in a group setting over at least a few sessions and are known collectively as Group Audiologic Rehabilitation (GAR). Boothroyd (2007) described AR as a holistic approach promoting the “reduction of hearing loss-induced deficits of function, activity, participation and quality of life (QoL) through a combination of sensory management, instruction, perceptual training, and counseling” (p. 63). AR performed in a group setting allows individuals with hearing loss to share solutions to these deficits of function and their residual effects on QoL. GAR has been shown to reduce the hearing aid return rate and improve an individual’s psychological, social, and emotional adjustments to hearing loss (Hawkins, 2005; Northern & Beyer, 1999). The group setting, while being financially feasible for the clinician and the patient, allows for a direct way to address the psychological, social, and emotional adjustments to hearing loss that go beyond traditional hearing aid fitting techniques. A group setting for an AR program allows an open atmosphere of mutual support and sharing of ideas and strategies for alleviation of the psychosocial effects associated with hearing loss (Preminger & Yoo, 2010).

Recent focus groups at the University of Louisville, including adults with addressed and unaddressed hearing loss, demonstrated a general lack of trust in audiologists that was tied to the high cost of hearing aids (Preminger, Rothpletz, Galloway, Smith, & Glasheen, 2018). This is consistent with qualitative research that has demonstrated that in audiology care, low trust is associated with a commercialized approach whereas high trust is associated with a patient centered care approach (Preminger, Oxenbøll, Barnett, Jensen, & Laplante-Lévesque, 2015). An ideal way to increase trust is to offer a comprehensive AR approach via GAR. This chapter will discuss how and why GAR works by reviewing the current literature and recommend how to offer GAR to patients.

Rationale for Group Audiologic Rehabilitation

When considering group rehabilitation, many audiologists immediately think of psychotherapy groups and, as a result, may feel unqualified to lead a group. But in fact, rehabilitation groups exist for a myriad of chronic health conditions. In a supportive group, patients can learn to cope with a health condition and to manage its psychosocial impact (Stewart, Davidson, Meade, Hirth, & Weld-Viscount, 2001; Thaxton, Emshoff, & Guessous, 2005). Groups provide a forum for participants to learn about their medical condition, to meet others who face similar circumstances, and to practice coping strategies (Moskowitz, Hult, Bussolari, & Acree, 2009). Successful rehabilitation in a group setting has been shown to improve QoL, improve mood, and to increase knowledge about disease in individuals with heart disease (Wolfgang, Phillips, & Leclerc, 2007), stroke (Larson et al., 2005), breast cancer (Goodwin et al., 2001), and chronic pulmonary obstructive disease (Woo et al., 2006). Group visits for chronically ill patients have been shown to reduce repeat hospital admissions and emergency care use, lower cost of care, deliver certain preventive services more effectively, and increase patient and physician satisfaction (Beck et al., 1997). A myriad of evidence exists that demonstrates the effectiveness of group therapy in adults with chronic health conditions. Hearing loss should be no different.

Hearing Loss as a Stigmatizing Trait

GAR serves a multitude of purposes in the AR process. One of the most important is it directly addresses the stigma associated with hearing loss to debunk stereotypes and promote positive coping strategies. According to Crocker, Major, and Steele (1998), stigmatization can occur when a person possesses (or is believed to possess) “some attribute or characteristic that conveys a social identity that is devalued in a particular social context” (p. 505). Stigma has been well defined within the context of other chronic health conditions, including mental health, Alzheimer’s, and obesity as a means to advance research for use with clinical interventions (David & Werner, 2016). David, Zoiazer, and Werner (2017) describe how public stigma becomes self-stigma; initially, there is awareness of the public stereotype, then individual agreement with the stereotype, and finally self-concurrence with the stereotype. In other words, self-stigma results from a multistep process involving cognitive attributions (e.g., perception of being old or stupid), emotional responses (e.g., feeling shame or pity), and behavioral reactions (e.g., concealment of stigmatizing trait) (David, Zoiazer, & Werner, 2017). For example, an older adult with hearing loss, when questioned, may acknowledge that if someone admits they have a hearing loss or use hearing devices they may be thought of as old or less able. Despite openly expressing that they do not agree with these stereotypes, their emotional and behavioral responses often suggest otherwise. This may include avoidance of social situations or simply nodding along in agreement despite not having heard what was said. A final step toward self-stigma may result, and can be categorized as harm. This would be when these responses result in reduced self-esteem or depression. It is important to note that not all end up reaching this step. Nevertheless, it is well established that stigma is a significant deterrent to managing one’s hearing loss (Wallhagen, 2010). Stigma is one of the primary reasons Irene did not seek help for her hearing problems. (For further discussion of stigma, the reader is referred to Chapter 4 in this text.)

