are used along with as much auditory information as is
  possible under the environmental circumstance.
• Knowledge that other people in the same environment may also be having difficulty
  understanding what others are saying and that they also may or may not be coping
  successfully with the stress.
• Freedom to manipulate the communication environment as much as possible by, for
  example, asking the person with whom they are speaking to move with them to a
  slightly quieter corner where they can talk with greater ease or move his chair to a
  more advantageous position so the speaker can be seen and heard more clearly, or
  other positive steps to enhance communication.
• Remembering that if difficulty in a communication environment seems to be increasing,
  and feelings of concern or nervousness begin to become evident, they should feel free
  to interrupt the conversation and talk about the noise or the activity around them that
  seems to be causing the difficulties. The other person will probably agree with that
  observation and, in talking about it, feelings of stress may be reduced and
  communication may be enhanced.
• Remembering that the amount of recorded noise used in treatment sessions is
  probably greater than will be found in other environmentally stressful situations. If
  success was noted in their treatment sessions, then similar success may be carried
  over into other stressful listening environments.

     One aspect of coping is stressed. That     the environment the patient(s) described is
is that few persons, whether they possess       introduced into the room. It is best to use a
normally functioning auditory mechanisms        tape or CD with multiple speakers system
or have hearing impairment, can tolerate        to recreate the noise environment most
every noise environment. They must learn        accurately. The noise is introduced gradu-
to recognize their limits in attempting to      ally at the beginning of these sessions and
develop coping behaviors.                       increased as tolerance and coping behavior
                                                likewise increase, until the noise is presented
Introducing Noise into the                      at such a level as to become difficult to tol-
Treatment Environment                           erate. If patients wear hearing aids, they
                                                also are asked to experiment with them as
As each patient’s difficult communication       they participate in the mock noisy commu-
environment is recreated by the audiologist     nication environments.
and other members of the treatment group,             The patients are told that the situation
taped noise that is the same as or similar to   during treatment is going to be made more

      difficult in regard to noise levels and/or        of frustration and even anger are expressed
      visual distractions than they will probably       freely among patients, the reality that those
      experience in the real world. Patients inev-      feelings are not uncommon among others
      itably desire such an approach, as they would     occasionally brings relief to those who per-
      rather practice in such difficult situations in   haps thought that they were among only
      the friendly environment of the treatment         a few who had such difficult time. These
      room than among less tolerant people.             persons are thus learning to cope with their
                                                        feelings and realize that they are normal
      Discussions of Adverse                            reactions to adverse and frustrating com-
      Listening Environments                            munication environments.
                                                             Discussing those feelings freely, with-
      Discussions of noise itself and its natural       out fear of negative responses from others,
      effect on speech perception are introduced        is an important part of the aural rehabilita-
      before the actual recreations begin. An aware-    tion process. As frustrations and anger are
      ness of different types of noise, the general     expressed regarding their difficulties toler-
      acoustical characteristics, emotional impact,     ating and communicating in a noisy world
      and other factors give patients a better under-   —and occasionally at the whole process of
      standing of the situation as they see it. When    growing older—the way opens for the aural
      one begins to gain an understanding of            rehabilitation program to move forward
      feared elements, the fear generally subsides.     toward the development of coping behaviors
            Almost without fail, some persons begin     and techniques for manipulating their own
      to become nervous and frustrated during the       communication environments as positive,
      noise sessions. The susceptibility of certain     assertive attributes. As one of this author’s
      patients to intolerance for noise can be ob-      patients so aptly stated, “In a noisy world
      served by an alert audiologist, even when         of generally poor speakers, we usually have
      low levels of noise are introduced.               to fend for ourselves. But we are looking to
            If the group (or individuals) begins to     you to teach us how, and to give inspiration
      become obviously frustrated, the audiologist,     to use what we learn.”
      rather than ceasing the activity immedi-
      ately, terminates it momentarily at a logical
      point and begins to discuss general feelings      Other Approaches to Aural
      about the noise rather than attempting to         Rehabilitation Treatment
      pinpoint individual personal feelings about
      it. The audiologist might appropriately say,      Other components of effective aural reha-
      “Noise makes me feel nervous. How about           bilitation sessions as utilized by this author
      you? Sometimes during these sessions I want       (Hull, 2001) involve the following elements.
      to turn it off. When I’m in a situation where
      I can’t turn it off, it even makes me upset       The Use of Time-Compressed
      sometimes. Is that a little like the feelings     Speech
      you have when you find yourself in a situa-
      tion like that?” Generally, the response will     In light of the probability of a slowing of the
      be affirmative and patients will agree that       speed of central nervous system processing
      those feelings are real for them, also.           of auditory-linguistic information with ad-
            The time-out periods are used to talk       vancing age (Humes, 2008; Madden, 1985;
      about feelings about noise. When feelings         Marshall, 1981; Schmitt & McCroskey, 1981;

