of communication partnership therapy in the context of current models of audiologic service delivery, particularly family-centered care (FCC).
Introduction
Audiologic rehabilitation practices are in the midst of a certain crisis of identity. While evidence grows for the nature of the impact of adult-acquired HI on everyday talk (Lind, Hickson, & Erber, 2004, 2006; Skelt, 2007, 2012; Pajo, 2012, 2013), the importance of communication-based AR (Laplante-Lévesque, Hickson, & Worrall, 2010; Scarinci, Lind, Hickson, Meyer, Tulloch, & Hall, 2018) and for person-centered and family-centered care as models of service delivery (Scarinci et al., 2018), there seems to be little confidence among practitioners about some of the clinical decisions to be made in offering these services. Solid research evidence for AR practices grows but remains patchy and incomplete, and the place of nontechnological AR remains unclear to many practitioners.
Pressures on patterns of practice arise from various sources; most commonly, government funding models, commercialism, and professional standards of practice (Tuohy, 1999). These complex and very real pressures on clinical practice drive clinicians to shape their practices toward certain activities. An analysis of international practices in audiology suggests the trends away from offering AR as an integral part of the adult rehabilitative process are commonplace (Egbert et al., 2012). In the absence of either appropriate funding models or stronger evidence for the practice of adult AR (as opposed to technological intervention, primarily hearing aid fitting or cochlear implantation), the clinical role of adult AR remains uncertain and its offering in clinical settings is infrequent and inconsistent.
The focus on adults’ perceptions of their HI as an issue in social participation is reflected in qualitative research findings that adults with HI report results from intervention (technological or otherwise) as “coming back to life” (Hallberg & Ringdahl, 2004, p. 117) or “becoming a new person” (Hogan, 1997, p. 239). Similar studies have reported that the key elements of intervention are increased social participation and, especially, increased interaction with family and friends, leading to improved quality of life and decreased isolation (Faber & Grontved, 2000; Hawthorne et al., 2004; Mo, Lindbaek, & Harris, 2005; Vermeire, Brokx, Wuyts, Cochet, Hofkens, & van de Heyning, 2005). So, the question arises: How do clinicians align clients’ perspectives (i.e., what they say they want) with the available intervention techniques (i.e., what they have to offer) and the appropriate assessment tools and outcome measures?
Over the last 25 or so years, rehabilitation practices have changed in both content and process. The clinical and research hegemony of lipreading/speechreading as the dominant rehabilitative paradigm has been replaced by a variety of therapy approaches, including hearing and environmental tactics (Kaplan, Bally, & Garretson, 1985), conversation tactics (Erber, 1996, 2002; Tye-Murray, 2009), and assertiveness skills (Trychin, 1995).
Most recently, patient- and family-centered care models (Gregory, 2012; Grenness, Meyer, Scarinci, Ekberg, & Hickson, 2016) have reflected the move away from hearing rehabilitation as a purely sensory-focused pursuit toward practices that contextualize the goals of rehabilitation and focus on the personal, interpersonal, and social consequences of HI. For example, the Active Communication Education (ACE) program (Hickson, Worrall, & Scarinci, 2007; Scarinci, Worrall, & Hickson, 2008) provided evidence for the effectiveness of group-based AR programs for the influence of adult HI on the spouse and for the effectiveness of the client’s informed selection of therapies to meet his/her perceived needs (Laplante-Lévesque et al., 2010). Saunders and Forsline (2012) have advocated for a model of short-term, individually based information counseling along similar lines to those espoused in this chapter. These developments may be seen to mirror the concepts underlying the World Health Organization’s (WHO) (2001) International Classification of Functioning, Disability and Health (ICF) model, in which problems of structure and function may be distinguished from limitations to activity and restrictions in participation. These models reflect the increased attention paid to overcoming problems of activity and participation by designing therapy that addresses the situation-specific interactional consequences of adult-acquired HI, as they might impinge on both the adult who has HI and his or her frequent or familiar CPs.
