As we enter the 21st century, it is encouraging to see expanded interest among audiologists and hearing healthcare professionals regarding the provision of organized programs of support for new hearing aid users and their families.
The Self Help for Hard of Hearing (SHHH) organization published a Position Statement in 1996, stating group audiologic rehabilitation support programs should be available for all new hearing aid users (SHHH; 1996). Schow and his co-authors conducted a survey among active audiologists and found 94% reported doing some form of audiologic rehabilitation (AR). AR ranged from individual hearing aid orientations (HAOs) to speech perception training, to education of family and friends (Schow, Balsara, Smedley, & Whitcomb, 1993). The authors found that although traditional AR (such as lipreading and speech perception drills) had declined from previous years, the surveyed audiologists reported a huge increase in the provision of systematic HAOs for new hearing aid users.
My experience in the decade following that study (Schow et al, 1993) is that the trend for audiologists to offer an organized program of patient and family support following the fitting of hearings, is increasing.
The conventional HAO consists of an explanation of how to use and care for hearing aids. However, this appears to be undergoing transformation.
Several authors have described group support programs for new hearing aid users. These programs focus on the psychosocial aspects of living with hearing loss, on collaborative problem solving, and on the use of facilitative and repair strategies to overcome communication difficulties (Abrahamson, 2000; Beyer & Northern, 2000; Kricos, 1997; Lesner, 1995; Warner-Czyz, 2000; Wayner & Abrahamson, 2000).
Audiologic rehabilitation groups may be content-based HAOs (e.g., how to clean and insert the hearing aids), counseling-based support groups (e.g., accepting hearing loss, dealing with the frustrations of difficult communication situations), or perhaps both.
The purpose of this article is to offer a contemporary view of AR, emphasizing the value of group support programs in helping individuals adjust to living with hearing loss. A rationale for providing group support programs for new hearing aid users and their "significant others" (SOs) will be provided, along with practical suggestions for the participants in a group to receive maximum benefit from the program.
Why Group AR?
There are a number of benefits of AR support groups for new hearing aid users and their SOs, and there are benefits for audiologists and hearing healthcare professionals (see tables 1 and 2). An important consideration when deciding whether to offer or attend group support programs is the impact of psychological and social variables on successful hearing aid use (Kricos, 2000).
Several researchers have found significant relationships between social support from family, friends and social contacts, and hours of hearing aid use (see Kricos, 2000). Why would social support have such a marked effect on the new hearing aid user?
The answer lies in the many ways hearing loss affects family functioning, intimacy and social interaction. Because families, friends and social contacts are affected by hearing loss, they too, may have a vested interest in encouraging the new hearing aid user to persevere in hearing aid amplification. In turn, the availability of social contacts may provide powerful motivation for the new hearing aid user. Therefore, it is important for a friend or family member to be involved in learning how to live with hearing loss. One way to involve friends and family is through participation in audiologic support programs with other new hearing aid users.
There are several ways support programs help new hearing aid users, their friends and families (Hallberg, 1999). SOs can be provided knowledge about hearing loss and its consequences, as well as technical information regarding hearing aids and assistive technology. Group programs offer opportunities to share experiences and provide support for mutual acceptance of hearing loss as well as responsibility for communication difficulties resulting from hearing loss, by new hearing aid users and their SOs. The SO and the new hearing aid user can be taught effective coping strategies.
Of course, group programs are not the only avenue of support for new hearing aid users and their families. Audiologic rehabilitation support programs can be incorporated into individual counseling at the time of the hearing aid fitting, or offered in organized, well-planned printed materials distributed at the time of fitting. New hearing aid users and their SOs can join consumer groups such as Self Help for Hard of Hearing (www.shhh.org), the Association for Late Deafened Adults (www.alda.org), or the Internet group known as the Say What Club (www.webcom.com/~houtx/swc2.htm). These groups focus on positive coping strategies for hearing loss (see table 6 for additional information regarding consumer organizations).
