Gradual Hearing Loss and Sensemaking

Kris English, Ph.D.Kris English, PhD

The University of Akron/NOAC

Recently, a friend described how her grown son currently chooses to be homeless. She doesn’t know how to find him, and doesn’t know how he manages. Needless to say, she is worried sick. Looking back, she now recognizes the early signs of mental health problems during his teen years, but at the time, she didn’t recognize them as such. After all, it’s not unusual for teens to be rebellious, non-communicative, disorganized, or moody. As any parent would, she applied what she knew in general about adolescence to make sense of her son’s decisions and actions; only when her explanations no longer made sense (this is not how teens typically act) did she feel ready to consider broader, more complicated explanations and seek help. The diagnosis of mental health problems was a first step toward making sense of a profoundly unfamiliar situation.

Most adults approach life’s uncertainties in the same way: we experience something we don’t fully understand and start by working through “what we know.” Our car makes a funny noise so we look under the hood. We notice a new ache or pain, and make changes in our diet or environment (maybe more exercise?). Our computer freezes so we turn it off, count to ten, and turn it back on. In doing so, we are applying the sensemaking process, which helps us understand a change or shift in our world. If that process fails us, we consider taking the next step of asking someone for help.

Although much of audiologic counseling focuses on emotional and psychological reactions to hearing loss, our patients of course are also decision-making individuals whose minds seek logic, facts, and answers that make sense. Here we will consider how the sensemaking process applies to our patients as they ask for our help.

It Might Look Like Denial

Sensemaking in health literature is often applied to the diagnosis of a life-altering disease or disability (e.g., Pakenham, 2008), as in “why is this happening to me?” and “what will become of me?” Acquired hearing loss is certainly a life-altering condition, and both patients and audiologists attempt to make sense of it. We understand our role: in our initial encounter with a new patient, we begin with the query, “What brings you here today?” to help us understand the patient’s concerns, and then we test. However, we may not understand that the patient is also striving to make sense of this appointment. For many patients, a gradual hearing loss does not yet make sense, as reflected in these remarks:

  • My family says I can’t hear them – but that can’t be true because I definitely hear them complain!
  • People speak too fast these days.
  • It’s not my hearing, it’s the background music on TV that’s the problem.
  • How can anyone be expected to hear in such noisy restaurants? They used to be quieter.

Gill et al. (2010) describe these types of comments as “candidate explanations,” offered to convey a patient’s efforts to make sense of the situation. However, we may be inclined to interpret these comments as denial (or stubborness, embarrassment, suspicion) instead of reasonable efforts to understand a problem based on what the patient currently knows: that one’s hearing seems to be generally adequate.

What patients don’t yet know is their actual hearing status. How we go about informing them can support the sensemaking process.

Do We Inadvertently Impede the Sensemaking Process?

 Knowing that many patients are trying to make sense of our time together, we have to ask ourselves if we help or hinder that process. Consider the information that we collect but do not share with patients until our testing is done:

  • During pure tone tests, patients have no idea of the intensity required to define their thresholds. Whether it was 20 or 70dB, as far as they know, it was soft and therefore assumed to be “good” hearing.skeptical copy
  • During word recognition tests, patients receive no feedback about the words they misheard, and are often shocked to be told they missed any at all.
  • During speech-in-noise tests, patients recognize at some point that the noise is a problem, but they don’t know that their abilities may be far from normal.

Their hearing concerns now make sense to us, but so far the patient has been kept in the dark. When we do convey test results, we must understand why some patients will still be skeptical, challenging, or confused. Our summary can be quite inconsistent with what makes sense to them (that they can hear fairly well). Can we do better?

Sensemaking as a Social Process Continue reading

Audiology and End of Life

headshot for AACLaura Rickey, Class of 2017

The University of Akron/NOAC

First, I would like to share the story that inspired me to write about this topic. Dr. Kristina English shared it with me after a hearing screening. The story is as follows:

 

A family had been given the news that their grandmother’s illness had received every available treatment, and it was now time to think about keeping her comfortable in respite care.  The patient had been a hearing aid user in the past but while managing several recent emergencies, the family realized the hearing aids were lost.  Now that the grandmother’s pain was under control, she wanted to talk to every one of her beloved family members — although she could talk, she couldn’t hear their responses.  So the family found the audiologist who had fit the most recent set of hearing aids and asked for help.  New hearing aids were quickly provided and the family made full use of them, sharing memories and stories, and laughter and tears with the grandmother for as long as she was able.  The time did not last long, however, and she peacefully passed away 10 days later.  The audiologist was contacted about her passing and also the memorial service.  She told the family she would arrange for a refund, but they declined.  They reported that they “got more than their money’s worth” in those 10 days, and they would rather have the audiologist hold on the devices for other families who could use the same kind of help.  The audiologist followed their wishes, and has lent the devices to other families in the same end-of-life situation. The devices are lightly engraved with the words, “Use with Love.”

