While we informed our patients they should come to us to discuss adjustment problems, etc., in reality, once the patient received the hearing aid from a dealer, the dealer -- more often than not -- assumed responsibility for after care. People rarely returned to us for follow-up.
For our part, we conducted "Aural Rehabilitation" in our university clinics, defined mainly as speechreading classes, for people we could convince to take advantage of our free services. These classes were supervised by master's level supervisors, and conducted by students needing practicum hours for certification. This type of practicum, divorced as it was from responsibility for the fitting and follow-up care of hearing aids, seemed more like an inertial deference to our roots, rather than appropriate clinical training which students could actually employ in their careers. Certainly, patients who attended these programs did benefit - in their acceptance and adjustment to the hearing loss, if not in improved speechreading skills. However, insofar as the students who conducted these classes were concerned, this may have been the last time in their career that they ever provided such services.
Our hopes of "doing it all" if we assumed responsibility for dispensing now seems like a forgotten dream. Instead, what we seem to have done is basically adopt the very model we criticized 30 years ago. We do the testing, fit the hearing aids, schedule one or two routine follow-up appointments, and ask people to "call if there is any problem." Aural rehabilitation (A/R), even the traditional types of speechreading and auditory training, rarely takes place. In a way, hard of hearing people are worse off now than they were before; traditional A/R programs are now less available in non-profit centers -- and only occasionally on a fee-for-service basis -- in any type of center.
I think it is instructive to review how it all began.
When the government decided during WW II to develop programs to rehabilitate servicemen with hearing losses, the military hospitals developed a concept in which the delivery of a hearing aid was just one component of a comprehensive A/R program. Their mission was not simply to provide hearing aids to servicemen, but to try to reduce the overall impact of hearing loss, as much as possible. Many professionals, representing a number of specialties, pre-planned an aural rehabilitation program to help prepare hearing-impaired servicemen to re-enter civilian life. The "planners" thought it would take about eight full weeks to accomplish this goal, during which time servicemen would receive a variety of perceptual and speechreading classes, auditory training activities, vocational and psychological counseling, information about hearing loss, and be fit with hearing aids.
Thus, patients who were issued hearing aids, also received a comprehensive A/R program -- at the same time. The residential program was the norm and it was in those settings that the "Carhart Method" of hearing aid selection was first devised. Hearing aids could be selected, tried for several days or even weeks, discarded and a new one fit, if necessary. Follow-up testing was scheduled weekly. Adjustment problems were managed as they occurred, earmolds could be made as needed, and there was always somebody there to discuss problems and issues. Hearing aid selection was treated as a component of an A/R program, not an end in itself.
After the war, the profession separated responsibilities for hearing aid selection from the rest of the aural rehabilitation program. Since we could not actually dispense hearing aids, we limited ourselves to hearing aid selection, usually based on results from the Carhart procedure. In the meantime, while developing the academic curriculum for the emerging profession of audiology, the content of the A/R course focused primarily on speechreading and auditory training. Hearing aids, psychosocial issues, and coping strategies were mostly ignored in many A/R courses. Thus, we saw a separation, enshrined in our training programs, between the selection of hearing aids and aural rehabilitation.
I believe that, as much as possible, we should return to the original model, in which the dispensing of hearing aids was but a single component of a rehabilitative process, rather than an end in itself. While we can hardly emulate the residential aspects of the initial military A/R programs, we now know enough about what is essential, and what is not essential, to distill its essence into a "do-able" program. Thankfully, we don't need two full months (as was the original military plan) to effectively respond to the communicative needs of people with hearing loss -- although I admit the interlude from military life was a welcome break!
We need to do more than focus on the hearing aid as a miracle device. We don't want to send the message that the hearing aid is a sufficient response to problems wrought by hearing loss. In fact, it is necessary to deal with all the other issues that accompany hearing loss. The most logical time to address these issues is when the person is being seen for a hearing aid evaluation. We also need to recognize that people do require more information and follow-up on issues specifically related to hearing aids.