Although these programs can be quite helpful, one of the most effective ways to gain knowledge and support while learning about coping strategies is through participation in programs focusing on group interaction for collaborative problem solving.
Many audiologists have described successful group AR models and have provided practical suggestions for planning and implementing group programs (Abrahamson, 2000; Beyer & Northern, 2000; Kricos, 1997; Kricos & Lesner, 1995; Warner-Czyz, 2000; Wayner & Abrahamson, 1996; Williams, 1994).
Are Group Programs More Effective than Individual Programs?
There have been two recent studies that addressed this question. The first was a study published in the British Journal of Audiology (Brickley, Cleaver, & Bailey, 1996) in which group support programs were compared to individual follow-up programs for 98 new hearing aid users. The investigators concluded that participants in the group programs were generally more positive about their hearing aids, required fewer follow-up appointments, and reported more benefit in various listening situations. The self-rated hearing aid performance of the group attendees was significantly better than for individual attendees, although the two groups did not differ in hours of hearing aid use and satisfaction. Attendance rates were significantly poorer, however, for group attendees.
The second study was reported in The Hearing Journal (Taylor & Jurma, 1999). The benefits of group support programs compared to individual post-fitting counseling included significantly lower perception of handicap and increased perception of audiologist effectiveness. The authors reported that new hearing aid users who attended the group sessions benefited in a number of ways from affiliating with others who were living with hearing loss. Their conclusions paralleled those of health education researchers (Lorig, Gonzalez, Laurent, Morgan, & Laris, 1998) who analyzed the benefits of group support programs for patients with arthritis. These investigators found that among the strongest perceived benefits from group support and education programs for individuals with arthritis were the sharing of coping strategies and support among patients, as well as an increase in the self-efficacy of the patients.
Reflecting on my 30 years working with new hearing aid users, I believe the most successful programs are the ones that encourage participation by group members, rather than lecture formats in which the audiologist does most of the talking! It takes an audiologist skilled in group facilitation to run interactive, shared problem-solving programs. In addition, for collaborative programs to work, participants must be prepared to participate in the group process.
How Do Group Support Programs Help New Hearing Aid Users and their Families?
It is important for family members and health care providers to appreciate that hearing loss itself is only one source of the difficulties experienced by hard-of-hearing individuals. Other potential sources of difficulty include:
- Environmental factors, such as distance and background noise
- Message factors, such as lack of knowledge of the topic of conversation, rapid shifts from one topic to another and unfamiliar vocabulary
- Listener variables, such as stress, fatigue, and lack of motivation.
- Talker variables, such as accent or foreign dialect, rapid speech, imprecise articulation, and covering the lips so that lipreading cues are not available.
Consider the difficulty many hard-of-hearing individuals experience at restaurants. Group discussion could be used to identify the sources of difficulty and what strategies might be used to eliminate or control these factors. For example, while conversing in a noisy restaurant, one might try to eliminate the source of noise or move to a quieter spot. Other options might include the use of FM devices. The participants may instruct servers and conversation partners regarding clear speech techniques. The list of possible solutions often becomes rather lengthy when a group solves problems in a collaborative fashion. Group members can try these strategies and report back to the group regarding which strategies worked and which did not.
Other topic areas for problem solving might include riding or driving in a car, family dinners, not wanting to remind people over and over again to speak clearly, using the telephone effectively, and many other topics will likely avail themselves through the group process.
Guidelines for Effective Group Participation
One of the most important concepts for participants in AR support groups is to understand and participate in the process as someone who offers, and also receives, assistance. Demonstrating genuine interest in other group members and their problems is of utmost importance. Therefore, one important skill for group participants is the ability to be an active listener.
Active listening occurs when you listen constructively, with interest and acceptance, to what someone else is saying. Active listening disallows interruptions of all sorts; those expressed out loud and those in your head!
One way to appreciate what it means to be an active listener is to realize when you're only going "through the motions" of paying attention to a speaker, rather than really listening to what the speaker has to say.
