When Hearing Aids Are Not the Answer

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photo[1]Nicolle Yopa, Class of 2015

Kent State University/NOAC

Last year I was presented with an ethical dilemma in clinic. The patient was a high functioning 21-year-old male with Down Syndrome (“John”), who had a bilateral mild-to-moderate mixed hearing loss. John was enrolled in college classes and was being evaluated as his hearing impairment was affecting his ability to follow along in large lecture halls. He was also about to move to campus and live independently, so it was more important than ever that his hearing impairment be treated.

John received much support and encouragement from his father to proceed with amplification. The father attended every appointment with John, including the hearing aid evaluation. We recommended RITE aids with custom molds, as John would likely have difficulty inserting a dome in his ears due to dexterity issues. The father agreed and chose to proceed with the fitting. The next day, the father called the clinic; when he discussed our recommendations with his wife, she requested we change the custom molds to an open dome for cosmetic reasons. My supervisor explained to him that we could fulfill that request, but John would have to display successful insertion of the hearing aids before we could let him leave with them. Privately, my supervisor worried that fitting John with domes would set him up for failure.

Worries Confirmed

Both John’s mother and father accompanied him at the hearing aid fitting. This is when we learned that the family was not in complete agreement with our recommended plan to treatment. Unlike the previous appointment, John now wanted nothing to do with the hearing aids and even cried after experiencing difficulty with inserting the dome tips. Despite his difficulties, his mother opposed switching to custom molds. Her main concern was that the hearing aids could be seen from behind. This concern in turn became John’s concern and he showed much discomfort in wearing them. His mother stood her ground when we wanted John to keep practicing. She told us that they were “educated people who could help John at home.” For reasons unknown, family and audiologists were not sharing the same goal: to confirm that John could manage this task on his own.

The appointment was scheduled for an hour but John’s mother cut us off at 30 minutes 10.30because John had class. We told her we had planned on an hour because many important things needed to be discussed; regardless, they opted to cut the appointment short so that John could make the last 20 minutes of class. My supervisor reluctantly agreed to let John leave with the hearing aids and have his parents practice with him at home.

As an educational clinic, we routinely video record the appointments so that we can critique ourselves later (with written patient permission, of course). When we later viewed this appointment, we learned that John had cried when we stepped out of the room and tossed the hearing aids on the table calling them “a total waste of time.” On his way out, he was heard to comment to his mother that he was taking them off before class.

Predictably, Things Got Worse Continue reading →

Sudden Patient-Audiologist Terminations and The Effect on the Patient

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AliAlison Marinelli, Class of 2018 (AuD/PhD)

The University of Connecticut

Ideally, patients form bonds with their audiologists because of the unique role in caring for them and their devices. Repeated positive interactions allow for greater relationships to develop. As a patient, I’ve had the pleasure of working with several talented audiologists over the years and have had a variety of experiences. Now that I’m in graduate school for audiology, I can’t help but use the academic material that I’m learning to take an analytical eye to my own audiologic experiences and evaluate them more thoroughly. A particular experience that was critical to my young life was the tragic death of my beloved audiologist, Dr. Toni Maxon.

Bonding ….

Toni was one of the first audiologists that my parents consulted after my diagnosis of hearing loss at nine months. My parents were seeking all possible avenues to treat my hearing loss, and were exploring the auditory verbal path when they visited her at the University of Connecticut Speech Language and Clinic. I don’t remember these early days, but it was always obvious to me that Toni’s empathetic counseling assisted my parents with the coping process associated with the diagnosis.

Maxon Toni

Dr. Toni Maxon

My father affectionately recalls the time when my parents were discussing amplification options and I was eating crackers, babbling to my parents about the toys I was playing with nearby. Toni gently pointed out to my parents how desperately I was attempting to communicate, and that the limited language I was producing was due to the limited inputs I was receiving. The kind manner with which she delivered the information touched my parents and started a very close working relationship that carried on throughout all future treatment. When Toni left the UCONN clinic to start the New England Center for Hearing (NECHEAR) with Dr. Diane Brackett, I continued services with her there. My parents and I looked forward to appointments and we continued our sessions with respect for her knowledge and appreciation of her superior services. As she had the ability to impart life experience, give advice, inquire and be truly interested in our family as time marched on, we valued her more and more.