To address hearing loss directly as a stigmatizing trait, Hétu (1996) proposed a two-step normalization process. The first step involves interacting with individuals who share the stigmatizing trait of hearing loss. As the trait of hearing loss is no longer deviant and is instead shared, the negative stereotypes associated with it can be explored in a supportive environment. GAR participants can share difficulties they have experienced as a result of their hearing loss and methods that have been used with varying degrees of success to overcome the issues raised. This interaction helps individuals realize they are not alone in their experiences and feelings regarding their hearing loss. In addition, they can learn new ways to cope with communication breakdown or other difficulties they may encounter as a result of their hearing impairment. The second step of Hétu’s normalization process is utilizing these new skills and emotional awareness to interact with individuals with normal hearing to restore former social identity. This process sounds a lot like GAR, doesn’t it? As everyone in the group shares the stigma of hearing loss, the stigma begins to fade. As a result, the members feel more comfortable practicing effective communication strategies and are better able to manage the consequences of hearing loss. For Irene, while attending GAR, hearing loss was no longer stigmatizing, and she finally felt comfortable enough to pursue hearing aids. After completing GAR, Irene continued to combat stigma by participating in volunteer activities with others who have hearing loss.

Reducing the Psychosocial Effects of Hearing Loss

GAR seeks to reduce the psychosocial effects of hearing loss. Psychosocial simply means the combined impact on an individual’s psychological and social function. The impact of hearing loss is multidimensional and may include the emotional, cognitive, interpersonal, behavioral, and physical responses to hearing loss (Trychin, 2002). Thus, a psychosocial approach addresses how hearing loss affects an individual in the psychological domain (e.g., self-image, stigma, denial, stress) as well as in the social domain (e.g., avoidance, family, social life, and work). Hearing loss usually impacts both domains, though it is important to note that the effect is individual and can vary along a wide continuum regardless of the degree of hearing loss. To avoid the stress involved in concealing one’s stigmatizing trait, an individual with hearing loss may avoid social interaction, leading to depressive symptoms, feelings of loneliness, and a reduced social network (Kramer, Kapteyn, Kuik, & Deeg, 2002; Pronk et al., 2011; Strawbridge, Wallhagen, Shema, & Kaplan, 2000). Recent studies show a correlation between hearing loss and social isolation, depression, and dementia (Amieva, Ouvrard, Meillon, Rullier, & Dartigues, 2018; Deal et al., 2017). For adults with hearing loss it is often easier to just stay home than to try and communicate in a public or group setting, especially when there are a lot of people and background noise present. Amieva et al. (2018) found that older adults, specifically men, showed a negative association between hearing loss and social isolation. That is to say, the greater the hearing loss, the less social activity reported by the participants. Conversely, other studies have found that hearing loss has been associated with greater degrees of social isolation in women (Mick, Kawachi, & Lin, 2014). Emerging evidence (Amieva et al., 2018) suggests that hearing aid use may protect against the detrimental concomitant effects associated with untreated hearing loss in older adults; successful completion of GAR may also reduce social isolation and thus could lead to similar positive outcomes. Participation in a GAR program helped Antonio to reengage in the activities he used to enjoy, thus reducing his social isolation and possibly reducing risk for developing depression and dementia.

Depression and social isolation contribute to psychosocial status, which is an important component to consider when assessing QoL. The World Health Organization (WHO) defines health-related QoL as individuals’ “perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns” (WHO, 1995, p.1403). As successful health care management has increased quantity of life, health care practitioners and researchers have looked toward methods to improve quality of life. Health related QoL can be measured with a variety of assessment scales, which fall into two categories: (a) generic areas of everyday life, which include both the physical and mental effects of a health condition; and (b) disease-specific areas, which for our purposes are the participation restrictions and activity limitations that arise from hearing impairment (National Institute of Health, 1993). (For additional information on quality of life, the reader is referred to Chapter 7.)

It is the expectation that GAR will address the psychosocial impact of hearing loss, thus improving health-related QoL. One way this can be achieved is by sharing, discussing, and practicing effective coping strategies. When faced with a stressful situation, such as communicating in a difficult listening environment, an individual with hearing loss inevitably develops some combination of positive and or negative coping strategies. Lazarus and Folkman (1984) described two types of strategies for coping with a chronic condition: problem-focused and emotion-focused coping strategies. Problem-focused coping emphasizes developing solutions to manage a health condition, whereas emotion-focused coping is achieved by managing one’s own emotional response to the health condition. A GAR program is an ideal setting to discuss and practice effective coping strategies. For example, most individuals with hearing loss report problems when going to the theater. In GAR programs, there is discussion about hearing-assistive technologies (HATs) that can be used in the theater (problem-focused coping). When group members hear about others’ successful experiences with these technologies, it helps to alleviate the stigma that may have prevented technology use in the past (emotion-focused coping). Rehabilitation programs that utilize a combination of problem-solving strategies have been shown to be most effective (Duangdao & Roesch, 2008; Preminger & Yoo, 2010). For example, success of the Active Communication Education (ACE) program (Hickson, Worrall & Scarinci, 2007a), a GAR program that focuses on communication awareness, education, and training for adults with hearing loss, has been well documented in the literature (Hickson et al., 2007a; Hickson et al., 2007b; Öberg, 2017). One of the primary activities of this program is the use of problem-solving interactive approaches that encourage participants to discuss their communication difficulties with group members and facilitators as well as to practice communication solutions. The group setting allows individuals with hearing loss to learn, share, and generate both types of coping strategies.