When you notice you are thinking about other things while supposedly listening to a speaker, do not chide yourself. Rather, gently remind yourself to stay in the present. With commitment and practice, you can develop the discipline required for active listening.
Active listeners want to listen. They paraphrase (in their minds) what the other person is saying. Active listeners convey interest and acceptance, restate ideas, reflect on the feelings expressed by the speaker and they mentally summarize major points the speaker is making.
Active listening is also physical: the listener maintains eye contact and has facial expressions which convey interest and non-judgment. Another aspect of active listening is behavioral: the listener does not interrupt, and may try to match the posture and gestures of the speaker. But the physical and behavioral characteristics of active listening are not nearly as important as the mental characteristics. The active listener has a basic attitude of genuinely wanting to hear and understand the speaker's thoughts. Table 3 contains a checklist that might be used to gauge one's active listening skills.
The "Right Stuff" for Effective Group Participation
Because many people have not participated in support groups, they may be unfamiliar with group protocol and they may not know what to expect. Many new hearing aid users view the audiologist as the "expert" and they come to the group seeking professional advice and help. As noted earlier, there is much to be gained from group interactions focused on sharing problems and solutions. Maximum benefit will be attained when there is considerable interaction between participants, rather than passive, non-interactive behavior. Hunter, Bailey, and Taylor (1995) suggest group participants be prepared ahead of time so they'll know what to expect and how to participate in order to achieve group goals. Table 4 provides guidelines useful for maximizing participation in an AR support group.
Another important attribute of successful support groups is solidarity regarding how the group will be conducted. Table 5 provides a list of "ground rule choices" the group might review prior to initiation of the group. The investment of time in the early stages of the group's development to discuss and decide upon ground rules, will prove important and worthwhile to group members.
Practical suggestions for participating in an audiologic rehabilitation support group have been reviewed in this article. The purpose of a support group is to provide support, and thus the role of both the participants and the audiologist is to enable group members to obtain and give support to each other.
The focus of all group member efforts should be:
- To facilitate the expression of feelings among group members.
- To foster open communication among the group.
- To promote successful coping strategies.
- To enable group members to provide useful information to each other.
- To help establish supportive networks among group members.
- To provide opportunities for each group member to assume a sense of self-empowerment in facing problems and dilemmas that accompany hearing loss.
Abrahamson J. Group audiologic rehabilitation. Seminars in Hearing 2000; 21:227-235.
Beyer CM, & Northern JL. Audiologic rehabilitation support programs: A network model. Seminars in Hearing 2000; 21:257-267.
Brickley, G.J., Cleaver, V.C.G., & Bailey, S. (1996). An evaluation of a group follow-up scheme for new NHS hearing aid users. British Journal of Audiology, 30:307-312.
Hallberg, L. R. - M. Hearing impairment, coping, and consequences on family life. Journal of the Academy of Rehabilitative Audiology 1999; 32:45-61.
Hunter, D., Bailey, A., & Taylor, B. The art of facilitation: How to create group synergy. Tucson, AZ: Fisher Books; 1995.
Kricos PB. Audiologic rehabilitation for the elderly: A collaborative approach. The Hearing Journal 1997; 50(2): 10-19.
Kricos, PB. The influence of non-audiologic variables on audiological rehabilitation outcomes. Ear and Hearing 2000; 21(4): 7S-33S.
Kricos, PB, & Lesner, SA. Hearing Care for the Older Adult: Audiologic Rehabilitation (PB Kricos & SA Lesner, Eds.). Boston: Butterworth-Heinemann; 1995.
Lesner SA. Group hearing care for older adults. In Hearing Care for the Older Adult: Audiologic Rehabilitation, PB Kricos & SA Lesner, Eds. (pp. 203-227). Boston: Butterworth-Heinemann, 1995.
Lorig, K., Gonzalez, V.M., Laurent, D.D., Morgan, L., & Laris, B.A. (1998). Arthritis self-management program variations: Three studies. Arthritis Care and Research, 11(6):448-54.
