during the following week and was asked to report back on the results at the next session.
We discovered that most of the problems or concerns raised were commonly experienced among all of us and our communication partners. We learned the power of role-playing problem situations and their possible solutions in the group setting as a means of directly seeing the root causes of communication breakdowns and the essential features of what can be done to prevent or reduce them. Early on, we learned the necessity of practicing and polishing new communication behaviors in the safety of the peer group prior to attempting to apply them out in the real world. We were struck by how difficult it is to change long-standing communication behaviors that are over-learned and often have a strong emotional undercurrent. These seemingly easy-to-modify behaviors often require practice over extended time before they become habitual (Watson & Tharp, 2007).
The process of establishing techniques for running groups for people with hearing loss and their communication partners evolved over time, but many of the methods I currently employ were developed during this first group encounter. This group experience had a profound personal effect on me. I became aware, for the first time, of the social and emotional effects of my hearing loss. I began to connect hearing loss to my tendency to be a lone wolf professionally; that is, to always manage to be an independent practitioner while still working within a formal organization such as a hospital, clinic, or university. Also, until that group experience, I had always preferred working with patients one on one, most likely due to my ignorance of effective communication strategies that enable understanding in groups. Since that group experience in 1984 to 1985, I rarely work with people individually, always preferring a group format. I also began to relate my tendency to be somewhat on edge to a chronic, low-level anxiety that often accompanies a lessened ability to be connected with the physical and social environments. From that group experience, I learned the necessity of monitoring my own tension level and finding ways of reducing it when necessary.
At the end of the first 8 weeks, the group elected to continue for an additional eight sessions, followed again by another. That first group continued for 32 weeks, during which we produced several books and videotapes demonstrating what we found to be effective in dealing with hearing loss-related communication problems. During the same time the first group was meeting, another group composed mainly of SHHH chapter members asked for similar meetings in Baltimore, MD. I went there as well and we followed the same format as the first group and continued weekly for 21 weeks. Over subsequent years, I have taken the information garnered from these early groups across the United States and to many locations in Canada. With each group, I learned a little more, but the basic information about people’s experience with hearing loss gleaned from those first two groups remains the same no matter the geographic location or time, whether 1984 or 2012 (Trychin, 2003a, 2006).
Virtually all of this work has been done with adults, but in 2002 my wife, Janet, an audiologist, and I were asked to conduct a weekend-long program for adolescents in Portland, OR, who have hearing loss. Forty adolescents from various areas in Oregon, Washington, and Idaho participated in the program. The following year, we were invited back to Oregon and conducted another weekend program. Several other adolescent groups grew out of this program and what we found was a little surprising: Early, middle, and late adolescents experience the same basic problems, issues, and concerns as adults, and the same strategies for effectively coping with hearing loss apply similarly to adolescents as well as adults.
Importance of Including Communication Partners
Because hearing loss is a communication disorder, it affects both the individual who has it and those who are attempting to speak to him or her—the communication partners (CPs). The perspectives and experiences of both must be taken into consideration during assessment, treatment, and follow-up. Table 5–1 describes the importance of CPs in the life of people with hearing loss.
Certainly, more intimate CPs—those who communicate with the person who has hearing loss most frequently and meaningfully—are likely to be most strongly affected by communication breakdowns. They are also the ones who can be most helpful in establishing interpersonal and environmental conditions that increase the probability that the person with hearing loss will understand what is being said. However, the vast majority of people who have hearing loss find themselves in situations that demand communication with other people as well.
In the past, we have focused on the term significant others when referring to those people with whom the person with hearing loss communicates. Usually, we think of significant others as a person’s spouse, lover, child, parent, other family member, and/or close friend. Most people communicate with a variety of people, however, in the course of a day, week, month, or year. The term communication partner is preferable because it encompasses any and all of these other people as well.1
Table 5–1. Importance of Communication Partnerships (CPs) for People With Hearing Loss
aWe always attempt to minimize or eliminate any dependencies of the person who has hearing loss on his/her communication partner. We encourage people to manage their own communication situations and rarely, if ever, depend on a partner as an interpreter. Independence fosters increased self-confidence/self-efficacy and minimizes resentment on the part of CPs.