….And Then Loss

This congenial relationship changed in 2007 when my family received a phone call that informed us that Toni had been in a car accident that claimed her life.  As anyone who experiences an unexpected event like this would be, we were devastated. A memorial to celebrate her life was organized, and I was asked to speak. I spent countless hours editing and revising my speech, but the words never seemed to accurately represent what Toni meant to me. I remember delivering my speech at her memorial, and choking up at the fact that I had to say goodbye. NECHEAR had also planted a memorial garden, and to dedicate it, they held a celebration of Toni’s life. Both of these special events helped to ease the pain of loss. In the aftermath following her death, qualified clinicians were brought in to program my cochlear implants. The co-founder of NECHEAR, Diane Brackett, also a long-time clinician of mine, sat in on the initial mappings and conveyed important audiological information to the new clinicians on my case. Since I had known Diane previously, she bridged the gap between the old and the new. Continue reading →

Sometimes Emotions Are the Point

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Kris English, Ph.D.Kris English, PhD

The University of Akron/NOAC

Scenario: Today an audiologist will meet a new patient, Mr. Jones. She asks about his concerns and obtains a comprehensive case history. When the testing is completed, she confirms the patient’s suspicions about his hearing problems. She begins to discuss treatment options, but then realizes her patient has stopped listening.  She pauses, and soon the patient breaks his reverie. He shakes his head, makes eye contact again and says:

The thing is … years ago, I was so impatient with my dad’s hearing problems.  I didn’t even try to understand and just stopped talking to him.  I was pretty awful about the situation. Then after he died, I started to realize how stubborn and selfish I had been.  This man I had loved so much – we had been become strangers.  And now it’s me – and maybe the whole cycle will start again with my kids! That would just … it would just break my heart.”   His voice breaks and he looks away again, sighing deeply.

In less than 30 seconds, several emotions have tumbled out: guilt, regret, self-blame, worry.  The audiologist was mindful of the change in demeanor, and gave the patient the opportunity to express these concerns.  But now that we know what the patient is experiencing, what do we do?  Do we assure the patient that everything will work out and then “get back to the point” of the appointment?  Are we defining “the point” only from our own perspective? And if so, are we ourselves missing an important point?

Portrait of an apprehensive senior man.

Portrait of an apprehensive senior man.

What Exactly Is The Point?

In a recent conversation, Tim Cook (webmaster at the Ida Institute) mentioned a concern shared by many Ida seminar participants: When patients get emotional, how do we redirect them back to hearing solutions – that is, get them “back to the point”?   This concern assumes that patient emotions will inherently impede progress — not to imply that the emotions are irrelevant to the patient, just irrelevant to the appointment goals. Emotions are perceived as a problem, a “noisy byproduct” that we need to manage, control, suppress (Stone et al., 2010, p. 13). Continue reading →

Avoiding the Enemy Camp

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ClarkJohnJohn Greer Clark, PhD

The University of Cincinnati & Clark Audiology, LLC

An enemy generally says and believes what he wishes.

Thomas Jefferson

While our patients are not the enemy, we most certainly at times can be viewed as theirs.  Adult patients arrive at our office doors at a set stage within their hearing loss journey.  This journey does not begin with the appointment with the audiologist (Gregory, 2012).  It often follows a long and circuitous path that may have only reached a point of suspicion of hearing loss at the time of consultation.  Along the way, patients who have not yet reached a stage of readiness to embrace our recommended hearing solutions may have categorized persons into one of two camps – the ally camp and the enemy camp.

The enemy camp is filled with those who want the patient to address the very situation he or she has been trying to deny.  Friends and family who have been noticing communication failures, and who are becoming increasingly frustrated living with someone else’s untreated hearing loss, have likely suggested scheduling a hearing test on numerous occasions.  As part of many patients’ pre-appointment journey, those with hearing loss may have progressed from scanning hearing aid advertisements in magazines and newspapers to reading these advertisements in detail.  They may have completed Google searches on hearing loss, hearing loss treatment and hearing aids.  And they may have asked friends and acquaintances who wear hearing aids (or who have tried hearing aids) what they think – with responses that sometimes are less positive toward the potential help available than audiologists might hope.  And of course, as the journey becomes more protracted the patient and the patient’s communication partners frequently become more frustrated.