After hearing this extremely powerful story relating to the end of life and audiology, I decided to try and find out more about this topic. I came to find that there is very little information in the literature about the end of life and audiology. This came as a surprise to me, as audiologists serve a population with whom the end of life topic must be considered. This got me wondering if, as professionals concerned with communication, are we focusing most of our interests on early life, and possibly negating a very important part of life, that is death? In the book, Death and Dying, Life and Living, the ideal is shared that death is a very important part, if not one of the most important parts of individual’s life. There is absolutely no doubt that it is important to make sure that children receive auditory input as soon as possible, but are we focusing so much on this aspect of audiology, that we are forgetting about other times in life that communication is of the utmost importance? Is it possible that the first few moments, weeks or years are just as important as the last? Do audiologist have a place in end of life care? Is it ethical to recommend amplification at the end of and individual’s life? These are all questions that, in my opinion, need answers.

Do we Have a Place in End-of-Life Care?19458894_s
According to the National Hospice and Palliative Care Organization (2011), hospice provides expert medical care, pain management, and emotional and spiritual support not only for the patient, but also for the patient’s loved ones. Hospice care involves an interdisciplinary team of specialists including; the patient’s primary physician, hospice physician or medical director, nurses, home health aides, social workers, bereavement counselors, clergy or other spiritual counselors, trained volunteers, and speech, physical, and occupational therapists, if necessary. Audiologists are not currently listed as interdisciplinary team members for hospice and palliative care, but should we be? Continue reading

“Can I Just Give You a Hug?”

Kris English, Ph.D.Kris English, PhD

The University of Akron/NOAC

Anna Hollingdale, MSc, is an Audiologist in West Sussex, England. She recently touched base after an audiologic counseling course at the Ear Foundation in Nottingham with the following patient encounter:

Recently, a 73-year old female came to see me for a fine tune. The patient’s initial complaints were ones, as Audiologists, we hear often: “I cannot hear in noise” or “I am struggling to communicate with others.” It would have been so easy for me to quickly do a fine tune, or respond with the ‘limitations of hearing aids’ script but instead, I listened…

meSoon I learned she has a busy social life and takes part in many activities, but having the hearing loss had started to affect all this. This patient has been coming to our clinic for over a year and had never had the chance to really speak about how the hearing loss was affecting her.

Once she had finished talking, I responded by reflecting what I heard, without adding any solutions: “It seems you are having a really hard time with this, it must be really tough for you.” This “invitation” then enabled the patient to open up even more, and share that she had been avoiding social events and was always looking for ways to cover up her difficulties. The hearing loss was significantly affecting her life and relationships with others. Notably, she did not ask for any answers. All this patient needed was for someone to listen and empathise with her.

At the end of the appointment the patient stood up and said, “Can I just give you a hug?”

I think this says a lot more than any words could!

long road

Another Dimension to Patient Journey: Traveling Together, We Go Farther

The Ida Institute encourages audiologists to consider a “journey” metaphor to better understand the patient experience. A patient’s entry into audiologic care is not an abrupt event, but rather is preceded by several influential experiences. We are charged to sort out those experiences, usually with a question such as “What brings you here today?”

The patient will relay salient facts, an important part of the journey — but not the only part. To date, the journey has also likely been lonely, stressful, confusing. If we fail to inquire about these concerns, the patient may fairly wonder if we even care. Without an indication that the audiologist is personally invested, the prospect of moving forward with no apparent  emotional support may seem daunting and unappealing. Consider, for example, a recent study that found a low degree of adherence to hearing aid recommendations when audiologists dominated the conversation discussing technology (Grenness et al., 2015). Our challenge is to convey with our counseling skills that we are not just watching from the curb as patients travel past, left to their own devices. Rathr, we are committed to travel this journey with them.