Process in Audiologic Rehabilitation
As mentioned above, the relationship between technical and communication-based intervention is an uneasy one, reflecting the various clinical, professional, regulatory, and commercial attitudes and exigencies in the delivery of these services. In the previous edition of this chapter (Lind, 2014), Lind distinguished between four models of delivery of AR services that reflect this relationship. The first, separated intervention, arises when the planning and execution of technological and communication-based activities occur entirely independently from each other. The clinical activities may be separated in time and even in place (i.e., delivered by different service providers). As a consequence, only a small subset of clients attending clinics in which this model is practiced may be offered communication-based AR services. In the second, overlapping model, the technical and communication-based activities addressing these goals may be offered in one setting and some assessments may inform both services, although they are still seen as distinctly different activities and are thus practiced quite separately. Often in these first two service delivery models, communication therapy is only considered after the completion of device fitting should the client report specific residual difficulties. Again, only a few clients may be offered communication-based intervention, as it remains largely dislocated from the technological intervention that is typically offered first.
The third model, shared intervention, may see a common assessment arising from a single point of planning for therapy offered by one clinician in some cases, but the communication-based therapy still sits at the edge of this planning. Despite a greater degree of integration between the technology and communication-based interventions to address situation specific needs, in which the success of the hearing aid fitting may be evaluated against the client’s communication goals, communication-based therapy is typically offered only after the completion of technological intervention and is seen as a secondary activity.
Finally, the integrated intervention model combines both technical and communication-based therapy approaches and coordinates their execution according to the client’s stated needs and in an order that reflects those needs. By contrast with the separated and the overlapping models, the ordering of therapy is defined by the individual with the HI and by the ability of the chosen therapy to address that difficulty. By contrast with all three prior approaches, it takes both forms of therapy to be of equal importance. It is sometimes the case that communication therapy alone addresses the client’s needs and technological intervention is not required.
Both the clinic’s preferred service delivery model and the clients’ needs dictate which of these models might be most appropriate. From a service delivery perspective, clinicians who do not feel well equipped to undertake communication-based therapy may refer clients to another agency. Alternatively, from the viewpoint of the client’s needs, the more widespread and the less situation specific the client’s reported communication difficulties arising from the acquired HI, the more likely that technological rehabilitation will be the appropriate first (and often only) action. Across these four intervention approaches, the key elements are the focus on situation-specific needs, the commonality of assessment across intervention types, and the selection of intervention activities to meet clients’ stated needs. Finally, the need for intervention-specific outcome measures is implied across all four service delivery models.
Content in Audiologic Rehabilitation
This section gives a brief overview of two models of AR therapy, specifically the distinction between audiovisual intervention, and communication-based therapies.
Audiovisual Speech Reception Training
Audiovisual speech reception training has been the predominant nontechnological intervention strategy for most of the last 60 years. It continues to be the preferred functional outcome measure in assessing hearing aid fitting and cochlear implantation. Speech reception tests abound and speech perception training has been developed as a tool to directly address the perceptual consequences of acquired HI on everyday talk. The intervention implies massed practice as a strategy and a long period of therapy via both direct (i.e., training in the enhanced use of residual auditory speech reception skills) and compensatory (i.e., training in the enhanced use of visual speech reception skills) treatments. Audiovisual speech reception training traditionally distinguishes analytic (typically sound-by-sound processing of a speech signal) from synthetic (typically speech reception combining all elements of a spoken message to arrive at its meaning) processing paradigms, as originally suggested by Jeffers and Barley (1971) (see also Erber, 1981). While measureable improvement in speech reception test scores in comparison of pre- and post-intervention measures in both analytic and synthetic training programs has been demonstrated over many years, attempts to apply speechreading principles to larger units of talk have not borne fruit as clinical activity. In part, this reflects the complexity of the linguistic models that underpin verbal communication outside of the confines of the well-constructed sentence.
The promise of research findings into speechreading across turns at talk (Erber, 1992; Flynn & Dowell, 1999; Gagné, Tugby, & Michaud, 1991; Lind, Erber & Doyle, 1999) have not translated well into clinical assessment or intervention. The singular exception remains continuous discourse tracking (deFilippo & Scott, 1978), although Okell and Lind (2012) identified several shortcomings in this approach from a conversational perspective.
