There is emerging evidence that suggests we are making considerable progress with regard to hearing aid satisfaction (Northern, 2001, personal communication). Yet, a large number of individuals fit with hearing aids either return them or do not wear them. In addition, sales of hearing aids have remained fairly flat over time, while the segment of our population who might benefit from amplification (those over 55 years of age) has been growing (Strom, 2002).
Traditionally, hearing health care professionals view hearing loss as an input problem. For example, attention has been focused primarily upon remediation of the auditory sensory deficit through judicious application of amplification. Our primary aim has been to improve audibility, equalize loudness, and improve word recognition (Dillon, 2001). Recognizing that amplification is not a perfect solution to hearing loss, we have augmented amplification with training in visual recognition of speech and manipulation of environmental variables to optimize multi-modal (auditory and visual) speech recognition. The assumption has been that restoring speech recognition will restore effective communication.
Although restoring speech recognition has intuitive appeal, this approach may not address the total needs of our clients. As Montgomery and Houston (2000) have noted, even "unimpaired communication is not error-free (p. 382)" and, even under the best circumstances, we cannot restore our clients' hearing to normal.
Accordingly, many professionals have stressed the communication needs of hearing impaired individuals should be addressed in a broader context. They define communication as an interactive process that requires periodic role switching by the speaker and the listener and as a process that requires frequent repair. (See, Erber, 1998; Tye-Murray, 1998, Alpiner & McCarthy, 2000 and Schow, 2001 for further discussion.) In other words, we need to address hearing impairment as both an input and an output problem. That is to say, people with hearing impairment should develop strategies as both a listener and as a speaker to enhance their communicative effectiveness.
Recently, several investigators have proposed models of service delivery emphasizing conversational management and the importance of communication as both an input and output process. For example, Tye-Murray (1998) reviews her considerable work in conversational repair. Similarly, Montgomery and Houston (2000) have proposed the WATCH procedure. This procedure incorporates listening and conversational strategies to be employed by people with hearing impairment. Most recently, Schow (2001) has proposed the CORE/CARE model that addresses assessment and treatment relative to the impact of the individual's hearing impairment on activities of daily living. This approach is consistent with the World Health Organization (WHO) definitions of impairment, disability and handicap.
The treatment program (CARE) Schow proposes relies on elements of service delivery that are customary and familiar to audiologists. Hearing instrument fitting and hearing instrument orientation are included in the CARE portion of the model. However, Schow goes beyond these familiar audiologic services and stresses the importance of personal adjustment, assertive communication, and conversational repair.
For most hearing health care professionals, notions such as affective counseling, assertive communication (not just assertive listening) and conversational repair strategies may be less comfortable and less familiar processes. To facilitate understanding of these less familiar strategies, this paper addresses a conversationally based approach to aural rehabilitation, grounded in the principles of the service delivery models mentioned above.
The specific focus of this article will be on elements of assessment and intervention that are critical to successful communication for persons with hearing impairment. In particular, this paper will address assessment procedures that facilitate conversationally based intervention, as well as two elements of intervention that our clients find most useful, acknowledgement scripts and communication repair strategies.
To efficiently and effectively implement any treatment or aural rehabilitation (AR) plan, it is necessary to use an assessment plan that facilitates the AR plan. In other words, the goals and objectives of our treatment plan should be clearly evident from the outcomes of our assessment.
To that end, Schow (2001) and Alpiner and McCarthy (2000) provide excellent examples of assessment models that lend themselves to conversationally based aural rehabilitation. In assessing our clients, we borrowed heavily from each of these sources and from Demorest and Erdman (1986; 1987). What we added to the process is an organizational tool referred to as the Aural Rehabilitation Profile. An example is included as Figure 1.