The most important CP at any given time is that person with whom the individual with hearing loss is conversing. Mary, for example, may be in face-to-face communication with her physician only once a year, but at that moment, the physician is her most important CP. In addition, the physician needs to ensure Mary understands the information being presented. A comprehensive program whose goal is helping people prevent or reduce communication problems needs to incorporate the fact that there is a wide range of communication demands on a person, not only those that concern the intimate partners. Such a program needs to include information and training on what can be done to reduce problems in a wide variety of challenging communication situations.
It is unlikely that these other CPs will participate in a program designed to improve communication; however, the more intimate and frequent partners may be more motivated to attend. The next section focuses on information, skills, and attitudes that have been found to be helpful for both the person with hearing loss and her/his intimate communication partner(s).
Strategies, Tactics, and Tools for PHLs and Their CPs
Overall, effective management of hearing loss requires specific attention to two different, but related, areas of human experience. First is learning to manage the external environments in which people find themselves, including the physical environment and the social environment. In the former are environmental stimuli that affect safety and pleasure, such as alarm signals and music. Support from the social environment is absolutely necessary for human survival at early ages and for continued health and wellbeing at later ages (Cacioppo et al., 2006; Hawkley & Cacioppo, 2003). It is most helpful for people who have hearing loss (PHLs) and their CPs to know about assistive alerting and listening devices to help stay in tune with the physical environment. It is necessary for both PHLs and CPs to know what to do to maintain social connectedness as well.
The second area of human experience involves learning to manage the internal environment or learning to manage one’s self. High levels of emotional arousal inhibit cognitive functioning, reducing the person’s ability to use good judgment in problem-solving attempts (Childre & Rozman, 2005, 2006). When a person is angry or anxious in a communication situation, that anger or anxiety interferes with that person’s finding ways to resolve the communication difficulty and often increases difficulty in understanding what is being said. It is important to address the effects of emotional responses because there will be times when people have done their best to improve understanding, but are unsuccessful because others will not cooperate or the environment cannot be altered.
Managing Communication Situations
We have found the following types of information to be critical in learning to manage communication situations: signs and symptoms of hearing loss, myths and misconceptions about hearing loss, problems frequently reported by PHL and CPs, and causes of and dysfunctional reactions to communication problems. Over time, we also found that this order of presentation of these topics (Table 5–2) works best and that it helps to cover only one topic at a time, rather than causing confusion by attempting to include multiple issues all at once.
Identifying Communication Problems and Their Causes
Signs and Symptoms of Hearing Loss
Many people are reluctant to inform others about the fact that they have a hearing loss. Some people do not acquire hearing aids and others who have them do not wear their hearing aids in public settings out of fear of embarrassment, being seen as different, or being rejected. Social stigma concerning hearing loss certainly contributes to these concerns (Gagné, Southall, & Jennings, 2009). In our groups, members are asked to identify and list signs or cues that might indicate that a person has hearing loss, such as the cues noted in Table 5–3. Table 5–3 illustrates the behavioral signs of communications breakdowns.
The reason for this exercise is to indicate that if others are not informed about one’s hearing loss, the signs and symptoms are still there and may be attributed to other, more negatively perceived characteristics (e.g., personality problems, rudeness, social ineptitude, dementia, uncooperativeness, etc.). I try to have members see that it is really in their own best interest to inform others that they have a hearing loss and that any difficulties that arise may be due to the hearing loss and not to some undesirable personal characteristic.
Myths and Misconceptions About Hearing Loss
There are several misconceptions about hearing loss that impede taking effective action and making necessary accommodations. The misconceptions occur both among those with hearing loss and those in the general public. Providing accurate information opens the door for adopting realistic attitudes and taking effective action. Table 5–4 provides examples of misconceptions that are commonly addressed in groups.
Problems Reported by People Who Have Hearing Loss
Group members who have hearing loss are always asked to report any problems they experience due to hearing loss. This is a useful exercise for three reasons. First, it allows people to consider the full range of effects of hearing loss on their lives. Second, it may clarify other issues they might not previously have considered being related to their hearing loss (e.g., fatigue, irritation, or digestive problems). Third, it provides opportunity for CPs to increase their awareness of the impact of the effects of hearing loss and that these problems are not due to a personal weakness or deficit in their partner who has hearing loss.