Ross (1987, 1997) and Gagné (1994) noted the qualified success of audiovisual speech reception therapy models in AR over its history. These limitations arise from several sources, but predominantly from the lack of functional post-intervention assessment by which training might be judged to have benefited the participant in everyday talk. It is important to note that this shortcoming is not specific to speech reception training. The greater the decontextualized nature of the intervention, however, the more adaptive work the client must undertake to apply skills learned in therapy to everyday interaction. This has been addressed in the revival of auditory and audiovisual speech reception paradigms by Sweetow and Sabes’ (2006) Listening and Communication Enhancement (LACE) program; by Levitt and colleagues (Levitt, Oden, Simon, & Lotze, 2011); and by Mauze, Schroy, and Tye-Murray’s (2011) computer-based auditory speech training exercises. All address HI adults’ perceived changes in everyday communication as outcome measures.
In the absence of more direct evidence of the link between speechreading training and advantages to the client in everyday conversation, speech reception training may be best offered as structured listening practice to adults with sudden and significant changes in speech reception; that is, either a substantial drop in speech reception as a result of sudden-onset loss or substantial improvement in hearing thresholds as a result of perceptual advantages following hearing aid fitting or cochlear implantation. Synthetic speech reception tasks, such as the Speech Perception in Noise (SPiN) test (Kalikow, Stephens, & Elliott, 1977) and Erber’s (2002) sentence predictability exercise, demonstrate the complex relationship between adults’ ability to use linguistic context and perceptual information in decoding individual words presented in the presence or absence of within-sentence grammatical and semantic cues. Patterns of results in speech reception tests such as these suggest that emphasis in therapy is best placed on the role of linguistic context in speech reception and may be expanded to include the influence of conversational context in speech reception (Erber & Lind, 1994; Flynn & Dowell, 1999). (Editors’ note: For more information on audiovisual speech perception training, the reader is referred to Chapter 14 of this text.)
Communication Partnership Therapy
Prior to outlining the communication partnership therapy model, the question arises as to what behaviors HI adults exhibit in conversation and, as a result, what might their CPs expect from them. Research has indicated that it is possible to observe directly the influences of adult-acquired HI on everyday interaction. For example, HI adults have been demonstrated to take fewer and shorter turns at talk with less semantic content than their CPs (Johnson & Pichora-Fuller, 1994; Stephens, Jaworski, Lewis, & Aslan, 1999). On the other hand, Wilson, Hickson, and Worrall (1998) noted the presence of longer turns and monologues by the HI adults in talk with strangers. HI adults’ topic management was marked by more topic changes and less topic elaboration or discussion (Pichora-Fuller, Johnson, & Roodenburg, 1998). As listeners, HI adults were noted to use more general fillers and to undertake more backchanneling (Pichora-Fuller, Johnson, & Roodenburg, 1998). Finally, HI adults have been noted to initiate repairs much more often than their CPs (Lind et al., 2004, 2006).
Conversationally oriented research indicates that conversation breakdowns typically occur when one person notes that a portion of another’s talk is unclear in the context of the conversational topic, and chooses to request that some or all of a previous turn be clarified to resolve the miscommunication. The evidence in research literature suggests that the strategies that the HI adult uses to mark their need for repair and those the communication partner uses to resolve the miscommunication are in essence the same as those adopted for the same purposes in interactions between people where HI is not present (Lind, Okell, & Golab, 2009). That is, the actions people take to mark the need for repair and to clarify the communication breakdown are not specific to adult HI. As such, the content or process of repair is seldom the goal of AR intervention. By contrast, the frequency of occurrence with which adult HI disrupts conversation marks the perceived communication difficulty for HI adults and their CPs. Work by Lind and colleagues demonstrates the substantial differences in occasions of repair initiation undertaken by adults with severe to profound hearing loss (a) prior to and following cochlear implantation and (b) by contrast with the number of initiations undertaken by the HI adult’s CP (Lind, Okell, & Golab, 2009). That is, it may be the asymmetry in instances of requests for repair rather than the patterns of their resolution that strikes to the heart of the communication difficulty arising as a consequence of adult acquired HI. To this end, conversation-focused adult AR may set a broad goal to ameliorate the effects of the HI by offering strategies to reduce the instances, rather than manipulate the content of breakdown and repair in everyday conversation. In the context of family-centered care, the therapy implies direct intervention involving both the individual who has a HI and their frequent CP/significant other toward this end.
