Working with post-lingually, severely deafened clients: Cultural vs. pathological perspectives.
Part three: Practical strategies for the clinician.
Graham Weir
M.A. (Counsl.)(Wash. D.C.) Cert. Audiom. (Syd.) FACAud
Audiometrist and Hearing Rehabilitation Specialist
This is the third and final installment of a three part article discussing a theoretical and practical framework for working with clients with severe to profound hearing loss since their formative years. The first installment identified eight cultural similarities with the pre-lingually deaf community. The second installment discussed a practical framework for understanding the implications of these cultural differences on communicative behaviour, and proposed a renewed focus on the impact of hearing loss on expressive communication skills, as the most effective foundation for building a rehabilitation plan.
In this final installment, we revisit the eight cultural differences described in part one, and in the light of the suggestions made in part two, suggest some practical working strategies that a clinician can adopt when dealing with clients with severe / profound hearing loss acquired during their formative years. Lastly, references to some useful treatment tools and further research are listed.
(1) Reliance upon vision as a key communication conduit.
Both the pre-lingually deaf and the post-lingually deafened, or severely hearing impaired client are vitally dependent upon a clear view of the face and lips of speakers during conversation. Since audible signals for these levels of loss are incomplete and easily misunderstood, even with amplification, visual signals from facial expressions and body language are far more critical for this group, than for people with mild or moderate hearing impairment who, with amplification, may still be able to follow conversation without necessarily seeing a speakers’ face.
STRATEGY:
All hearing services professionals should be fully aware of this need among all their clients. But it can be easy to forget and mumble a few words while working with the computer. When working with the severely hearing impaired, it can be critical to demonstrate understanding by ALWAYS facing the client and speaking clearly, without exaggerating lip movements. Male practitioners should be extra careful to be clean shaven, or at least ensure that the complete lips are not obscured by hair. Especially the corners. It is amazing how many lip-reading cues can be destroyed by this one factor. Also be careful to keep hands and objects away from your mouth while speaking.
(2) The use of sign language (either as a first or second language)
It is quiet common for many post-lingually deafened or severely hearing impaired people to have some degree of fluency in sign language if their deafness occurred in childhood, usually because they have been exposed to it at school or in social activities involving sign language users. There are some notable exceptions to this, namely children who have been educated in a strict “oral” only environment where any use of sign language was forbidden in the belief that exposure to signs would somehow damage their language and speech development. For people suffering severe or profound hearing loss later in life, this will rarely be the case. Frequently, the psycho-social impact of hearing loss on this latter group is far more significant than it is for those who, although of the same age, may have had the benefit of a lifetime of adaptation, and may be more likely to be able to utilise sign language as a secondary, supplementary language to maximise their communicative input, in difficult listening environments.
STRATEGY:
A working knowledge of sign language can sometimes be helpful when working with profoundly hearing impaired clients who are familiar and comfortable with using it as a supplement to their audition. But it can be a very sensitive matter that must be approached with great care. As a general rule, I will not use sign language unless it becomes obvious verbal communication isn’t working, and then I will first ask in both sign and speech, if they understand signs and would like me to use it to supplement my speech. A hint that sign language might have been part of their cultural environment can be the presence of a typical “deaf voice”, indicating long standing profound hearing loss. But this isn’t always a reliable indicator. Some deafened people might have grown up in an “oral only” environment where the use of sign language was forbidden and there will be a strong aversion to it’s use. There is a complex and heated history behind the “Oral vs. Signs,” debate so it is wise to always respect the client’s preferred method. If verbal communication methods simply don’t work and either or both of you can’t use sign language, then the easiest thing to do could be to open up a blank Word document on your computer screen and use this to type your questions / statements etc. allowing the client to answer verbally.
(3) Delays in educational development
Again, if the loss has occurred during childhood or very early adulthood, delays in educational development can occur due to iniquities in access to classroom presentations and audio-visual materials. This was very common as recently as 10—15 years ago, less so to-day with equal opportunity / anti-discrimination legislation impacting educational institutions. The impact of these delays can be profound, often producing a deep sense of injustice and resentment and even a fear of further educational or learning experiences. This can translate to a low tolerance for ambiguity that, in turn, can negatively impact social attitudes and interpersonal communication strategies.
STRATEGY:
Clients who have suffered educational delays due to their hearing loss, may benefit from some specialised vocational guidance assistance. Expressing an interest in their overall welfare by asking questions about how their hearing loss impacts their family and work life can often bring any unmet needs to the surface. Particularly in regard to the need for technological assistance in the workplace or classroom. Older clients who may have missed out on the current benefits of equal opportunity legislation in educational settings, and are interested enough to explore opportunities again, might benefit from a referral to a specialised disability counsellor at a nearby further education facility. Making contact with the counsellor on behalf of the client and offering your expertise to help ensure technological interface needs can be met by the facility, can go an extra mile that can make an enormous difference to your client’s rehabilitation potential.
(4) Delays to social development
In the normal hearing population, where a mild or moderate hearing loss may be suffered later in life, it is usually the impact of hearing loss on social function that prompts the sufferer to seek professional help. These barriers to social function are far more severe and significant for those with severe or profound hearing loss, particularly post– lingual, total deafness. An inability to fully participate in social function, especially during developmental years, has a dramatic effect on perception, personality and social engagement, particularly if the sufferer is living among a group of normal hearing people. 2 This is not dissimilar to the social isolation experienced by a non-English speaking new Australian. Surprisingly, this is much less a problem among a community of deaf sign language users, for the simple reason that there is usually only minimal language diss-fluency or impoverished communication diet among them. Social isolation only becomes a problem for sign language users when dealing with “outsiders” in the hearing world who cannot sign fluently.