The Ultimate Confirmation

It seems safe to say that being asked to give a hug is the ultimate confirmation of patient trust. Patients may initially resist hearing help, and therefore resist us, but if we can mindfully travel with them, help them drop their guard, consider change, and know we care, the subsequent relief can be tremendous! When a patient feels words alone will not convey that relief, and instead asks for permission to enter our personal space, trusting that  our answer will be YES, she has made an important break-though.

Most patients don’t ask for a hug, but they all ask, somehow or other, for our attention and support.

Reference

Grenness, C., Hickson, L., Laplante-Levesque, A., Meyer, C., & Davidson, B. (2015). The nature of communication throughout diagnosis and management planning in initial audiologic rehabilitation consultations.  Journal of American Academy of Audiology, 26, 36-50.

 

Patient Care 365 Days a Year

Screen Shot 2016-05-10 at 10.07.36 AMDevon Weist, AuD

Audiology Clinical Instructor, Externship Coordinator

The University of South Florida

As 2014 comes to a close, I find myself a little overwhelmed with the holiday bustle and those pesky year-end tasks we tend to put off until the last moment.  This past week, I woke up one morning with the intention of getting to my office early to finish grading exams and papers from my third year AuD students. I was anxious to get this task completed because I knew I had a full clinic schedule the following day. As I just finished grading my first couple exams, another clinical instructor popped into my office holding a very sad looking ITE aid.

The Best-Laid Plans

She explained that an older gentleman had just shown up at the front desk. He mentioned coming to our clinic in the past and appeared to not only be having difficulty hearing, but also seeing.  He thankfully was with his teenage grandson, but was clearly struggling with both senses we often take for granted.  He told my colleague he had broken off the switch and couldn’t turn the hearing aid on.

My colleague normally works with cochlear implants, so she wanted to make sure she wasn’t missing anything during her troubleshooting.  She and I checked the aid and discovered it was an old analog, trim pot hearing aid.  The brand and serial number were not legible, likely from years of use.

We also discovered this gentleman had not been into the clinic since 2000, so we no longer had his records.  We both grumbled to each other about the patient waiting until a few days before the Christmas holiday to seek help.  She then met with the older man and told him that due to the age of the hearing aid, it was unlikely it could be repaired and if it could, the cost would be significant due to the age.

He then began to tell her he would have to save up little by little to make the repair costs, and it would likely take him a great deal of time to save for a new hearing aid. As the conversation progressed my instincts and looming paperwork made me think at this point we couldn’t do anything further and could schedule him for an appointment after the holidays to discuss financing and options.

Suddenly a Solutionaha

Just as it looked like he would be returning after the holidays, our audiology assistant reminded us of a donated hearing aid we had in the cabinet.   A few weeks back, the family of a patient who had recently passed away sent us the aid and a note asking to please donate the aid to someone in need.  My grinch-like tendencies quickly remembered the reason and responsibility we have to those who seek our services.

In short, we were able to fit the patient with a much newer, higher quality working hearing aid.  We also learned during the time we spent testing his hearing that his wife had passed away several months ago, his daughter and grandson recently began living with him, and he was battling the effects of diabetes which include the deterioration of his vision.  He was able to set up a payment plan for a new earmold and office visit fees, but more importantly left the clinic hearing, smiling, and for the first time in a long while able to carry on a conversation with his grandson.

While this unexpected patient didn’t allow me to finish those grades like I had planned, he fortuitously reminded me of the value we serve to patients each and every day.  We each take an oath when we receive our white coats that states, “I will act to the benefit of those needing care, striving to see that none go untreated.” (Steiger, Saccone, & Freeman, 2002).  If we had told the patient to come back after the holidays, we wouldn’t really have honored this oath.

This Year and Every Year2015 happy new year

Our profession has long realized that the patient’s encounter is the centerpiece for patient-centered care (American Academy of Audiology, 2004). Patient-centered care is not about making a sale or fitting patients into a neat and tidy schedule.  It means making a commitment to serving your patients’ needs even when they don’t have a “scheduled” appointment.