Prior to describing elements of the therapy, it might be worthwhile to consider who the clinician might expect the CP to be. In response to questions, almost all clients will readily identify people who are important to them, with whom they talk regularly, or particular occurrences of talk that are important to them that are threatened by their HI and thus warrant attention in therapy. These interactions arise across entire social networks of individuals in the HI adult’s life. Analysis of social networks (Antonucci & Akiyama, 1987) highlights the importance to HI adults of communication patterns with the various people who populate them as a function of the immediacy or importance of the interaction with them (Lind, Hickson, Worral, Lovie-Kitchin, Yiu, & Barnett, 2003; Montano & Al Makadma, 2011).
Manchaiah and Stephens (2011) tailored Antonucci and Akiyama’s original concept for use especially in communication disorders by depicting frequency of communication and emotional proximity, as well as the presence or absence of communication problems as links between the HI individual and his/her contacts. If conversation is an activity whose content and purpose are shared by participants, then it is reasonable to assume both partners have equal or at least similar commitment to its successful outcome. As such, it is reasonable to assume both partners have equally vested interests in the success of the interaction and, if that is the case, then they may both wish to address the issues at risk as a result of one partner’s acquired HI.
As a starting point in therapy, a combination of clinical work in hearing, environmental, and communication tactics (Kaplan et al., 1985) may be designed to assist the HI client and CP in the conduct of their interaction. In some instances, clients might not be able to articulate or respond to the communicative needs imposed by the HI when they interact. It is useful in these cases to assist the client and CP in addressing the various elements of the communicative environment that impinge on his/her interaction. These clients might be described as having poor metacommunication skills (i.e., people who are poor at talking about talking). This type of therapy is also valuable for adults who report specific situations to be problematic without strategies to resolve them or who require situation-specific needs that focus on the setting rather than the person.
The emphasis on the CP in therapy is particularly pertinent when they report doing most of the compensating for the other’s HI. This therapy is designed for adults who see that both partners need to work on conversation skills. This therapy model implies the adult client knows of the tactics they might use but is not sure how to implement them or does not know how to shape the management of their needs leading to successful conversation. This work may include assertiveness training (Trychin, 1995), giving clients the skills to address issues concerning their HI with others, or Tye-Murray’s (1992) anticipatory strategies by which, for instance, clients might work to prepare for contingencies in upcoming interactions. Pedley, Giles, and Hogan (2005) provided a range of useful exercises to assist clients in addressing the interpersonal aspects of their HI.
These AR practices ideally reflect the integrated model outlined above, combining device- and communication-based intervention in some balance, selected to address client-, partner-, and situation-specific daily needs. This chapter will not address device fitting in any detail, and will assume that AR is able to be offered as a combination of services with a clear and defined relation to the individual client’s stated and observed needs. The remainder of this chapter addresses aspects of participation, specifically everyday talk, as influenced by an individual’s acquired HI. In so doing, the chapter will reinterpret the application of the interactionally motivated therapy models (specifically, hearing and environmental tactics, conversation strategies, and psychosocial intervention) from a conversation partnership perspective.
Communication partnership therapy incorporates the current AR therapies with a focus on an understanding of the WHO’s two ICF categories—activity and participation—and their manifestation in a clinical setting in family-centered care. The approach has the adult with HI and his or her chosen CP attend the AR session together and discuss situations in which HI impinges on their interaction with each other or with others. Thus, within any particular situation, physical environmental factors, personal interaction styles, and/or differences in understanding the impact or consequences of the HI may all conspire to reduce the effectiveness of interaction. The aim of the therapy is to address these in any combination as they are indicated by the adult with HI and/or the CP according to several premises:
■ If everyday talk is the most common site of difficulty arising from an acquired HI, then therapy that attempts to ameliorate the conversational consequences of an individual’s HI is an appropriate and valid clinical activity. Furthermore, while this might be the primary goal of all (or almost all) AR, the more directly the therapy assesses and addresses the problem, the more immediate will be its application and potential benefit.