To accomplish these goals takes time. Indeed, much more time is required than is routinely devoted to follow-up counseling by the current generation of hearing healthcare professionals. Kochkin found that 87% of new hearing aid users received one hour or less of follow-up counseling, while 43% received a half-hour or less. No matter how efficient we are in providing services, this simply is not enough time to effectively communicate A/R issues and strategies. With such little time allotted, the focus has remained on the hearing aid itself. This type of practice trivializes the sense of hearing and the role audition plays in our lives. It ignores the importance of being able to efficiently engage in interpersonal communication. A hearing loss is not an ingrown toenail that can be "fixed" with one or two visits to the doctor.
In brief, what I'm recommending is hearing aid dispensing should be redefined, such that the hearing aid itself, would serve as a component of a rehabilitative process.
We (hearing healthcare professionals) shudder at the acquisition of mail-order hearing aids, in which the absence of an audiological evaluation is touted as a benefit. We maintain that hearing aids cannot be appropriately fit without professional skills and a comprehensive audiologic evaluation. Therefore, we should accept the same logic as it applies to the rehabilitative process...the hearing aid dispensed is part of the process only, and to separate the item from the process, yields an unsatisfactory result.
The decision to purchase hearing aids is not one taken lightly by hard of hearing people. Beyond the specifics of where to go and what to buy, they must first accept the reality of their hearing impairment. For many people, this is a difficult period and they need all the help, information, guidance and support that they can get. Some hearing aid users expect more from hearing aids than is realistically possible, while others may not be deriving as much benefit as they can from the device they purchase/own.
During the course of the hearing aid selection process and several follow-up appointments, most hearing aid dispensers make a sincere effort to respond to their client's informational needs. However, much of this information will be incompletely understood or retained by the hearing aid user. It takes time to assimilate new information, and this simply can't be done in the traditional post-dispensing "counseling" sessions.
Additionally, there are inherent limitations in the effectiveness of the one-on-one dispenser-client relationship. There are some topics and areas of need that can best be met in group settings, where people with hearing loss have an opportunity to learn and share with others who have similar problems. The exchanges and opportunities that occur in group settings offer advantages and possibilities that cannot be met in individual appointments. The effectiveness of group hearing aid orientation programs has been repeatedly demonstrated in studies which compared hearing aid satisfaction and use by people enrolled in such programs, compared to those not enrolled.
While many clients will not accept the option, people who purchase hearing aids should be offered an opportunity to participate in a group hearing aid orientation program. Typically, group hearing aid orientation programs consist of weekly 1 ½- to 2-hour meetings for about 4 to 6 weeks. While the specific content and outline varies, the intent is to provide an instructional component and time for the emergence of group exchanges. The goal of group meetings is to foster interactive dynamics in such a way as to stimulate mutual support and information among the members. Since hearing loss is a "family affair," the participation of relatives and friends should be seen as a key objective. A group hearing aid orientation program is also a good way to communicate the partnership concept that all of us - professionals, family, friends and patient - are working together towards a common objective.
Implementing the Program:
I would like to make it clear that I am not making an original suggestion. Some version of group hearing aid orientation programs has been practiced since WW II, when the profession of audiology started. There are some excellent group hearing aid orientation programs across the nation, and there exists extensive literature on the topic.
When the subject of group hearing aid orientation programs is raised, two objections seem to emerge:
- The economic constraints of providing this service, and
- The apparent lack of interest by clients in the service (although few question their potential effectiveness).
After it has been "launched," it is estimated that no more than two hours per week need be devoted to the group hearing aid orientation program. Ordinarily time is money, but this appears to be one of those propitious instances where time can pay for itself.
Consider:Lack of Interest or Need:
- The incidence of hearing aid returns is likely to be considerably lower for people who attend hearing aid orientation programs than for those who don't.
- An ongoing program allows problems and unrealistic expectations that come up during the first months of hearing aid usage to be remedied as they occur, before people lose patience and return their hearing aids.
- Time spent troubleshooting and sharing "normal" problems can preclude returns and reduce unscheduled drop-in visits.