Experiencing the emotional joy that occurs when a patient is given the ability to hear is one of the main reasons we as audiologists love our profession.  It is also equally fulfilling to see family members’ emotional joy when they are able to re-connect with a loved one who can now hear.  Seeing this gentleman and his grandson have a conversation together and the smile on both their faces more than makes up for spending an extra hour in my office grading papers.  It is important to remember that every patient has a story and a journey in regards to their hearing loss, and we as audiologists have a responsibility to provide them care that is patient-centered, no matter what day of the year it is!

References

American Academy of Audiology.  (2004).  Audiology: Scope of practice.  Available at  www.audiology.org/resources/documentlibrary/Pages/ScopeofPractice.aspx

Steiger J., Saccone P., & Freeman B. (2002).  A proposed doctoral oath for audiologists.  Audiology Today, 12(5), 12-14.

 

The “Real” Tinnitus Story: Lessons Learned About True Patient-Centered Care

IMG_3261Peter Huchinson, Class of 2016

The University of South Florida

 

When I hear the word tinnitus, my eyes widen and endorphins race to my brain. Ringing in the ears—one of the most common issues associated with any type of hearing loss— is the topic of research for my doctoral project. When I hear the words ringing, buzzing, whooshing, or pulsing my hyper focus kicks in and I say to myself “this is my thing”. I have read article after article discussing statistics about who tinnitus affects, what might be the cause of this debilitating ringing, how it is measured in humans and animals, and the general lack of understanding in this subject. So when I found myself face to face with a patient who was so deeply disturbed by her tinnitus, that she was willing to request a nerve section, I realized that I did not know that much at all. What I realized that I lacked, was personal connection, empathy, and the counseling ability that I knew was going to be crucial to this case. Additionally, I realized how much I did not know regarding tinnitus and management in a clinical population. I learned two important lessons with this patient; the first being serving the patient and not just the condition. The second being that sometimes there are things that are simply out of my control and my scope of knowledge.

tinnitusProviding patient-centered care is something that sounds appealing and makes logical sense, but often I find difficult to practice. When I see a moderate, sloping, high frequency hearing loss, I think about the hearing aid I will recommend at the end of the appointment. When a patient complains of dizziness upon getting out of bed, I consider BPPV. These initial thoughts are natural, and there is nothing wrong to start thinking about the issue at hand and the recommendation that I will make. The problem is that I often find myself stopping there. I forget to consider the needs and desires of that particular patient. I forget to consider the patient’s activity limitations, participation restrictions, and perceived or experienced stigma. I forget to consider the emotional journey that the patient has been on for much longer than the last 30 minutes that they have been in my sound booth.

I realized that I needed to practice better patient-centered care the day I first met the patient with the debilitating tinnitus. Tears poured from her eyes the entire appointment. I tried to offer knowledge, suggestions, and recommendations, but the tears would not stop. Upon reflecting on this appointment, I realized that I tried to provide informational counseling, when what she needed was emotional counseling. I tried to suggest technology and rehabilitation programs without developing a common ground with the patient.

“At the end of the day, patients are autonomous beings, and they decide whether to follow our recommendations. Those decisions depend heavily on the partnerships we develop via counseling. And this approach is an evidence-based practice. Finding common ground has been shown to be a key to a successful clinical outcome. (Brown, Weston, & Stewart, 2003)” (Clark & English, 2014)

It did not matter what I suggested at the moment. At the moment, my patient wanted support counseling. She wanted to know that we haven’t reached the end of the road. She wanted to know that the people she was looking to for help understood what she was going through, and that we weren’t going to just give up. She wanted to start a relationship of complete care and trust, instead of a regiment.

A different issue that I encountered was including and counseling this patient’s husband. Counseling loved ones is something that my (lack of) experience has not afforded me yet. The husband, while being caring and defensive for his wife, tried time and time again to get information out of me that I was not confident to or capable of answering. “What is causing this? What is the likelihood of it getting better? Why are you passing us off to the physician? Why won’t you give us answers?” This reminded me that counseling the communication partners, as well as the patient, is an equally important activity. I had not appropriately devoted time to helping the husband understand my role in the process. He heard my suggestions for technology and other options, but he had not heard me validate his or his wife’s personal journeys.