■ Conversation difficulties arising from an adult’s acquired HI have consequences for his/her CP(s) also, and those most often communicating with the HI adult are likely to be most affected by these difficulties. As a result, CPs have as much of a vested interested in the amelioration of the consequences of the acquired HI as do the adults who have HI.
■ The interactional goal of everyday conversation is the maintenance of ongoing shared or mutual understanding. From a conversational perspective, there are only two goals for those participating in a conversation: to establish and maintain this shared understanding, and to restore it via repair when it is compromised. Thus, for HI adults and their partners, reducing the number of breakdowns (and their subsequent repair) arising as a result of mishearing and in some cases reducing the time (specifically the number of turns) taken to resolve repairs when they do arise are reasonable and valid therapy goals. To this end, conversational fluency and the establishment and maintenance of shared understanding are tasks shared equally by CPs and HI adults. Each participant has roles to play to promote conversational success and fluency.
■ Conversational fluency, while a reasonable goal for therapy, remains a poorly defined and understood term. It is not to be seen as a consequence of improved auditory or audiovisual reception alone. It is embedded in the constellation of social, interpersonal, linguistic, perceptual, and environmental influences. Ultimately, it is embedded in the co-construction of shared meaning. That is, it is embedded in the way participants in a conversation take their turns at talk and the way they construct the meaning of their turns with their CP in mind.
■ Direct assessment of conversational fluency is the primary and most ecologically valid means by which to judge the success of any rehabilitative activity aimed at influencing conversational behavior. There is little precedent for the assessment of communicative behaviors other than by self-reported measures with their attendant complexities and indirectness, and/or by reference to clinical tests that typically sample component skills rather than the activity itself.
The scenario set out below takes the reader through a typical clinical interview between the clinician, a HI adult, and his CP. The section that follows then addresses, from the clinician’s perspective, each of the issues that have been raised by the two clients.
Assessing Rehabilitation Needs Using Communication Partnership Therapy
Referral
Mr. A. (67 years) is referred to the AR clinic following a recent upgrade of his bilateral hearing aid fitting subsequent to a noticeable change in his hearing thresholds and his report of increased difficulties, particularly in conversations where there is background noise. Client-Oriented Scale of Improvement (COSI) (Dillon, James, & Ginis, 1997) goals were identified as part of the hearing aid refitting, and background noise consistently arose as his major concern. Although the hearing aids had been adjusted to his and the clinician’s mutual satisfaction with respect to sound quality and his loudness tolerance issues, the problems identified by the COSI persisted for Mr. A. and, as a result, the audiologist fitting Mr. A.’s new aids suggested referral to the AR clinic conducted by her colleague. The audiologist requested that Mr. A. invite his wife to accompany him to the AR appointment that was scheduled for 6 weeks following the final appointment for the adjustment of the new hearing aids.
Hearing and Communication History—Mr. A.
Mr. A. and Mrs. A. attend the AR appointment together, not really sure what to expect. It had been explained only that they would talk about communication strategies that might assist with his everyday hearing difficulties. They say that they were led to expect that this might last one or two sessions only. The appointment commences with the clinician asking Mr. A. to give a brief history of his hearing loss and hearing aid use.
Mr. A. tells the clinician that his hearing problems started gradually about 10 years earlier, but that he had not done anything about it until about 3 years ago, when he and his family noticed he was missing things others said to him or in general conversation. He had first attended another clinic for assessment and hearing aid fitting but had found the aids unhelpful and had shelved the idea of wearing aids until about 6 months prior, when he came to this clinic on a friend’s recommendation. He reported that he had been happy with the hearing aid fitting service he had received; however, he gave the hearing aids “about 6 out of 10” for the help they provided.
The clinician asks Mr. A. to identify both the situations in which conversation is successful and those in which he finds his hearing lets him down.
Mr. A. lists several situations in which he feels hearing is an issue for him:
■ Mr. A. notes that he manages well in one-on-one conversation, especially when he is face to face with the person to whom he was talking and when there is little or no competing noise. He notes that he manages well in conversation with his wife and with a couple of his close friends.