- A hearing aid orientation program translates into more satisfied and loyal clients, and they're going to stick with you when they need hearing aids in the future. Your clients will get to know you as a person as well as the presence behind the audiometer. More satisfied users also means more word-of-mouth referrals, which is arguably the most effective marketing strategy there is. The inclusion of family members and friends multiplies the number of contacts and future referral sources. There's always going to be more than one person in the extended family or social circle that has hearing loss and can use hearing aids. Make a good impression through your group hearing aid orientation program, and some of these people may come flocking to your doors.
- The group hearing aid orientation program provides sufficient time to display, demonstrate, and dispense other types of hearing assistance technologies, such as assistive listening systems and signaling and warning devices. From my perspective, this is a major weakness in current dispensing practices; we can all agree that hearing aids are necessary, but they are also insufficient in many instances. In a group, the decision by one person to purchase some assistive device or other accessory, or to sign up for a battery re-supply program, encourages other clients to do the same.
- While a group hearing aid orientation program should supplement and not supplant individual orientation programs, it's likely that the group meetings may eliminate the necessity of some individual meetings, particularly the unscheduled drop-ins that occur when people are having problems.
I sometimes hear hearing healthcare professionals claim that a group hearing aid orientation program is not needed because they already take "adequate" care of their clients. I don't doubt the sincerity of the statement, nor do I don't doubt that care can be improved with a group program. It is a little self-serving to assert that one's clients don't really need a more intensive follow-up program when one is not available for them. We all seem to get a little defensive when possible procedural improvements are suggested, since this implies a criticism of ongoing practices. We need to keep in mind, though, that the point is not criticism but professional growth; moving towards a new way of practicing inevitably implies a movement away from a previous practice.
Other hearing healthcare professionals claim they've offered group programs in the past and that people didn't show up.
Yes indeed, that does happen; many clients will not take advantage of all of the follow-up opportunities offered, even when there is no charge, including a group hearing aid orientation program.
But how was the recommendation made? Did it begin with an incidental comment subsequent to the hearing aid selection process, or was the group HA orientation program built into the process from the beginning? If we define the entire selection process to include the routine inclusion of a group HA orientation program, if we really believe in its necessity and efficacy, and if we communicate our conviction to our clients, people will come. They will follow our professional recommendations. Not everybody, certainly, but since when do we base the inclusion of any recommended therapeutic procedure on the fact that some people choose not to comply? We do what we can for whom we can.
A group hearing aid orientation program is not psychotherapy, and a hearing healthcare professional (whether an audiologist or hearing instrument specialist) is not a trained psychotherapist. We have to know our limitations and when they have been exceeded. The focus of the group should be upon the global impact of the communication problems caused by hearing loss, and how these can be minimized or alleviated through various devices and appropriate communication strategies.
Occasionally, as a consequence of group dynamics, feelings and issues may arise which transcend the communication focus of the program. This won't happen often, but when it does, the emphasis must be brought back to communication. This is not to say that all expression of feelings must be avoided or diverted. If the conversation veers to feelings of exclusion due to a hearing loss, there is a communication explanation for this feeling, and this is an appropriate topic for group discussion. If, however, someone expresses feelings of intense depression or recounts instances of childhood abuse, this clearly is beyond the scope of the group hearing aid orientation program and referral to an appropriate specialist is necessary.
In a perfect world, I prefer that anyone offering these programs be trained as a group facilitator and have a background of formal courses in adult Aural Rehabilitation. In this imperfect world, however, there are people dispensing hearing aids with neither the training nor supervised practicum to conduct such groups. The informational component in a group is basically an extension of what goes on individually, and should present little difficulty. It is when group interactions occur, which is indeed one of the primary goals of such a program, that many dispensers will have to transform themselves from technicians into clinicians. Fortunately, there is a wide array of material available that can help them make this transformation.
On balance, therefore, I think the advantages of incorporating a group hearing aid orientation program into every dispensing practice outweighs the disadvantages. The needs of hard of hearing people are immediate and must be met as well as possible now, not at some distant future date.
In other words, it is now that we have to do the best we can in this imperfect world.