Kris English, PhD
Professor Emeritus of Audiology
The University of Akron, Ohio US
In a previous posting, active listening was described as “listening + engagement.” The “listening” part is our forte: we heed not only the spoken words but also tone of voice, body language, eye contact, energy levels… all of which can tell us when patients are struggling with stress, self-doubt, discouragement, guilt, depression, or other challenges to their overall well-being — much like many adults.
The mental and emotional impact of hearing loss has been well documented, e.g., high levels of chronic stress and anxiety;1-4 an association between moderate to severe hearing loss/tinnitus and an increased risk of depression, including suicide ideation;5-7 social isolation contributing to depression, irritability, and feelings of inferiority;8-9 parenting stress10-12 and more. We usually perceive these concerns … although, with no clear indication of self-harm, maybe it’s just a bad day? Perhaps we mention something in our clinical notes (“seems somewhat depressed”) …but do we engage?
Many Times, The Answer is NO
In the U.S., counseling coursework and competencies have been a component of audiology training for more than 25 years, and the associated person-centered care (PCC) principles have been fully developed – and yet, evidence continues to alert us to an urgent reality: patients often expect us to not just listen but to engage/help them when they present with hearing loss-related mental health challenges.13,14 We are fully aware of our professional “helping” limitations, as well as the need to refer when those limits are reached, but the next step — advancing a referral — can be daunting.15-17
Readers can probably predict the perceived barriers: a lack of confidence or comfort level with screening or even broaching the topic of referral; no clear pathway to referral; no knowledge of qualified persons to whom we could refer.18,19 Many reasons, but ultimately only one solution: to find a way to address this concern that will work in our unique contexts and environments.20, 21
An Undeniable Challenge: Finding a Psychologist/Counselor Who Understands Hearing Loss. Here is One We Already Know:
Michael Harvey, PhD22 is a clinical psychologist with more than 40 years of experience supporting persons with hearing loss and mental health issues. To bolster our confidence and comfort levels, he recommends the following:
- Validate the patient’s feelings. For example, “Many people also say that they feel anxious about their hearing loss. This makes sense.”
- Normalize (de-stigmatize) the referral. Be careful when using loaded words such as therapist, mental health, etc. Instead, we can say “There are audiological ways of helping with hearing loss and there are also psychological techniques. The first is something I do; the second is another professional I know.”
- Humanize the mental health professional. The more patients know about who they are being asked to see, the less anxiety and fear of the unknown they will experience. For example, “I’ve known Dr. Smith for over 20 years. She’s nice, been practicing psychology for over 30 years. She has a dry sense of humor. I think you’ll like her.”
- Emphasize the value of a team approach. You can refer to the mind-body connection or terms such as “holistic or multi-disciplinary approach” which are recognized and accepted in today’s culture. The team can be framed as a partnership between audiology and psychology.
These steps are reassuringly familiar: they are within our boundaries, respectful of the patient’s autonomy, and communicate understanding, care, and acceptance. We know how to do this! More of Dr. Harvey’s approach, experiences, and writings can be found here.
There is a caveat, however: we cannot refer to a “Dr. Smith” until we have established a working relationship with said person. Obviously, the infrastructure must first be in place. How to go about it?
Upskilling to a Necessary Standard of Care
Referring a patient to a mental health professional is the kind of skill we acquire after graduation, when we turn to experienced colleagues, mentors, and professional leaders about addressing real-life and context-based audiology issues. The growth process could involve:
- Asking local and state organizations to develop task forces to design and test viable referral protocols customized to the region;
- Developing support systems of colleagues who want to learn from and share with each other, and are committed to the PCC principle of overall patient well-being;
- Identifying local mental health professionals with a deep understanding of the impact of hearing loss and hearing care, and/or the willingness to learn and develop this specialized expertise;
- Sharing successes and “lessons learned” with the larger audiology community.
Given the serious nature of this aspect of audiology, it seems safe to say that time is of the essence. Clinics and practitioners who have already worked out a process – we need to hear from you!
References
- Canlon, B., et al. (2013). Associations between stress and hearing problems in humans. Hearing Research, 295, 9-15.
- Gomaa, M. A. et al. (2014). Depression, Anxiety and Stress Scale in patients with tinnitus and hearing loss.European Archives of Oto-rhino-laryngology, 271, 2177-2184.
- McClannahan, K. K. S., et al. (2025). Social anxiety, negative affect, and hearing difficulties in adults.Trends in Hearing, 29, 23312165251317925.
- Bigelow, R. T., Reed, N. S., Brewster, K. K., Huang, A., Rebok, G., Rutherford, B. R., & Lin, F. R. (2020). Association of hearing loss with psychological distress and utilization of mental health services among adults in the United States. JAMA network open, 3(7), e2010986-e2010986.