There are three basic types of communication problems that are frequently raised in my groups. The first type of problem occurs when the person who has hearing loss is unaware that someone is speaking to him. Given this situation, there is no possibility that the message will be received, and even if the person at some point tunes in to the fact that he is being addressed, the speaker will most likely have to go back and repeat the earlier part of what was said. The second problem occurs when the person who has hearing loss is aware of the fact that she does not understand what is being said to her. This type of problem is easy to correct if she knows how to identify the cause of the problem and offer a solution, e.g., “I need you to speak a little louder.” Depending on who is talking and the nature of the situation, however, many people resort to bluffing rather than revealing that they do not understand. The third type of communication problem can produce the greatest difficulties and that occurs when the person who has hearing loss misunderstands what is being said.
The problems created by misunderstandings are often not revealed until a later time when it may be too late to make a correction. For example, the boss tells the employee to not exceed $15,000 on the Smith contract and the employee who has hearing loss hears $50,000 instead of $15,000 and signs the contract for $25,000—$10,000 more than the boss had budgeted, thinking he has made a good deal. We often devote time during group sessions for members to report any misunderstandings they recently experienced. When shared with understanding peers and viewed more lightly, the emotional effects of the misunderstandings can be softened, especially when they can be reviewed with a dollop of good humor.
The following is a personal example of one of my own misunderstandings. During the time that President Clinton was running for office for his second term, I was listening to the radio and heard the announcer say, “Voters don’t like politicians who take aspirin.” I wondered what kind of pollster would go into people’s medicine cabinets to determine how they would vote. Thinking that what I had heard was probably incorrect, I listened more carefully and discovered that he had said the word action and not aspirin. My brain had heard the beginning a and the ending n of the word, missed the middle part, and filled in the gap with a word from its lexicon. This process did not result from a conscious decision; it happened automatically and instantly.
Another example I frequently use during presentations is as follows. I was to do a week-long training on coping with hearing loss at the California School for the Deaf in Riverside, CA. Two people came down from Riverside, CA, to pick us up at the Los Angeles airport and guide us back to the training site. I was seated in the back seat next to the left-side window and one of the women who had driven down to get us was sitting next to me in the middle of the back seat. I noticed she was wearing hearing aids and decided to make some conversation with her. We drove past a large building and I asked her what its name was. She replied, “It’s not very far.” I said, “I don’t think you understood my question; I asked the name of that big building we just passed.” She responded (somewhat testily), “IT’S NOT VERY FAR!” Now, I was getting a little annoyed and said (somewhat louder than before), “We passed a large, tower-like structure about a mile ago, and I want to know its name!” She replied, “IT’S KNOTT’S BERRY FARM!” (which is a local theme park). The main point of this example is that I had been doing this work with folks who have hearing loss for about 15 years at that time and would have bet $1,000 that she had misunderstood and that I had heard correctly, but I was the one who had misunderstood. That experience really penetrated my consciousness and increased my awareness of the insidiousness of misunderstandings.
We find it very important to ensure that group members are aware of the possibility for, and results of, such misunderstandings because they occur frequently and in a variety of situations. A very recent example that is much more alarming than humorous occurred during a tour of the White House in Washington, D.C. A man who has hearing loss and his wife were attending the tour and standing with a group in the basement of White House waiting for the tour to begin. A uniformed security guard came into the room and told the tour guide to wait because, “We just found out Obama is on the first floor.” The husband had a panic attack, felt faint, and had to be seated on the floor. What he had heard was, “We just found out a bomb is on the first floor.”
It is important that both the people who have hearing loss and their frequent CPs know about misunderstandings and their effects. A good rule is: If something you hear seems strange, check it out. Another good rule is: Always repeat the important parts of a message, e.g., who, where, when, and numbers. In that way, if the person has misunderstood, it can be corrected on the spot. As illustrated in Table 5–5, the pervasive impact of hearing loss can affect all of a person’s life, from the time of arising to going to bed at night. For some, it even affects their sleep.