Figure 1. This figure conceptualizes a three-dimensional profiling system for aural rehabilitation clients. The profile acts as an organizational tool for the assessment and treatment plans. Examples of the assessed domains and sub-domains are indicated along the X and Z-axes. The assessed domains remain invariant, but sub-domains may change relative to the activities and perceived needs of the client. The Y-axis represents the scaled score obtained in each domain or sub-domain. Detailed descriptions of each domain and corresponding sub-domains are available from the author (adapted from: Miller, 1981).
This profiling notion is based on the concept of intralinguistic profiling introduced by Miller (1981) and refined by Fey (1986). While these original sources address the area of child language disorders, the basic principles seem well suited to aural rehabilitation. The purpose behind this profile is to ensure that the clinician addresses all the functional domains that contribute to effective communication. The domains assessed remain constant, but the sub-domains assessed may vary depending upon the client's activities or perceived needs. In carrying out the assessment, the clinician is expected to use history taking, testing and observation. The testing process includes both formal and informal measures that are applied to gain a clear picture of each client's primary communication needs as well as his/her communication strengths within and across various contexts.
We rely heavily upon self-assessment instruments in this process. To assist in scoring these instruments, we have either purchased or developed computer-based scoring methods. Because our assessment relies heavily on self-assessment scales, the client's time investment is significant. The time required of the professional will vary depending upon the number and complexity of the instruments applied.
Our initial report (assessment summary) follows the same format as the Aural Rehabilitation Profile and specifies under "Recommendations" the primary goals of therapy, based on areas of the client's profile that yielded lower scaled scores. The assessment summary thereby serves as both a diagnostic report and the basic AR plan.
Quite often, these extensive assessment profiles reveal clients need assistance in communication strategies and acceptance of their hearing loss. As mentioned previously, two of the intervention methods we apply are acknowledgement scripts and communication repair strategies.
Background on Communication Style.
Kaplan, Bally and Garretson (1985) identify three distinct conversational styles, passive, aggressive, and assertive. Table 1 summarizes the relative characteristics of each style as noted by Tye-Murray (1998). It should be recognized that each of these interactional styles produces commensurate listening and speaking behaviors that are unique to each style.
Most professionals recognize the inherent benefits of an assertive listening style and make recommendations to their clients via handouts or brochures aimed at helping the hearing impaired person to become a more assertive listener. For example, clients are often advised to manipulate environmental variables to optimize listening and viewing conditions. Patients are also provided materials that advise those who interact with hearing impaired persons on how to talk with a hearing impaired person. While these resources are useful, it seems important to recognize, that these materials are limited to resolving input issues. More importantly, this approach of using preprinted literature may work against our clients achieving healthy self-advocacy.
By not actively training our clients on how to personally educate their communicative partners, that is, to self-advocate, we are reducing our effectiveness and limiting severely the circle of people with whom our clients may interact successfully. There is evidence to suggest that implementation of the communication strategies we recommend requires direct training beyond provision of printed materials (e.g., Tye-Murray, 1992). The intervention approach advocated here seeks to actively modify the listening and speaking behaviors of our clients to reflect an assertive conversational style and a pattern of healthy self-advocacy.
Investigations by Collins & Blood (1990) and Blood & Blood (1999) provide useful guidance in structuring the output, or "speaker side" of our clients' conversational style. These investigations determined that speakers who acknowledged their disability were noted as more likeable, sincere and reliable, and were preferred as conversational partners over persons with disabilities who provided no such acknowledgement. To capitalize on this effect, we have worked with our clients to develop what we refer to as "acknowledgement scripts." This technique incorporates elements referred to as instructional strategies (Tye-Murray, 1998), as well as aspects of Montgomery and Houston's (2000) WATCH procedure.
To construct an acknowledgement script, the professional and the client negotiate a list of instructional strategies that the client feels a majority of his/her conversational partners might use to facilitate understanding by the client. Typically, this list consists of three to five interactional/instructional strategies. The specific strategies employed are selected on the basis of the professional's assessment and the client's perceptions of which conversational features enhance the client's understanding.