The other lesson that I learned was that sometimes there will be cases that are out of my ability to handle or out of my scope of knowledge. When the husband pressured me for medical advice I had to be careful regarding what information I could offer. It was a situation that I had never been presented with before, and it made me realize that I need to be prepared to refer a patient when their issues are beyond my ability to help. I think that much of this tension could have been avoided by developing a more trusting relationship through better patient centered care.insight

Regardless of what happened during the appointment, I am thankful for the learning opportunity that this patient and her husband offered me, as a growing clinician. I learned the importance of listening to the patient’s journey and experience, and I learned that I need to know when I am no longer capable of providing adequate care and when to refer. I hope that every student and young clinician has an experience where they feel uncomfortable, unprepared, and less than qualified. These are the experiences which transform us from mere button-pushers and technology experts into the exceptional clinicians that our patients deserve.

Reference

Clark, J. G., & English, K. M. (2014). Counseling-infused audiologic care. Upper Saddle River, NJ: Pearson Education, Inc.

 

 

“All I Did Was Listen”

Kris English, Ph.D.Kris English, PhD

The University of Akron/NOAC

Matt White is an audiologist in the UK National Health System, and works in Doncaster in South Yorkshire, England. He recently participated in a counseling course at the Ear Foundation in Nottingham, wherein he described the following patient encounter:

photo

Matt White, BSc (Hons) Aud

My patient was a man in his late 70′s who has had a rubbish time over recent years. Multiple organs are in failure, one kidney has also been removed for cancer treatment and he’s had other cancer issues too as well as issues like pancreatitis. His mobility is greatly compromised and he carries a “do not resuscitate” order with him as his physicians have told him that the efforts required to resuscitate him are likely to kill him, but in a much more horrible way than just going. He told me that his family is already grieving him in advance and he just can’t wait to be with his wife again, who passed away a few years ago.

I wasn’t sure at first what type of person he was going to be, some elderly people that I see in this condition have given up and just want to die. Others, like this gent are very positive and just want to get what they can out of the time they have left. This chap, for example, was off to get his cataracts done under local anaesthetic so he can see better. He talked about seeing the faces of his great-grandchildren more clearly. He talked about all this while explaining that he just wanted to hear as well as he could, which I was able to improve for him in the appt. Explaining all the non-hearing related parts of his life this seemed to help him.

All I did was listen.

listen-guitar-island

“All I Did” … But It’s Actually a Lot!

Audiologists almost inevitably downplay their supportive role as listeners, not from false modesty but because little has been said about the skills involved. These skills come easily to a few, but can be a genuine challenge to many others. Happily, they can be learned. As with any skill, it helps to break it down into steps. Consider the following steps that might occur as an audiologist meets a patient:

  • As we prepare our own work, we keep alert for expressions of patient troubles, sometimes only indicated nonverbally or “between the lines.”
  • When we perceive our patient is a “troubled sender” (Pollack et al., 2007), we consciously decide to “stop all the clocks” (W.H.Auden, 1937), re-prioritize, and put our agenda to the side.
  • In doing so, we put the patient’s needs before our own tasks. Needless to say, easier said than done! It takes an act of selflessness to suspend our natural self-absorption (Nichols, 1995).
  • We create an emotionally safe place and time for the patient to express those concerns and offer our support.
  • We sustain undivided attention and focus. We do not day dream and wait it out.
  • We consider whether follow up is warranted (referrals, e.g.), or whether the patient just needed to make a human connection.
  • We willingly choose to open ourselves to another’s distress and share pain for a brief time.
  • And then, when it seems appropriate, we find a way to transition the conversation back to the appointment, and manipulate the remaining time available to complete the “business” portion of the appointment and keep everyone on schedule.

Mastering each of these steps requires training, practice and feedback.

Learning to Mask is Hard. Learning to Listen? Much Harder!

Brownell (1996) once posed the question, Does listening require conscious effort? He answered his own question with a resounding YES.

Although individuals can hear when they are passive, effective listening is active and mindful” (p. 55).

Someday we will find a more meaningful way to say, “All I did was listen.”   When our listening is exactly what the patient needed, and when it was a conscious decision on our part, and when the patient leaves feeling better than when he arrived, “just listening” isn’t “just” anything but in fact becomes the epitome of patient-centered care. Listening is an advanced clinical skill, always worth developing and considered by many to be a life-long learning process. When students modestly describe a successful “listening moment” as accidental, let’s be sure to articulate the sophisticated skills they employed, and the value of these skills.