Problems Reported by Communication Partners
Having the CPs report the difficulties they experience related to the hearing loss highlights its impact on others. Listening to someone else’s CP report difficulties that their own partner has been voicing for some time allows the person who has hearing loss to step back a moment and consider that the problem is valid and not simply due to some idiosyncratic complaint of their partner. It is truly eye opening for people who have hearing loss to see that CPs’ list of problems is as long as their own.
As reflected in Table 5–6, consideration of this list reveals the many ways in which hearing loss can negatively affect relationships, as well as the personal status of both the person with hearing loss and the CP.
Problems Reported by People Who Have Hearing Loss Related to Specific Situations
Along with the problems and concerns cited in the preceding list, people who have hearing loss are vulnerable to barriers to understanding that are often inherent in specific types of situations such as business meetings, church services, and classroom settings. Table 5–7 illustrates the unique barriers of one such situation—a work training site.
Table 5–6. Examples of Problem Situations for Communication Partners
Note. Examples of communications partners referred to here are family, teachers, and friends.
Employees or trainees who have hearing loss are at high risk for failure to miss important information in training environments. When appropriate accommodations are in place and instructors or trainers are using communication tactics that enable all trainees to understand what is being said, people who have hearing difficulty can reach or maintain their potential and be equally productive. It may be helpful to keep in mind that the major tasks for people who have adult onset hearing loss are continuing their education or training and maintaining their jobs or career, relationships, self-respect and confidence, and health. Appropriate accommodations during orientation and training sessions and on the job increase an employee’s ability to accomplish these tasks and function up to her/his ability.
Causes of Communication Problems
It happens with some frequency that if you ask someone who has hearing loss about why they did not understand what was just said they respond with something like, “Because of my hearing loss.” It can be fairly depressing if the person has bought expensive hearing aids and uses them regularly, but still has communication difficulties. Fortunately, that limited view of the cause of hearing loss-related problems is incorrect. There are many other causes of difficulty understanding what is being said and most of those can be prevented or reduced. There are things that the person speaking is either doing or not doing that contribute to communication breakdowns. The same is true of the listener who has hearing loss. Additionally, there are features of the physical environment in which the message is delivered that contribute to communication problems (Trychin, 1994). Table 5–8 provides examples of the kinds of variables that can be causal factors creating communication difficulties. When the person who has hearing loss and his/her CP become aware of these causal factors, it is then possible to determine the source of a specific communication breakdown and suggest and implement a correction.
It is most important that people who have hearing loss and their CPs become aware of the physical environmental factors that can interfere with understanding what is being said and/or prevent hearing or locating the source of important environmental sounds. Environmental barriers to hearing well are often the major contributors to communication breakdowns and their effects can usually be prevented or reduced once their presence is known. Some of the environmental factors listed in Table 5–9, such as background noise, are obvious; others are more subtle and people need to consciously watch for them.
A major contributor to communication problems is the inability to pay attention. When it is difficult to understand what is being said, a normal response is to tune out and think about something else. Some people in our groups have practiced tuning out so frequently that they now have difficulty tuning in. Sometimes, the person who has hearing loss only attends to his/her frequent CP and becomes dependent upon that person for everything said by others.
A good example of this dependency occurred at Ghost Ranch in Abiquiu, NM, where for 12 years each summer I taught an intensive 7-day class for people who have hearing loss and their CPs. At the beginning of each session, there was a general orientation meeting. I always put an induction loop system in an area of the auditorium where the general orientation session was conducted to allow people who have hearing aids to more easily understand speakers’ remarks. One year, I was seated behind a married couple within the looped area and observed that after every statement made by a speaker, the husband, B., turned to his wife and asked, “What was that?” She then repeated what had been said. After watching this for a few minutes, I tapped B. on the shoulder to say that if he had a t-switch on his hearing aids he could hear directly what was being said. His response was, “Yes, I have them and they’re on.”