When introducing interactional strategies to a conversational partner, the hearing-impaired client is encouraged to include acknowledgement of his/her hearing loss. As an ongoing part of AR, the hearing-impaired client is familiarized with a number of interactional strategies and, through role-playing, is instructed on how various strategies are more applicable in certain situations.
For example, the client might be encouraged to develop a different script for one-on-one interactions, rather than group interactions. A key difference might be that the script for the group interaction might include an instructional strategy that requests participants to speak one at a time. Similarly, the client's script might be somewhat different for noisy situations versus quiet environments. A list of some of the instructional strategies commonly used by our clients is included as Appendix 1.
Implementing these scripts is a study in successive approximation. Client preferences and comfort levels are keys to actualizing this approach. The client must be actively involved in development of the script(s) and be allowed to exercise his/her preferences even when his/her preferences are contrary to the professional's view.
The best script will be the one the client will use. The client must feel comfortable with, and feel ownership of their script before he/she will attempt to apply it. Even then, overcoming personal apprehension about admitting to one's hearing impairment will require careful guidance by the professional.
The professional must set up opportunities for acknowledgement that allow the client to use the script in a context(s) within which he/she feels comfortable. In some cases, the client might preliminarily feel most comfortable using his/her scripts only with the clinician. In other cases, the client may prefer working with a family member or friend. Importantly, we find that having clients report on their experiences in a group setting often motivates even the most passive or reticent client to give it a try.
Acknowledgement scripts do a great deal to foster the affective foundation that is fundamental to successful communication. These scripts help clients resolve their apprehension, reduce their withdrawal, and increase self-confidence. Many clients report receiving much more favorable and helpful reactions from conversational partners when the hearing loss and accompanying constraints are addressed through the acknowledgement script.
These scripts are of little use, however, in mending the breakdowns in communication that are inevitable when people converse. Moreover, our Aural Rehabilitation Profiles (particularly the Communication Strategies subscale of the Communication Profile for the Hearing Impaired) frequently indicate that clients with hearing impairment are ill prepared to repair disrupted communication. Accordingly, we often pair the use of acknowledgement scripts with training in conversational repair strategies.
Table 2 summarizes a protocol of conversational repair devices initially developed to study the conversational interactions of children with hearing impairment and their caregivers (Kenworthy, 1984; 1986). Subsequently, this protocol has been successfully applied to adult-adult interactions. It also affords the opportunity to compare results directly with the work of Tye-Murray and others who have examined the conversational strategies of persons with hearing impairment.
There are several phases to implementing conversational repair strategies. These phases include the Observational Phase, Familiarization Phase, Discrete-trial Phase and the Implementation Phase.
First, the observational phase is where we inventory the repair strategies employed by the client in a natural conversation. To ensure that we have ample opportunity to observe the client's repertoire of repair strategies, we sometimes introduce noise or limit visual input through use of referential communication, or barrier tasks. These more demanding listening conditions often facilitate communication breakdown and force the interactants to employ natural repair strategies.
Next, is the familiarization phase, wherein the client is informed about the repair strategies he/she most frequently employs. Typically, we inform the client about the various types of repair strategies and what the advantages and disadvantages of each may be, based on the previous research. Our goal in this phase is to increase the client's understanding of six basic principles.
SIX BASIC PRINCIPLES OF CONVERSATIONAL REPAIR
ONE: Use of requests for clarification improves understanding between conversational partners (e.g., Tye-Murray, Purdy, Woodworth & Tyler, 1990).
TWO: Specific training in the use of repair strategies is effective (Tye-Murray, 1991).
THREE: Some requests for clarification are considered specific, or contingent (e.g., requests for confirmation) whereas others (e.g., neutral queries) are considered non-specific, or non-contingent (see, Table 2).
FOUR: Contingent requests for clarification are more likely to sustain interaction over multiple turns than non-contingent requests (Kenworthy, 1984).