References

Brownell, J. (1996). Listening: Attitudes, principles and skills. Needham Heights, MA: Allyn & Bacon.

Nichols, M. (1995). The lost art of listening. NY: Guildford Press.

Pollak, K.I., Arnold, R.M., Jeffreys, A.S., Alexander, S.C., Olsen, M.K., Abernethy, S.P., et. al. (2007). Oncologist communication about emotion during visits with patients with advanced cancer. Journal of Clinical Oncology, 25(36), 5748-5752.

 

Counseling Thyself: “Did I Really Say That?”

Jane FLJane Seaton

Seaton Consultants, Athens GA

 

A few years into my career as an educational audiologist, I was shocked to hear a mother whose child I had seen at 10 months of age tell a parent group how devastated she was to hear the audiologist say that her daughter would never talk. Assuming (incorrectly as it turned out) I was that audiologist, I was appalled to think I would have said anything that could possibly be interpreted this way. Reflecting back on my reaction then, I now realize how often our comments can be taken out of context or misinterpreted in stressful situations such as when parents first learn of their child’s hearing loss.

What Was Said / What Was Heard

Margolis (2004) reported approximately half of new information is forgotten immediately, and half of unfamiliar information is remembered incorrectly. Add in the increasing cultural diversity and non-native English speakers being seeing in all audiologic practice settings, and we have the perfect recipe for miscommunication.

It has been well documented that most children with congenital hearing loss are born to parents with typical hearing, and the vast majority of these parents have little or no prior exposure to or experience with deafness. To say that identification of hearing loss through the universal newborn hearing screening process is often unexpected, shocking and stressful for new parents is a huge understatement. In our eagerness to help families access state-of-the-art technology and services as quickly as possible, we may unintentionally compound parent confusion and stress by providing lots of new information in a short period of time at the end of a diagnostic appointment. Too frequently little time is left for questions or feedback concerning what parents have heard from the audiologist.

Reducing Misunderstandings

Parents report they need for us to take time to listen to them and encourage them to ask questions (Luterman and Kurtzer-White, 1999). However, when the diagnosis of hearing loss is unexpected, some parents may not feel emotionally ready or knowledgeable enough to ask questions until they’ve had time to process what has been heard. It can be helpful to encourage parents and caregivers to let you know how they are feeling prior to, during and after their initial diagnostic appointment. Asking a parent what they will tell a spouse or other family member about our results and recommendations is a strategy that can help us know what has been heard and what information needs repeating or re-explaining in nontechnical terms. Use of an interpreter for non-native English speakers can be helpful, but this also adds another link in the communication process where misunderstandings can occur (Alberg, 2003).

Helping parents clarify their “next step” (e.g. scheduling another appointment, talking with pediatrician, contacting their early intervention service coordinator) facilitates parent empowerment and should be automatic each time a family is seen. Providing names, job descriptions and reasons why other professionals in the EHDI and/or education systems may be contacting parents can lessen some of the confusion felt by families when starting their journey with hearing loss. I’ve often found that parents appreciate a brief phone call 2-3 days after we’ve met to find out how they’re doing and answer any questions, even when we have a follow-up appointment scheduled later.

reflectionsAudiologists as Reflective Practitioners

I admit I was relieved to find out that I wasn’t the audiologist being referred to in the situation described above, but I often wonder how many times misunderstandings have occurred without my realizing it. Donald Schöen described the need for reflective practice more than 30 years ago, and it is probably more valuable than ever today (Scaife, 2010). Now that a wealth of information is available instantly from a variety of sources, the value of taking time to listen to ourselves as well as our clients and their caregivers is immeasurable.

References

Alberg, J. (2003). BEGINNINGS serves families with diverse needs. Volta Voices, 1, 15-17.

Luterman, D. & Kurtzer-White, E. (1999). Identifying hearing loss: Parents’ needs. American Journal of Audiology, 8, 13-18.

Margolis, R. (2004). Audiology information counseling: What do patients remember? Audiology Today, 16, 14-15.

Scaife, J. (2010). Supervising the reflective practitioner: An essential guide to theory and practice. London: Routledge.