I was struck by the fact that B. could hear both me and his wife when his hearing aids were on the telecoil program with the room microphone feature turned off, but could not understand what was coming directly through the telecoil. It was apparent that B. only took information from his wife, not from anything or anyone else in the environment. I separated B. and his wife during the first class session so that B. would not be able to rely solely on his wife for information. B.’s wife became visibly upset at being separated and I inquired about the cause of her appearing to be upset. She responded, “I don’t think he’s going to make it.” I asked if she was concerned about his physical survival, and she stated that she did have that fear. We agreed to keep them separated for an hour or so to see how he would do. He was able to survive the separation so we continued keeping them apart for the whole week. B.’s habit of depending on his wife was so strong, however, that it took two and a half days before he began to be able to function independently in the group. For the first 2 days, he made no active effort to understand what others in the group were saying. I repeatedly asked B. what had just been said and he responded with, “I have no idea!” in an irritated/angry tone of voice. I would then ask the speaker to repeat what had been said and ask B. to look at the person speaking. Then, I would again ask B. to repeat what had been said. Usually he was then able to understand correctly what had been said.
Other group members began to express irritation at this process, but on the third day B. began to learn that, with some effort and practicing paying attention to whomever was talking, he could follow what others were saying. From Thursday to Sunday, B. became an active member of the group and was mostly able to follow whatever was being discussed. At the end of the last day, his wife took me aside and said, “I think this experience has saved our marriage.” She was caught in the bind of believing he was unable to “make it on his own,” but hating the role of being a “walking hearing aid.”
One moral of this story is that being a frequent interpreter is a real burden and CPs can quickly come to resent that role, resulting in damaged relationships. Another moral of this story is that some people who have hearing loss need training to recover their ability to pay attention to what is being said by whomever is speaking at the moment. There are habits, such as depending on others, that become so ingrained that special efforts are often required to establish new, more functional, habits in their place.
As discussed earlier, Tables 5–8 and 5–9 highlight multiple influences, often interacting, that render conversation difficult to understand. Experience indicates that when people are able to use this information to determine the cause(s) of a communication problem and find a way to correct or repair the situation, they are less likely to keep returning to their audiologist to have her fix the hearing aid so that it will work better, that is, eliminate communication difficulties.
Reactions to Communication Problems
Once a communication problem arises and is noticed, both the person speaking and the person listening will react to the communication breakdown in some way. Some reactions are productive—they resolve the problem. Other reactions are unproductive—they fail to solve the problem, or make the situation worse (Trychin, 1995). It is most important for people who have hearing loss to identify their own unproductive reactions to communication breakdowns and replace them with reactions that are more productive.
Rather than becoming upset and withdrawing or blaming the other person, it would be more productive, for example, to identify the cause of the problem and offer a solution such as the following: “I was not paying attention when you said that and I’d appreciate your repeating it; I’d really like to know what you said” or “I’m unable to follow what you are saying unless I can see your face; can you please come around where I can see your face when you talk? That’s much better, thanks.”
People respond to a communication breakdown in several ways: physically, emotionally, cognitively, behaviorally, and interpersonally or socially. Table 5–10 illustrates these reactions to communication problems.
Physical Reactions
Physical complaints are a result of the body’s activation as it attempts to prepare to defend against threat or danger. These built-in protective processes include changes in heart rhythm/rate; blood vessel constriction; blood shunting from digestive processes; respiration changes—shallow, rapid breathing; hormonal activation; increase of adrenalin, cortisol, etc.; neurotransmitter activation; and pupil dilation. These reactions occur below the level of conscious awareness and therefore are often not under conscious control. Acute, transient physiological reactions subside rather quickly and do not pose a risk to health, but prolonged or chronic physiological arousal is implicated as a causal factor in many different forms of disease. Chronic physiological arousal also produces fatigue. Fatigue affects ability to pay attention and inability to pay attention increases difficulty understanding what is being said: A cycle develops that needs to be interrupted.
Emotional Reactions
When emotional arousal is high or prolonged, the verbal areas of the brain shut down, rendering it difficult to use judgment to solve a problem, such as determining what might be the best solution for a communication breakdown. Additionally, negative emotional arousal produces discomfort that induces the sufferer to withdraw from the distressing situation that produced the discomfort (Kanfer & Goldstein, 1991). Unfortunately, some people who have hearing loss experience social anxiety resulting from repeated embarrassing communication difficulties and isolate themselves to avoid risking re-experiencing the anxious feelings.
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