FIVE: Strategies that elicit rephrasing by the speaker are more likely to repair the communication breakdown (Gagne & Wyllie, 1989).
SIX: Requests for specific clarification are viewed more favorably by the speaker than non-specific requests (Gagne, Stelmacovich, & Yovetich, 1991; Caissie & Gibson, 1997). In other words, both interactants communicate more effectively when more specific, or contingent, repair strategies are employed.
Once the client is fully oriented to the types of repair strategies and their characteristics, we enter the discrete-trial phase. In this phase, the client is either an observer or a direct participant. As a direct participant, the client is asked to converse with the professional or a friend or family member. To increase the need for repairs, the professional uses noise and/or a barrier task, as mentioned previously. After each repair sequence, the professional asks the client to review which strategy he/she used and which other strategies may have been appropriate.
Some clients are reticent at first to participate directly and benefit from first participating as an observer. In these cases, they may watch other clients under professional guidance or they may watch role-playing repair sequences. In either circumstance the client is asked to identify and evaluate the repair strategies used by others. Whether the client chooses to participate directly or to observe, the professional provides immediate and direct feedback regarding the client's decision-making.
Once the client begins direct participation and demonstrates use of a full array of specific strategies, we begin the implementation phase. This phase is similar to discrete trials except that barrier tasks are eliminated and the professional only observes the client in natural conversations, while charting the client's repair attempts. After approximately 15 minutes, the conversation is terminated. The professional and the client engage in an open-ended discussion of the client's impressions of the preceding conversation, during which time, the professional keeps brief chart notes. After that discussion is completed (about 5 to 10 minutes) the client and professional jointly review the accumulated data and the client is once again given the opportunity to self evaluate his/her performance.
During the implementation phase, conversations are initially one-on-one, and later with small groups of 3-5 interactants. Conversations are carried out in various natural environments with regard to distance, background noise, visualization, lighting and related variables.
Not every client requires all training phases. Some skip directly to the implementation phase. Progression through each phase is predicated on the client meeting specific performance criteria. Our overriding aim is to increase the client's use of specific repair strategies within natural conversations.
Overall effectiveness of the therapy is based on post-therapy changes in the Aural Rehabilitation Profile. In that regard, the Communication Strategies subscale of the CPHI, has proven to be a valuable and sensitive measure.
Recent policy developments and various market forces demands that audiologists and other hearing health care professionals view our clients' needs from a more comprehensive perspective. Traditionally, audiologists and other hearing healthcare professionals tended to view hearing loss primarily as an input problem that can be effectively remediated by use of amplification or other sensory devices.
More recently, practitioners in the area of aural rehabilitation have been emphasizing the need to address both input and output issues for our clients with hearing impairment. In other words, the scope of intervention must be expanded to provide interactive strategies for improving communication, as well as interactive strategies that facilitate acknowledgement of and adjustment to hearing impairment and amplification devices.
Within the context of providing comprehensive assessment and intervention to our clients with hearing impairment, this paper provides three key elements. The first is an assessment based on an aural rehabilitation profile that acts as an organizational tool for a comprehensive aural rehabilitation assessment that addresses a broader range of client needs. The second is information regarding development and implementation of acknowledgement scripts. The third is suggestions for conversational repair.
The Aural Rehabilitation Profile assures that a complete array of clients needs is measured across six critical behavioral domains, including sensory/perceptual, cognitive, linguistic, social, affective and conversational. Information gathered within the assessment period then acts as a baseline against which client progress is measured. Client outcomes are documented through systematic data keeping, as well as changes noted on some of the functional measures applied during assessment. The use of acknowledgement scripts facilitates acceptance of and adjustment to hearing impairment by the client. Consequently, it also affords them increased success as a conversational partner due, in part, to improvement of others' perception of the client. We discuss how to negotiate with the client concerning development and implementation of these scripts across multiple environments. Finally, conversational repair strategies are discussed as a complement to the acknowledgement script. These strategies further improve the client's conversational performance within multiple conversational settings and expand his/her credibility and effectiveness as a conversational partner. The reader is provided with a multi-phase approach to developing or improving their clients' use of these strategies.