When 1 on 1 Just Isn’t Enough …

photoChelsea Twyman, Class of 2016

Kent State University/NOAC

When audiologists and patients discuss amplification, the topic of realistic expectations must be carefully discussed. This discussion lets the patient know that adjusting to amplification will take time, patience and effort, and that struggles might occur along the way.  Some patients have minor challenges that we can readily solve with programming adjustments.  Most patients can also acquire new communication and coping strategies, especially if we remember to provide that support.  However, how can we help patients who still struggle with the following challenges after their month-long hearing aid trial?

  • Not advancing to appropriate amplification target/not obtaining enough benefit;
  • Not tolerating high frequency input/not improving speech clarity;
  • Daily HA maintenance and/or using hearing assistive technology (HAT);
  • Psychosocial distress (perceived HA benefit but burdened by cosmetics, stigma, etc.);
  • The hard work of adjustment outweighing perceived benefit.

Patients struggling with these challenges could benefit from group support, defined by Katz and Bender (1976) as “voluntary small group structures for mutual aid in the accomplishment of a specific purpose…usually formed by peers who have come together for mutual assistance in satisfying a common need, overcoming a common handicap or life disrupting problem, and bringing about desired social and/or personal change” (cited by Solomon, 2004, p. 393).

Support groups can help not only patients but also their communication partners, since they too are directly affected:

Brooks et al (2001) described frequent misunderstandings and resulting frustrations in couples in whom one member had a hearing loss. Piercy and Piercy (2002) reported that limited communication can negatively affect a couple’s intimate relationship. Most recently, Scarinci et al (2008) noted a broad range of effects that hearing loss had on the SPs [spouses] in their everyday lives. They noted difficulties in carrying out normal conversations, effects on the SPs’ emotions such as frustration or embarrassment, limitations in their social lives, and increased tensions in their marital relationships. (Preminger & Meeks, 2010, p. 316)

These studies highlight the importance of including both patients and their communication partners in a support group, specifically a group aural rehabilitation program.

10872735_sRecently, I attended a support group for patients with cochlear implants (CI) and their significant others.  The patients at this support group all had difficulty with two or more of the categories discussed above.  Usually, this support group splits into two subgroups — one for CI users and one for their communication partners, to chat separately before coming together near the end of the session.  On the day I visited, attendance was small due to the weather, so the group stayed together the entire meeting. Continue reading

Trust, Catharsis, Change

PicsArt_1397486111881Chanel Rogers, Class of 2017

Kent State University/NOAC

This past February I had the opportunity to be involved in a hearing screening at a senior health center. I never imagined a hearing screening would provide me with as great of a life lesson as it did. I had the pleasure of meeting and screening a woman (“Ms. B”) who was around 65 years old. She reported interest in our screening program because she had been experiencing difficulties in many areas of life that require hearing, such as not following what was being said in one-on-one conversations, contributing to conversations in a group setting, and understanding song lyrics while attending church.

With all of the many listening challenges that Ms. B had described, I expected her results from the hearing screen to show that she had at least a moderate hearing loss, but that was not the case. The results that I collected showed a mild hearing loss with no frequency tested being greater than 35 dB, but it affected her greatly on an everyday basis.

Earning Trust

My preceptor and I summarized our brief test, relating the results to the troubles that she had mentioned.  She seemed to feel safe with us, because she then began to recount not just other hearing problems and her family’s frustrations, but other health and safety concerns and their impact on the quality of her life.  The more she shared (“This is the first time I’ve said this out loud”), the more she seemed to understand her resistance to help (“As they say, denial is not just a river in Egypt”). I believe Ms. B started to trust us (English & Kasewurm, 2012) and her trust showed through the emotions that she shared.

Ms. B began to cry and as more information came out, a revelation occurred to her. We silently marveled as Ms. B moved herself out of the state of denial, into acceptance. By the end of the screening, she was ready to make an appointment to discuss the options available to her for amplification and other assistive technologies.

Catharsis and Change

When she felt ready to leave, Ms. B put on her coat and while tying her belt, she said with some surprise and relief, “I feel better!”  Later, we reflected on that comment, indicative of catharsis.  When given the opportunity (i.e., given time, respect, compassion), patients may feel ready to unburden themselves of worries and fears. Once these are shared with a receptive listener, the speaker does not feel alone and defensive, but instead feels understood and supported (Stone et al., 2010).  The subsequent emotional relief changes how we view change: perceived barriers are no longer insurmountable, and options can be considered.