Prior to making an appointment with the audiologist, most persons with hearing loss gradually come to the realization that the communication frustrations are the result of, or at least aggravated by, their own existing hearing loss.  They come to the realization within their journey that much of the problem lies with them and that they do indeed need to take action.  Those family members who may earlier have been viewed as soldiers within the enemy camp, may gradually be viewed as having the persona of a supportive comrade.  And these comrades frequently come to the initial hearing consultation appointment with the patient to lend their aid as together they embark on a new leg of the hearing loss journey.

frustratedcoupleBut not all patients who come through our doors have reconciled themselves with their hearing loss.  Some still harbor varying degrees of denial, continuing to place much of the blame for communication failures on the speaking habits of others.  And these others continue to be viewed as residing in the enemy camp, pushing for actions that are not wanted or that are not perceived as needed.

How Do You Want to be Viewed? Continue reading →

When Your Patient is Not Your Patient

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IMG_4803Kerri Hudson, AuD

Audiology Solutions, Inc.

I work as a contract audiologist for a small private mobile practice. We provide bedside hearing services to patients who live in nursing homes or at home with assistive living services. I recently had a few interesting visits with a lovely lady and her son.

My patient is in her 90’s and resides in an assistive living facility. Meals are provided and she receives limited help with daily living needs. Her hearing loss is treated with BTE hearing aids bilaterally. Her son reports unspecified dementia with no other significant health concerns. He is a friendly, middle-aged man with a wife and grown children.

Interactions with the patient and her son were tense from the start. As I entered the room, they were arguing about the temperature of the room. The son was patient and accommodating at first. I attempted to start the case history. However, the patient refused to look at me, and would instead look to her son to answer my questions. She became quickly frustrated, stating that she could not hear a word I was saying. I attempted to redirect her attention to me. The son began to intervene by asking me if he could give his mother the directions himself. Before I could stop him, he was soon screaming at his mom. Things quickly began going downhill.

I began to give the patient instructions for the evaluation. Again she became very upset. Hoping to use some of my training in counseling, I tried my skills. I expressed to her that I felt her frustration so maybe we could talk about the situation.  No sooner had I begun, the son informed me that she was frustrated and suggested that he take over in giving the instructions. I convinced him to let me continue and was finally able to start the test. A few thresholds were obtained before the patient suggested a break due to discomfort and fatigue. The son began to sigh in frustration and appeared to be in a hurry to get everything completed. Continue reading →

Children with hearing loss, parents, and “auditory imprinting”

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Kris English, Ph.D.Kris English, PhD

The University of Akron/NOAC

 

Even the most family-centric audiologists can find themselves on a different page than parents on the topic of consistent amplification. One reason may be our training: we have been taught to emphasize the relationship between amplification and the development of speech and language. While true, it is also possible that families are not following our logic. In fact, logic may not be part of their reactions at all. At the moment, families’ uppermost concern may be centered around their child’s emotional development: Will our baby be happy? Feel safe? Will she know we love her?

Families intuitively want to nurture and bond with their baby, and hearing actually supports that process. But even as hearing is taken for granted, so are the effects of hearing on parent-child bonding. Our challenge is to align our communication with what families value, and be comfortable talking to parents about the importance of their child hearing “the love in their voice.”

Following are two topics: A brief summary of selected research describing listening skills in infants with no hearing loss, and then a suggestion on how help families use amplification for the express purpose of bonding with their baby. We can think of this process as “auditory imprinting.”

duck_imprint

Babies are Born Listening

Babies hear their mother’s voice for many weeks before they are born, and after birth are ready to listen for mom at surprisingly sophisticated levels. For instance, Querleu et al. (1984) tested 25 newborns, all less than 2 hours old, by presenting recordings of five women speaking the babies’ names. One voice was the baby’s mother, and four voices were unknown to the baby. Three observers independently rated each baby’s reaction to each voice as nonexistent, weak, or strong. They found that when the babies heard their mother’s voice, they had strong reactions almost half the time. Not a robust finding, but remember, the babies were only 2 hours old but already telling us that mom’s voice is meaningful to them.

A classic study by DiCasper and Fifer (1980) found that not only does baby recognize mother’s voice, but actively prefers it to others. The researchers recruited 10 mothers to record reading from Dr. Seuss immediately after they delivered their babies (agreed, that alone is amazing). Their newborns were later placed under headphones before they were 24 hours old. After obtaining baseline sucking rates (using nonnutritive nipples and computer software to calculate rates per minute), the researchers presented recordings of mother and other women reading. Babies quickly learned they could control the input: when they sucked on the nipple at a rate lower than their baseline, that action would deliver an unfamiliar female voice. When they increased their sucking rate, they would hear their mother’s voice.  Once they learned the relationship between sucking rates and voice input, they consistently “chose” mother using an increased rate. Think about it: a 1-day old baby is capable of mastering an elementary lesson in cause-and-effect based on what he or she heard, and it is mom’s voice that facilitates that learning. Continue reading →

Counseling Adolescents: How to Manage the Transition from Child to Young Adult?