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Collins, C.R. and Blood, G.W., (1990). Acknowledgement and severity of stuttering as factors influencing nonstutterers' perceptions of stutterers. Journal of Speech and Hearing Disorders, 55(1), 75-81.
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1The term mode is used here to indicate whether the conversational strategy employed is linked either semantically or syntactically to the preceding utterance of the conversational partner. When the strategy somehow reflects the semantic or syntactic content of the preceding utterance, it is considered to be contingent, or specific. Non-contingent, on non-specific, strategies simply attempt repair without providing information back to the interactant about what was heard or what may have been missed. (See, Kenworthy, 1984 for further discussion.)
Common Instructional Strategies
Employed in Acknowledgement Scripts
The following are examples of instructional strategies that clients with hearing impairment have developed and used as part of their acknowledgement scripts. It seems important to note three characteristics of these statements. First, they represent an appeal for help. Second, they are generally "I" statements. That is, they state what the person with hearing impairment needs rather than directing the interactant on how to behave. These two characteristics signal to conversational partners that the person with hearing impairment accepts responsibility for his/her hearing impairment. Finally, these statements are framed in a positive manner. They focus on what will help rather than stating what will not help. For example, if you want someone to walk, it is better to say, "Please walk," rather than, "Don't run."
- It really helps me if I can clearly see your face and mouth. This may mean that sometimes I will stand just to the side of you rather than directly in front of you.
- I need to put my glasses on before we start talking.
- I need to be looking at you before you speak. Please get my attention before you start speaking.
- When I look away at something you are talking about, please wait until I look back at you before you start talking again.
- Listening is hard work. If I seem really tired and what you have to say is very important, you may want to wait until we are both more rested.
- It really helps in only one person talks at a time in group settings, like the dinner table.
- Please remember that what you are saying is important to me and I am trying very hard to hear you.
- Noise makes hearing very difficult. For important conversations, let's move to a quiet place.
- When light is shining into my eyes, it is very hard to see what you are saying. When the light is shining on your face and mouth it helps me "hear" better.
- Big rooms with high ceilings and rooms with big windows and no curtains are hard to hear in sometimes. If I am having trouble hearing you, I may ask to move to a smaller, quieter room.
- It is easier to hear in the bedroom or living room than in the kitchen.
- The closer we are to one another, the easier it will be for me to hear. A distance of three to six feet is best.
- I must be in the same room with you to understand what is being said. Please give me time to come to you before we start talking.
- Give me time to turn off the TV before we start talking.
- Sitting in a booth in a restaurant makes it easier for me to hear.
- Letting me choose where I will sit or stand in a group situation is very helpful.
- If I know the topic of our conversation it really helps me fill in what I can't hear. If the topic changes, please make sure I follow you by asking questions.
- Sometimes, it is easier for me to hear people who speak in a normal, but slightly raised voice.
- Very loud voices are often harder for me to hear. If someone's voice seems too loud to you, it is probably too loud for me too.
- I hear better when people slow down a little and put clear "space" between their words.
- Short, active sentences that are simple in structure are easier for me to follow. For example, it's easier for me to understand, "The boy hit the ball," than "The ball was hit by the boy."
- If I seem to have trouble following what you're saying, try saying the same thing using different words. Repeating the same thing over again is less helpful.
- Gestures and facial expressions should add something to the message. Extra hand movements add dramatic flair, but may be visually distracting to me.
- Asking questions helps me stay on track. If I don't ask any questions for a long time, it may be because I am lost. You can help me by stopping the conversation to ask questions..
- In group situations, it is easy to lose track of the conversation. It will help me, if we stop once in awhile and confirm that I am following what's being said.