In this experience, I learned a very important lesson that I will carry with me throughout all of my future years of practice. That lesson is that, no matter what the hearing loss looks like on paper, it can affect each individual differently. Before this day, I did not think a mild hearing loss would have such a great impact on someone’s everyday life as it did with Ms. B. She helped me see firsthand that being in the healthcare field requires us to be compassionate and empathetic to the issues that the patient faces and also that just because the patients are in to see for a particular reason, there may be something deep down that has been suppressed that may come to light with their time with us.

This day made me realize that it is true that we must treat the whole patient and not just the hearing loss, which is an essential mental note I will carry with me forever.

References

English, K., & Kasewurm, G. (2012). Audiology and patient trust. Audiology Today, 24(2), 33-38.

Stone, D., Patton, B., & Heen, S. (2010). Difficult conversations: How to discuss what matters most. NY: Viking.

Supporting the Unsteady: Counseling in Vestibular Rehabilitation

Thumbnail picSimon Howe, Clinical Scientist (Audiology)BSc (Hons), MSc

Audiology Department
Manchester Royal Infirmary

 

Rehabilitate (v): To restore to good health or useful life

As an Audiologist working for the National Health Service in the UK, it is my job to rehabilitate both patients with hearing loss and those with vestibular deficits. Whilst full recovery from vestibular deficits is likely, up to 2/3rds can become chronic, disabling conditions (Yardley & Luxon, 1994). As General Practitioners (GPs) tend only to refer those cases of dizziness persisting for months for a specialist opinion, the majority of patients seen in our Vestibular Rehabilitation Clinic at the Manchester Royal Infirmary have developed chronic dizziness, present for many months or years.

Many patients experiencing an acquired loss of vestibular function will recover fully without the need for any therapeutic intervention. So what causes some patients’ vestibular deficit to become a chronic balance problem? Firstly, the long-term prescription of vestibular sedatives by GPs is commonplace, and inhibits the natural process of recovery, and secondly, the natural behaviour for motion-provoked or situation-specific dizziness is to avoid the movements or environments which elicit the symptoms, again hampering recovery. Often these avoidance strategies can result in almost phobic thoughts related to these triggers of the dizziness.

Exercise-based vestibular rehabilitation is the primary therapeutic approach for such patients, focusing on promoting central compensation for the acquired vestibular deficit. The application and benefits of vestibular rehabilitation are well documented (Hillier & McDonnell, 2011). However the more I work with patients with chronic balance problems, the more I find myself increasingly perplexed by their unpredictable prognosis. Three things strike me as unexplained:

  1. Some patients struggle to make any meaningful progress with vestibular rehabilitation, despite apparently adhering to their exercise programme.
  2. The time taken for patients to recover seems to be completely independent of the degree of vestibular deficit.
  3. Attendance at rehabilitation appointments and adherence to exercise programmes is inconsistent, even if the patient’s difficulties would appear to act as sufficient motivation.

Reassuringly, it appears I am not alone in seeing this variability (Herdman et al, 2012), therefore there are clearly other factors at play which are influencing recovery. But there is a piece missing from the puzzle; something still unaccounted for in all the research thus far.

The Missing Piece

Chronic balance disorders can be functionally limiting conditions because of our reliance on balance to fulfil the most basic of personal, household, and occupational responsibilities. Difficulties in performing these tasks can increase dependence on family and friends, and can place strain on relationships. Where such a support network is not readily available, the resulting social isolation can have profound emotional effects. Reduced activity levels can also lead to an increased incidence of co-morbid conditions which can in turn exacerbate the psychological impact. Some chronic balance disorders can also be unpredictable in the frequency and severity of their presentation and this can further increase emotional stress.

So here is the paradox, the missing piece: this inter-relationship between dizziness and emotion is well recognised and documented (Yardley, 1994), and yet there is a very poor correlation between patient and clinician ratings of dizziness severity (Honrubia et al, 1996).

In many ways this poor correlation is not unlike the mismatch we might see in Aural Rehabilitation between the hearing difficulties the clinician might predict from a patient’s audiogram and their self-perceived disability. In fact hearing loss and loss of vestibular function are not dissimilar. Difficulties are often specific to certain activities or situations and can therefore cause a change in self-concept; the functional capabilities of the patient have changed and this can have a profound effect on their feeling of self-worth.

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