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DSC_1990-819x1024Emily Pajevic, Class of 2015

The University of Akron/NOAC

Over the years it has become clear that counseling is a key component in patient care and in promoting patient success. In pediatrics this counseling is primarily focused on the parents. It is, after all, the parents who will be responsible for raising the child and helping the child over the many challenges they are bound to face as a family. Here a large assumption is made: we assume that at the point of diagnosis, the child is too young to understand the implications of the news presented to the parents. We often picture an infant, asleep in the mother’s arms or a child playing with blocks on the floor while the results are being discussed. When the child gets older we ask parents for a progress report: How is she adjusting in school? Is he wearing his hearing aids? Making friends? Developing some self-advocacy skills?

All valid and important questions but what about when we evaluate teenage patients who are old enough to understand what is being said? Here we may be at a loss. We are now looking at too many unknowns. Will they trust us enough to explain their challenges? Will they understand what we are trying to explain? How might they react? Should the parents be the one to explain? How much information should we give them? How are we to begin to explain to an adolescent when we still struggle getting parents to understand? How do we know when they are ready? Unless we consider these questions ahead of time, we tend to take the familiar route, the route of safety: we talk to the parents, picturing that child to be the infant we are perhaps more comfortable with. We then allow the parents to fill in the gaps at home.

A possible scenario

Consider how this tendency affects this thirteen year old patient as she learns of the results of her auditory processing assessment:

Amanda shuffles her feet back and forth, staring down at the floor, wondering what the cafeteria at school had served for lunch today and what her friends were doing during gym class at this very moment. She sits on her hands and kicks her feet back and forth more vigorously, deep in thought until she catches her mom’s narrowed eyes, clearly telling her to knock it off. Man, mom is in a bad mood today. She glances over at her mom who is now drumming her fingers on her thigh with a furrowed brow. What’s her problem? Amanda thinks. I’m the one who has been asked stupid questions all day and had to sit in that tiny room for over an hour while she just read magazines.

Just then the door opens and her mother quickly straightens up and folds her hands in her lap, her expression eager. Amanda rolls her eyes and goes back to kicking her feet. She watches the feet of the audiologist as she walks in and sits down across from her. Amanda goes back to thinking about her friends, idly listening to her mother and the audiologist talk. “Just so you know, an auditory processing disorder is not considered a learning disability in this state so be prepared to push a little to get Amanda the help she needs.” Amanda’s right foots kicks the leg of her chair and she throws out her arms to steady her chair as it tilts. Learning disability?! Amanda flushes and stares at the floor listening carefully now, her feet still. The audiologist is talking about giving papers to the special education department and tutoring and then… “Amanda, what are your thoughts?”Amanda feels her face and eyes burn, her head spinning with the words disability, special education, help…she keeps her head down but raises her eyes to see the audiologist and her mom staring at her with strange, forced patronizing smiles on their faces. “I’m fine,” she says quickly, suddenly wishing she had gone to school today instead. “Amanda please tell us what questions you have, you must have some.” “No!” Amanda says too loudly, startling both her mother and the audiologist. Amanda stares furiously at the floor. She takes a deep breath to steady her voice, “No. Fine. Mom, let’s go.” Her mom stands up to shake the audiologist’s hand. Amanda stays seated until she sees her opening and then slides off her chair, aims for the door, and walks back to the waiting room without another glance at the audiologist.

sadgirlHow does an audiologist best serve Amanda and other adolescent patients? We cannot continue to primarily address the parents, undermining the patient’s knowledge and concern for his/her own healthcare and yet cannot ignore the parent’s need for understanding and the crucial role that they play. In healthcare, as well as our own profession, this topic of interacting with adolescents needs to be explored. If the unknown prevents us from providing the best care to this patient population, it is time to delve into this uncharted area, further expanding our knowledge and understanding to enhance our field and our impact on those we serve. Continue reading →

Balancing Power in Patient Relationships

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Kris English, Ph.D.Kris English, PhD

The University of Akron/NOAC

Here is a thought-provoking experiment. Ask audiology students to visualize the first moments of a typical appointment with a new patient.  The patient sits down, and the audiologist says, “So what brings you here today?”  Got the image? Now freeze that frame! And then ask, “In this scenario, who has power: the patient or the audiologist?”