Stach, 1990;Welsh,Welsh, & Healy, 1985; and        particularly as it relates to speed, accuracy,
others), the use of time compression of            and visual vigilance (Hull, 1989).
speech has been found by this author to be
a method through which patients can learn          Environmental Design
to compensate to some degree for that
decline. Some older patients can increase          Hull (1989, 2001) has described avenues for
their ability to comprehend speech with            educating older patients who have hearing
speed and precision that is greater than           impairment regarding techniques and strate-
they had before the training.                      gies of environmental design. This involves
     Patients practice by listening to progres-    modifying the acoustical or environmental
sively time-compressed sentences and para-         design of their homes, offices, and other
graphs, attempting over an 8- to 10-week           communicative environments to their listen-
sequence of sessions to increase the speed         ing and communicative advantage. Training
with which they are able to synthesize             also involves how to make modifications in
and make auditory-linguistic closure. Some         those and other situations in which they
patients have increased their accuracy of          find themselves, including social environ-
speech comprehension for sentences and             ments, meetings, and business environments
paragraphs up to 40% at time-compression           that otherwise may have placed them at a
levels of 35% (65% of the message received         communicative disadvantage. These can be
over time). These same older patients have         very powerful aural rehabilitation sessions
been found to correspondingly increase their       that provide patients with tangible methods
accuracy of auditory-only speech recogni-          for modifying their most difficult communi-
tion by as much as 24% (Hull, 1988).               cation situations.
     This is a very exciting and tangible
method for enhancing the speed and accuracy
of speech comprehension among individual                         Summary
patients who can tolerate the demands of
the process. Usable aided or unaided hear-         It is important for older patients to be given
ing is a prerequisite, however, because this       the opportunity to make decisions regard-
is an auditory-only task.                          ing areas of communication in which they
                                                   desire to improve. Even though many may
Interactive Laser Video Training in                feel discouraged because of the embarrass-
Speed and Accuracy of Visual                       ing difficulties they experience in their
Synthesis and Closure                              attempts at understanding what others are
                                                   saying, they have communicative priorities
Interactive laser video technology recently        that must be addressed through their aural
has evolved for use in training Olympic ath-       rehabilitation programs.
letes, Air Force fighter pilots, and air traffic          As adults who probably possessed nor-
controllers to increase their speed and accu-      mal hearing during the majority of their life
racy in making visual closure, visual track-       and whose case histories may reveal noth-
ing, and visual synthesis. This technology         ing more than that they have become older,
also has been found by this author to be an        they deserve to participate in the decisions
effective and motivational way of training         regarding their treatment program. How-
adults who have hearing impairment to              ever, guidance must be provided by the
increase their visual compensatory skills,         audiologist.

          End of Chapter Examination Questions

Chapter 19

1. The author describes two circumstances in which individual treatment ses-
   sions would be appropriate for adult patients. What are they?

2. Some older adults begin to exhibit passive behaviors in communication
   situations in which one would expect them to “take charge” of the environ-
   ment or person causing the problem. Why may passivity begin to take the
   place of positive assertiveness among older persons who are hearing

3. Describe the role of a significant other in the aural rehabilitation process.

4. List and describe the six components of aural rehabilitation services for
   adult patients as described in this chapter.

5. Briefly explain the process that seeks to help a patient be less passive and
   more assertive in making positive change in difficult listening environments.

6. The author describes reasons why some approaches to aural rehabilitation
   work and why others do not. Briefly describe those reasons.

7. To improve a patient’s communicative environment, the audiologist might
     a. that the patient move closer to the speaker.
     b. that the patient move away from a window that may be casting shadows on the
        speaker’s face.
     c. that the patient move to a quieter place, where communication can take place.
     d. all of the above.

       8. Individualizing an aural rehabilitation treatment program for a patient
            a. focusing on the family’s concerns.
            b. group therapy.
            c. a long-term aural rehabilitation program.
            d. focusing first on the patient’s communication concerns and priorities.

       9. “Counseling” involves:
            a. listening.
            b. building the patient’s confidence in himself.
            c. all members of the family.
            d. giving the patient current information about hearing loss and hearing aids.
            e. all of the above.

      10. What is the complement of vision to audition?

               End of Chapter Answer Sheet

Name                                               Date

Chapter 19

1. a.




4. a.








       7. Which one(s)?   a   b   c   d

       8. Which one(s)?   a   b   c   d

       9. Which one(s)?   a   b   c   d      e


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