Schow RL, Balsara N, Smedley TC, & Whitcomb C. Aural rehabilitation by ASHA audiologists: 1980-1990. Am J Audiol 1993; 2:28-37.
Self Help for Hard of Hearing People, Inc. (1996). Position statement on group hearing aid orientation programs. SHHH Journal, 17:29.
Taylor, K.S., & Jurma, W.E. (1999). Study suggests that group rehabilitation increases benefit of hearing aid fittings. The Hearing Journal, 52(9):48-54
Warner-Czyz AD. Clinical application of adult audiologic rehabilitation programs. Seminars in Hearing 2000; 21: 235-245.
Wayner, DS, & Abrahamson, JE. Learning to Hear Again: An Audiologic Rehabilitation Curriculum Guide. Hear Again, 1200 Madison Avenue, Austin TX 78757-1928, 1996.
Wayner, DS, & Abrahamson, JE. Audiologic rehabilitation = Good hearing health care. Audiologyonline Article, 9-25-00.
Williams, CI. See/Hear: An Aural Rehabilitation Training Manual. Everett, WA: CI Williams (available from the AG Bell Association for the Deaf), 1994.
Table 1. Benefits of AR group support programs to new hearing aid users and their significant others
- Greater competence in handling hearing aids
- Increased hours of hearing aid use
- Continued use of (and therefore benefit from) hearing aids
- Support, insights, and camaraderie from other new hearing aid users and their significant others
- Improved family functioning as a result of increased hearing aid use
_____Do you maintain eye contact?
_____Do you try to paraphrase what has been said before you respond?
_____Do you ask questions at the end of the speaker's statement in order to completely understand what has been said?
_____Do you make an effort to understand the speaker's point of view?
_____Do you give speakers the opportunity to finish what they are saying before you speak?
_____Do you consciously watch the speaker's body language for additional clues as to how the speaker feels about the topic under discussion?
_____Do you maintain eye contact with the speaker at least 90% of the time?
_____Does your facial expression, posture, and body language indicate your interest in what the speaker is saying?
_____Do you resist the temptation to verbally or mentally finish what you think the speaker is going to say?
_____Do you put aside preconceived opinions about the speaker's viewpoint and really listen with an open mind?
_____Do you periodically assess your listening skills by reflecting on your listening strengths and weaknesses?
Table 4. Guidelines for Effective Group Participation
Table 5. A Checklist for Ground Rule Choices
The following statements of ground rules have been used in different kinds of meetings. From the list, you may check those rules (no more than eight) that you believe will most contribute to the success of your meeting. Combine and edit rules as appropriate, keeping them clear and direct. The rules can be either:
a) Chosen by the facilitator before the meeting, or
b) Selected at the meeting by the group members.
- No phone calls in or out during scheduled meeting sessions.
- Turn off beepers, pagers, and cell phones.
- Sessions start and end on time.
- Commit to being on time for all meetings; if you will be late for a meeting, let the group know in advance.
- Everyone is encouraged to participate.
- One person talks at a time.
- Anyone can pass on any activity
- It's OK to move around when you need to.
- It's OK to have fun.
- (a) Take your own breaks. There will be no group breaks.
(b) Breaks will be taken every _____ hour(s) for _______ minutes.
- People need not agree.
- Stay tuned into the meeting.
- Use "I messages".
- Speak first from your own personal experience.
- Monitor your participation (Some need to hold back to allow others to share. Others need to force themselves to share more).
- Contribute thoughtful exchange.
Table 6. National Support Groups
Association of Late Deafened Adults (ALDA)
2600 W. Peterson Ave., Suite 202
Chicago, IL 60659
Cochlear Implant Club International (CICI)
5335 Wisconsin Ave., Suite 440
Washington, DC 20015-2034
Self Help for Hard of Hearing People, Inc. (SHHH)
7901 Woodmont Ave, Suite 1200
Bethesda, MD 20914