■ Mr. A. reports that, although it is quiet at home most of the time, he and his wife experience some difficulty in everyday talk. He says he tends to miss the first words of the things she says. Further, Mr. A. reports that these difficulties are worse when they try to converse from different rooms, when Mrs. A. does not get his attention before starting to talk, or when background noise such as the television or kitchen noise compete with her voice. Mr. A. says that these miscommunications are resolved often once he is attending and that they deal with these miscommunications with relatively good humor, although sometimes there can be some tension between them.
■ Mr. A. indicates that he struggles to keep up with conversation at restaurants, family dinners, or other sit-down occasions. He says that, typically, Mrs. A. sits on his right side as he feels he hears slightly better on the left and thus prefers to have that ear toward the less familiar person. He feels that Mrs. A. “acts as his ears,” especially for things said to the right of him and at a distance. Most commonly, difficulties arise when Mr. A. does not hear a person speaking to him so either does not respond or speaks over the top of them. He notes that at family events, where typically 12 to 15 people attend, he manages well, unless “everyone talks at once.” His family members know about his hearing loss, but he finds some adult voices and most of his young grandchildren’s voices very hard to follow. Mr. A. is less keen to go out to a café or restaurant for fear of not being able to join in. He feels he can manage reasonably well if there are only four people at the table (he, his wife, and another couple, for instance) and as long as there is only one conversation at a time. If there is any background noise he struggles but is aware that others might also struggle in the noise. He notes there are particular people whom he struggles to understand more in conversation than others. He notes that quiet voices, rapid speech, high-pitched talkers, and people with accents cause most difficulties for him. Mr. A. reports feeling disconnected and isolated in some of these situations but is pragmatic about the loss of hearing and the consequent loss of enjoyment at his time of life. He is sure many others are in a similar position.
■ When Mr. A. attends monthly meetings of his local council, he reports struggling to hear all the voices in the room. Even though some of the others at the meeting have hearing problems as well, they do not seem to compensate for his needs, which he finds distressing. He reports positioning himself at the front of the meeting if the speaker is at the front of the room or either beside or across from the speaker if the meeting is around a table. He tries to arrive early to get the best seat, but if he arrives later, he often finds himself sitting in a poor position and missing out on a lot of the meeting.
Hearing and Communication History—Mrs. A.
Following the interview guidelines of the Goal Sharing Partnership Strategy (GPS) (Preminger & Lind, 2012), the clinician invites Mrs. A. to comment on Mr. A.’s concerns and to add her own perspective as the person who shares (or at least is present for) much of his daily communication. Mrs. A. raises several issues in response to what she has heard so far:
■ Mrs. A. agrees with Mr. A.’s perspectives on most matters related to his hearing. She agrees that they find social events with large groups, lots of talk, and thus lots of background noise, quite difficult and while she is willing “to be his ears,” she finds this restricts her enjoyment of the event. She notes that Mr. A. is less keen to attend social events such as these now and, as a result, her social life is also being curtailed.
■ Mrs. A. says her primary concern when they socialize together relates to the times when she knows Mr. A. has difficulty in noisy places. She is constantly on alert to ensure that Mr. A. does not talk over others and she says that she has to always be ready to “jump in” if he responds to someone by saying something that “doesn’t make sense or has missed the point.” Mrs. A. feels as if she is being controlling in these situations and it distresses her. In any case, both Mr. A. and Mrs. A. are embarrassed by these events and are at pains to explain to people who do not know about Mr. A.’s HI that he missed what they said but was not ignoring them.
■ Mrs. A. says that the television is a problem also, although Mr. A. does not always realize that he has the volume up so loud. Mrs. A. says the TV is up too loud for her if Mr. A. sets the volume. Mr. A. says that he can hear the news but not the movies or dramas because so much is spoken off screen, in the dark, or too rapidly for him. They agree that it limits their enjoyment of the TV when Mr. A. is constantly saying, “What did they say?” Mrs. A. says, “We don’t talk about the shows we watch like we used to do.”
The clinician reflects on the care and detail with which they have responded to the questions and asks if there are any other situations that the two of them feel are influenced by Mr. A.’s hearing loss. Mr. A. and Mrs. A. suggest that they have covered all the major things they can think of. Mr. A. and Mrs. A. have been talking for about 35 minutes and the clinician has taken careful note of the issues they have raised. He feeds back to them the major problems they have reported to ensure that he has understood them properly and clearly.
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