GAR programs facilitate reduction of the psychosocial effects of hearing loss in accordance with the Social Comparison Theory. According to this theory, people with similar health problems inevitably compare the physical and behavioral effects of the condition (Martin, Suls, & Wheeler, 2002). Downward social comparison occurs when a group member believes that he or she is coping better than others; for example, “That guy must have a really bad hearing loss because he keeps asking me to repeat myself. I can usually get it after the first repeat. Maybe I am doing OK.” Upward social comparison, on the other hand, occurs when a group member believes he or she is coping as well as others who appear to manage their condition in a satisfactory manner (Martin et al., 2002). Upward social comparison can inspire individuals to try new strategies or devices to manage as well as other group members. Individuals in a group setting find solace in realizing there are others like them. This comparison generates an understanding among participants that their stressful situations and reactions are not caused by some personal deficit. After comparing themselves to others, group members may feel that their problem is not so bad, that they are managing better than others, or that they can improve their situation. This comparison can have a huge impact on an individual’s psychological and emotional adjustments to hearing loss and is one of the keys to explaining the rationale for GAR.

As discussed in this textbook, a comprehensive view of AR takes a biopsychosocial approach rather than a biomedical approach. (For additional information on the biopsychosocial approach, see Chapter 11 of this text.) A biopsychosocial approach is consistent with the view that hearing loss is a chronic health condition rather than an acute health condition (Convery, Hickson, Keidser, & Meyer, 2019). A chronic condition cannot be cured; rather, it can be managed. For successful management to be achieved, the patient must actively participate in the process. James can benefit from GAR by learning about the connection between hearing loss and tinnitus and how to manage these chronic conditions.

Convery et al. (2019) describe the Chronic Care Model (CCM), which can be applied to hearing loss. In the CCM, the patient and the audiologist collaborate, and it is up to the audiologist to guide the patient in how to obtain support from the health care system (e.g., how to participate in shared decision making, where to get self-management support) and from the community (e.g., participation in support groups, self-help groups) (Convery et al., 2019). A GAR program is an ideal location to offer self-management support. Indeed, many self-management programs for individuals with chronic conditions such as diabetes or arthritis are delivered in small group workshops (Stanford School of Medicine, 2015). An effective self-management program includes the components in Table 18–1. Most of these components can be addressed effectively in GAR programs (Preminger & Rothpletz, 2016).

Effectiveness of GAR

When planning a GAR program, it is important to consider not only the class content, but also the process involved in creating and leading the group. (See Table 18–2, which lists seven factors to consider when designing and implementing a GAR program.) The majority of these process points are based on the work of Dr. Sam Trychin (2014). The first process point to consider is the role of the audiologist. The audiologist leading the group should not act as an instructor, whose role is the teaching of content, but rather should structure the class so that participants can begin to address the negative feelings and behaviors they may have developed as a coping mechanism. As an example, consider Irene from earlier. It is unlikely that she would have benefited from listening to a lecture on “understanding your audiogram” or learning about hair cell loss in the cochlea. After all, will learning how to read an audiogram help to destigmatize hearing loss? Will learning the difference between conductive and sensorineural hearing loss assist one in utilizing effective communication strategies? Likely not. Instead, the authors believe most individuals with hearing loss would benefit from actively generating and practicing effective communication. The processes and strategies described here are appropriate for both new and experienced users of hearing aids and cochlear implants as well as for those considering device usage (Abrams, Hnath-Chisolm, Guerreiro, & Ritterman, 1992; Heydebrand et al., 2005; Öberg, 2017).

One way to manage the group flow is to consider the class rules shown in Table 18–3, which are based on the recommendations of Trychin (Gagné et al., 2019) and Hogan (2001). These rules may be considered in the implementation of a typical group activity in which the facilitator describes a problem and the participants collectively offer solutions. Typically, the audiologist goes around the room and asks each participant to offer solutions. By following the first class rule (only one person speaks at a time) class members will learn an effective communication strategy: It is easier to hear one talker at a time. If a participant feels uncomfortable with the conversation, he/she should not be pressed to contribute (rule 2). Sometimes there are difficult class members who continually go off topic or who may present their thoughts in an unacceptable manner (rule 3). The facilitator can flag ineffective communication with a kind word, humor, or an example of a more acceptable way to contribute one’s opinion. Finally, if a class member is having difficulty understanding, he/she should speak up so that adjustments can be made (rule 4). As with all of the class rules, this one demonstrates an important communication strategy that may be used outside of GAR.

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