Interestingly, students tend to say, “the patient.”  When asked why, the explanations tend to recognize the patient’s power of autonomy: ultimately, a patient can and will decide whether to follow to our recommendations (Calman, 2004). A reassuring answer! But remember, I was referring to the beginning of the appointment, not the end.  It seems possible that we could overlook a new patient’s vulnerability, and be unaware of an initial state of powerlessness. If we are blind to it, we are not likely to take active steps to start shifting the balance of power in the patient’s direction (Goodyear-Smith & Buetow, 2001).

Empathy 101 and Power.  To understand what powerlessness feels like from a patient’s point of view, let’s put ourselves in their shoes. Before and during our first appointment, we would have many questions, and experience some anxiety, worry and doubts. We would have absolutely no idea what to expect. We would see unfamiliar technology, framed diplomas and licenses hanging on the wall, and models of strange anatomy sitting on shelves. We would see brochures and posters about new hearing aid technology – something we have been avoided thinking about, and now it’s “in our face.” At this moment, we have little going for us – except for our unique story. This is a type of latent power: our story is valuable but it will have no impact if we are not given an opportunity to share it.  Is anyone interested?

Across from us is the audiologist, Dr. Somebody, with a white coat and specialized training and expertise. Dr. Somebody will determine how we start the appointment, what steps we take along the way, and how we conclude the appointment. It is reassuring to have an expert take the lead; it’s why we made this appointment in the first place. But it does means that we are still relatively powerless.  Will it always be that way?

balanceofpower

Initially, there is an inescapable power inequity in the patient-clinician relationship, a situation not unique to audiology. Palmer (1998) notes that “Virtually all professionals have been deformed by the myth that we serve our clients best by taking up all the space (i.e, holding all the power) with our hard-won omniscience…” (p. 132). Continue reading →

Consult to Psychology: Why the Hesitation?

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Screen Shot 2016-05-09 at 10.52.07 AMMichael Squires, Class of 2014

The University of Akron/NOAC

In a clinical rotation I came across a patient who, I was told, was having a very difficult time with her hearing aids. I learned that she had been making almost bi-weekly visits to our clinic and had been through multiple trail periods with hearing aids from different manufacturers. The resident audiologists had gone above and beyond to make sure that this particular patient had as many opportunities as possible to realize her potential for hearing with hearing aids. The appointment that I had with her was no different than ones previous; her hearing aids were not working for her. She came in and sat down with a very stern look on her face. She began removing the sets of hearing aids from her purse and laying them on the table. She would mention that one was more comfortable than another but another pair seemed to be louder, and so on. When all sets of hearing aids were in front of her she began to cry. She looked at the audiologist and myself and said, “Am I going deaf?” She talked about how tired she has been and that she feels like she always has to try so hard to listen to people. My preceptor stepped out of the room to clean and check each set of hearing aids. I stayed behind with the patient and thought I would try to talk to her. I asked her, “Forget about the hearing aids for a moment. How have things been going otherwise?” I mentioned to her that she seemed a bit tense and asked if everything was alright with her outside of our clinic. She began to cry again as she explained that her husband had just been diagnosed with Alzheimer’s disease a few months ago. I was the first person to whom she had told this information. We talked briefly about how she should focus on feeling better and that her hearing aids would help her much more when she could be confident in them, and herself.

depressedelderWhat went wrong? It is obvious that this appointment had come to a point where an audiologist was no longer able to help. Unfortunately, this patient was never referred to anyone who could. There are many instances when a patient in an audiological setting should be referred to another professional for further examination. However, there is one such instance that is consistently ignored; depression. It seems intuitive that any major life changes, including learning of one’s hearing loss, has the potential to cause symptoms of depression. Audiologists are many times the first to notice depression and stress caused or exacerbated by a hearing loss. Yet, when these signs are noticed, whether they are caused by news of a hearing loss or some other event, what is the next step for an audiologist? According to the American Academy of Audiology’s Code of Ethics:

Rule 2a: Members shall provide only those professional services for which they are qualified by education and experience.