- Park, J., Lee, O., & McKee, M. (2021). Association between hearing loss and suicidal ideation among middle-aged and older adults.Aging & Mental Health,26(6), 1287–1294. https://doi.org/10.1080/13607863.2021.1919991
- Tan, Y., Fang, L., Zhu, Y., & Hashimoto, K. (2024). Relationship between hearing loss and depression: A cross-sectional analysis from the National Health and Nutrition Examination Survey 2015–2018.Journal of Psychiatric Research,178, 1-7.
- Lawrence, B.J., Jayakody, D., Bennett, R.J., et al. (2020). Hearing loss and depression in older adults: A systematic review and meta-analysis, The Gerontologist, Volume 60, Issue 3, April 2020, Pages e137–e154, https://doi.org/10.1093/geront/gnz009
- McClannahan, K. K. S., McConkey, S., Levitan, J. M., Rodebaugh, T. L., & Peelle, J. E. (2025). Social Anxiety, Negative Affect, and Hearing Difficulties in Adults. Trends in hearing, 29, 23312165251317925.
- Monzani D, Galeazzi GM, Genovese E, Marrara A, Martini A. (2008). Psychological profile and social behaviour of working adults with mild or moderate hearing loss. Acta Otorhinolaryngol Ital. 2008 Apr;28(2), 61-66. PMID: 18669069; PMCID: PMC2644978
- Continisio, G. I., D’Errico, D., Toscano, S., et al. (2023). Parenting stress in mothers of children with permanent hearing impairment.Children,10(3), 517.
- Dall, M., Weber, C., Holzinger, D., et al. (2024). Preschool children with hearing loss: Social communication and parenting stress. Journal of Personalized Medicine, 14(1), 47. https://doi.org/10.3390/jpm14010047.
- Marie A, Clabaut L, Corbeil M, et al. (2023) Parenting stress and needs for social support in mothers and fathers of deaf or hard of hearing children. Frontiers in Psychology, Aug 30;14:1229420. doi: 10.3389/fpsyg.2023.1229420. PMID: 37720653; PMCID: PMC10499620
- Bennett, R. J., Gerace, D., Meyer, et al. (2024). Supporting older adults’ mental health: A Delphi survey identifying audiology best practices. International Journal of Audiology, 1-10.
- Bennett, R. J., Donaldson, S., Kelsall-Foreman, I. et al.. (2021). Addressing emotional and psychological problems associated with hearing loss: Perspective of consumer and community representatives. American Journal of Audiology, 30(4), 1130-1138.
- Bennett, R. J., Meyer, C., Ryan, B., Barr, C., Laird, E., & Eikelboom, R. (2020). Knowledge, beliefs, and practices of Australian audiologists in addressing the mental health needs of adults with hearing loss. American Journal of Audiology, 29(2), 129–142. https://doi.org/10.1044/2019_AJA-19-00087
- Bennett, R. J., Meyer, C. J., Ryan, B. J., & Eikelboom, R. H. (2020). How do audiologists respond to emotional and psychological concerns raised in the audiology setting? Three case vignettes. Ear and Hearing, 41(6), 1675-1683.
- Laird, E. C., Bryant, C. A., Barr, C. M., & Bennett, R. J. (2022). Psychologically informed practice in audiological rehabilitation: audiologist perceived barriers, facilitators, and preparedness. Ear and Hearing, 43(6), 1853-1865.
- Woodward, E., & Saunders, G. H. (2023). Do UK audiologists feel able to address the hearing, social and emotional needs of their adult patients with hearing loss? International Journal of Audiology, 63(11), 867–874.
- Nickbakht, M., Meyer, C. J., Saulsman, L., Pachana, et al. (2022). Barriers and facilitators to asking adults with hearing loss about their emotional and psychological well-being: a COM-B analysis. International Journal of Audiology, 62(6), 562–570. https://doi.org/10.1080/14992027.2022.205609
- Timmer, B. H., Bennett, R. J., Montano, J., et al. (2024). Social-emotional well-being and adult hearing loss: clinical recommendations. International Journal of Audiology, 63(6), 381-392.
- Warren, S. E., & Barron, A. L. (2024). Audiologists’ attitudes and practice toward referring for psychosocial intervention with cochlear implant patients. Frontiers in Rehabilitation Sciences, 4, 1306485.
- Harvey, M. (2024). 20Q: Audiologist-psychologist collaboration. Accessed March 29, 2025: https://www.audiologyonline.com/articles/20q-audiologist-psychologist-collaboration-29133