STRATEGY:
The audiologist can be instrumental in identifying the need for remediation by using the questionnaire previously illustrated in table 1. If satisfactory change doesn’t occur at post-fitting follow-up sessions, that is a good indicator that more extensive communication skills training will be needed, both on an individual and group basis. If specialised professional assistance is not available, a self-help group such as S.H.H.H. or Better Hearing may be the best resource to use. Often, even if they don’t conduct formal courses in effective communication, members of these organizations can be highly effective change agents by being role models of communicative behaviours, thus helping the client unconsciously develop adaptive strategies that work best for them. Here, they can learn while also having a good time in a less threatening environment, with people who understand and accommodate their communicative needs. Helping clients to improve their communication diet doesn’t always need to involve formal sessions with a specialised trainer. Association with effective and understanding role models can sometimes be all that is needed to achieve a satisfactory transfer of skills.
(5) The importance of spatial orientation in communication interaction.
Unlike the normal hearing or mildly hearing impaired population, who can usually communicate in a variety of spatial arrangements without the need to change layouts to see speakers faces and minimise acoustic interference, people who have become severely or profoundly hearing-impaired, pre or post-lingually, have a critical need to maximise their receptive communication skills by organising the spatial layout of room furniture and controlling acoustics to minimise environmental negatives, even if they are wearing hearing technology. However, many will not be aware of this need ,or may feel powerless to change their environments as needed. A culture of “learned helplessness” from years of passive compensation strategies, can inhibit the development of the necessary levels of confidence and assertiveness to change environmental negatives.
STRATEGY:
Again, there isn’t much an audiologist can do about this need in the clinical setting, other than counsel the client about how to change room acoustics for optimal benefit. The difficulty usually isn’t that the client doesn’t know how room acoustics affect their hearing ability. They may just not know what to change or how to change it in social situations. Again, involvement with a self-help group may give the best opportunity to learn effective coping strategies. Practical demonstrations can save many words.
(6) Barriers to conventional use of media and communication devices.
We live in an increasingly media dominated world. In particular, ability to utilise audio based telecommunication devices is critical to employment and social engagement. But in spite of technological breakthroughs in hearing instruments that enable improved access for the mainstream of hearing aid users, access to these technologies is still largely very difficult for both of the groups under discussion here. Even as access to telecommunication audio signals does improve, there is still the insurmountable barrier, that with such severe levels of hearing loss, only part of the audible spectrum can be improved with hearing aids. A degree of residual disability (albeit a lesser one) still remains that demands a visually based, technological solution. (e.g. S.M.S.; Email etc.)
STRATEGY:
This is one area where the skill and knowledge of the audiologist can be vitally important to successful hearing rehabilitation. The need for interface with audio based media and communication devices should be part of every client’s initial history questionnaire and recommended technology must be selected with these needs foremost in mind. Never make assumptions about this. Always ask about their current experiences and needs and demonstrate the benefits during the fitting process. In my clinic, we have an audio loop and an infra-red TV listening system plus a telephone with very good inductive coupling in the handset. Every client experiences the use of the phone via their hearing aid’s telephone program as well as the television interface as part of their routine fitting experience. In some cases, specialised business phone or classroom interface devices need to be sourced. This requires a professional interest in ALD hardware and a commitment to ensure these vital needs are not allowed to fall through cracks in the hearing rehabilitation program just because of neglect to equip a clinic effectively for financial reasons. Investments of time and money in this area will reap immeasurable benefits for the client and their commitment to you as their preferred practitioner.
(7) The communication diet may be severely impoverished.
Mental health is significantly impacted by the frequency, quantity and quality of communication interchanges with significant others in relationships. No relationship can survive on a diet of superficial communication most of the time. There must be sufficient meaningful, personal interaction on a regular basis. This is easy enough among families or groups with normal hearing. Untreated hearing impairment directly affects these variables in much the same way as inequality in language fluency, (e.g. non-English speakers in Australian society.) For the severely or profoundly deafened individual however, where hearing technology cannot fully restore receptive hearing ability, significant challenges to fluent and easy communication still exist. Frequently, this impacts negatively on the individuals’ communication diet and can result in compensative communication behaviours that may be seen by un-impaired individuals, as unusual, inappropriate or even aggressive.
STRATEGY:
The presence of an impoverished communication diet will not always be evident without targeted questioning. Again, the questionnaire in table 1. can be helpful in flagging this need, especially if technology solutions don’t produce much change in the five critical questions at post-fitting follow-up sessions. With severely impaired clients, hearing aids alone are unlikely to entirely solve their speech-in-noise problems. FM technology will usually be needed to optimise their performance in difficult listening environments. Identification of the listening environments critical to their lifestyle or culture is a vitally important component of an initial questionnaire. Especially if the audiologist is able to establish which environments cause the difficulties recorded in table 1. Perhaps the best time to explore the health of the client’s communication diet is during discussion of their responses on the initial questionnaire. Then bring the subject up again during the follow-up interview if it becomes obvious little change has occurred in the five questions in table 1.
(8) The use of interpreters or advocates to assist articulation of needs or ideas.
In the non-English speaking community and also the Australian Sign Language community, the use of advocates or professional interpreters in important communicative situations is an accepted norm. And at least where sign language is involved, will be a government funded service in some, if not all situations.
Unfortunately, no formal interpreting assistance structure yet exists in Australia for a person with profound hearing loss who is not a sign language user. In Australia the National Association for the Accreditation of Translators and Interpreters (N.A.A.T.I.) does not formally recognise “Oral interpreting” as a legitimate translation as lip-speaking is not a “language”. In contrast, the USA’s interpreting assistance programs allow for “lip-speakers” or “oral interpreters” as an alternative to sign language interpreters, if needed.