Rule 2b: Individuals shall use available resources, including referrals to other specialists…

If this is the case, then why are more referrals not being made to psychologists for patients who may benefit from psychological counseling? In my opinion, it comes down to training and experience.

In an article written English and Weist (2005) examining counseling in Doctor of Audiology programs, about 85% of the, then, 56 university doctoral programs included counseling, in some capacity, in their curriculum. Although, according to the American Speech-Language and Hearing Association’s list of CAA-accredited audiology programs, there are now 74 institutions offering a doctorate in audiology. Though there is no recent data showing the current number of counseling offered in Audiology doctoral programs, the American Academy of Audiology proposed new Educational and Community-Based Programs Objectives for Doctor of Audiology granting colleges, schools, and programs or audiology in 2012 (Keetay, 2012). One of these new objectives includes increasing the inclusion of counseling for health promotion and disease prevention in Doctor of Audiology curricula. The rationale states:

“Audiologists are often the first healthcare professional to identify hearing loss and/or balance disorders and to recognize the opportunity for promotion of healthy hearing and balance practices and prevention of hearing and balance disorders. Developing skills in counseling is essential to the provision of hearing and balance healthcare but can be overlooked in current AuD curricula…”

The fact still remains that professional audiologists tend to shy away from making psychological referrals. Could this be a residual effect of Master’s level training, or are counseling courses not incorporating the importance of not only identifying and empathizing with patient symptoms of depression and stress, but also making the proper referral to get patient help?

The fact that audiologists are “groomed” to be clinical counselors puts us in a position of responsibility to our patients to be able to effectively counsel them through problems regarding hearing healthcare. In their book “On Becoming a Counselor,” Eugene Kennedy and Sara Charles, M.D., state that the interview, or case history, is the chief tool for making an accurate diagnosis of depression. When an individual is identified as having the vast range of symptoms associated with depression a referral should be made for psychiatric consultation. They go on to mention that depression is often recurrent and if symptoms can be addressed when they are still mild, then the disorder can be treated before severe symptoms grossly affect a person’s life.

It is a duty of all audiologists to provide the best hearing healthcare possible for our patients. It is a duty of all healthcare professionals, including audiologists, to ensure that patients are given every possible chance to improve their overall quality of life. Upon entering a Doctor of Audiology program, many students recite the “Audiology Oath” written by Steiger, Saccone, and Freeman in 2002. This oath represents the idea that we, as audiologists, are to adhere to

professional standards that includes giving patients every opportunity to improve the quality of their lives. I would like to leave you with this oath as well as a thought. What are we able to do as students, professionals, and a field, to make certain that we are prepared to make decisions regarding patient well-being, even if those decisions require us to reach out to other professionals beyond the audiological scope of practice?

The Audiology Oath

As a Doctor of Audiology, I pledge to practice the art and science of my profession to the best of my ability and to be ethical in conduct. I will respect and honor my teachers, and also those who forged the path I freely follow. According to their example, I will continue to expand my knowledge and improve my skills.

I will collaborate with my fellow audiologists and other professionals for the benefit of our patients.

I will, to the best of my ability and judgment, evaluate, manage, and treat my patients.

I will willingly do no harm, but rather always strive to provide care according to the standards of the profession.

I will act to the benefit of those needing care, striving to see that non go untreated.

I will practice when competent to do so, and refer all others to practitioners capable of providing care in keeping with this oath.

I will aspire to personal and professional conduct free from corruption.
I will keep in confidence all information made known to me about my patients.

As a Doctor of Audiology, I agree to be held accountable for any violation of this oath and the ethics of the profession. While I keep this Oath inviolate, may it be granted to me to enjoy life and the practice of the art and science of audiology, respected by all persons, in all times.

References
English, K., & Weist, D. (2005). Growth of AuD programs found to increase training in

counseling. Hearing Journal. 58 (4), 54-58.

Keetay, V. (2012). Draft of responses to proposed healthy people 2020 objectives related to educational and community-based programs (ECBP) objectives. Retrieved Feb. 20, 2013 from http://www.audiology.org/news/Documents/201212_HP2020_ECBP_objectives_Academ y%20Responses.pdf

Kennedy, E., & Charles, S. (2001). On becoming a counselor: A basic guide for nonprofessional counselors and other helpers. The Crossroads Publishing Company; New York, NY.

Steiger, J.R., Saccone, P.A., & Freeman, B.A. (2002). A proposed doctoral oath for audiologists. Audiology Today. 14(5), 12-24.