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challenging situations, practice making adjustments if they’re available to you (for example, change your listening program or the volume).

If you experience discomfort or something doesn’t sound right, contact your audiologist right away. The problem might be simple and easily fixed.

Don’t get discouraged; remember, the brain needs time to adjust to hearing sounds in a new way. It won’t happen overnight but with practice it will happen, and it will happen more quickly if you wear your hearing aids at least part of every day.

HEARING REHABILITATION SERVICES BEYOND HEARING AIDS

The previous section discussed hearing rehabilitation services directly related to hearing aids. This section discusses rehabilitation services that go beyond hearing aids. Together, the two sections describe a menu of services from which your personal hearing rehabilitation program should be created. Services included in this section fall into two major categories: learning about a variety of hearing-related topics and practicing strategies that complement aided hearing.

Learning about Hearing and Hearing Loss

It stands to reason that you’ll be better at finding solutions to your hearing problems if you know something about hearing and hearing loss. A structured hearing rehabilitation program is likely to cover information about normal hearing, hearing disorders, and the effects of hearing loss. This information can also be found in Chapters 2, 3, 5, and 6 of this book.

Learning How Your Hearing Loss Affects Communication

Different types, degrees, and configurations of hearing loss cause very different problems (see Chapter 4). Most people don’t understand how their hearing loss affects their ability to understand speech or to hear other sounds in the environment. Because they’re unaware of the difficulties they’re likely to encounter in various communication situations, they can’t prepare for them. Your audiologist can answer questions about the problems you’re likely to experience as a result of your particular hearing loss. For example, if you have a bilateral, high-frequency, sensorineural hearing loss, you probably will have difficulty understanding young children.

Learning about Hearing Assistance Technology (HAT)

For situations in which hearing aids fall short, hearing assistance technology may be the answer. For example, you might find an assistive listening device helpful when you’re communicating over the telephone, watching

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television, or traveling in the car. You might find it helpful to use an assistive listening system when attending meetings, movies, concerts, lectures, or religious services. In the workplace, you might use an amplified telephone, a vibrating pager, or a personal FM system with a conference microphone.

Alerting devices typically substitute flashing lights or vibration for a sound signal (for example, a lamp that flashes when the telephone rings). These devices can increase safety and solve many of the problems experienced by people with hearing loss, especially those who live alone. They can be useful in the home, at work, or during travel.

With or without hearing aids, assistive technology can help you to participate more fully in every aspect of your life. Ask your audiologist if there are devices that might solve your particular problems. Information about assistive listening technology is the subject of Chapter 9.

Learning to Make Adjustments to Your Surroundings

Controlling the listening environment, to the extent possible, is an extremely important strategy. For example, at home you should

Make rooms as quiet as possible (for example, install carpeting and hang draperies). When you’re trying to communicate, minimize background noise (for example, turn off running water, the television, or the washing machine). When eliminating noise is impossible, move your conversation away from it.

Arrange your furniture so that communication can be close and face to face (for example, if you and your spouse have favorite chairs, draw them together and position them so that you can see one another’s faces).

Be sure the lighting is good; you’ll understand better if you can see the speaker’s face clearly (for example, arrange seating so that the light shines on your spouse’s face).

Arrange seating so your better ear (if you have one) is pointed toward the conversation (for example, be sure that your spouse sits on the side closest to your better ear).

Position your favorite chair so that you can see people entering the room.

If you have directional microphones on your hearing aids, position yourself so the background noise is behind you. For example, at the kitchen table sit with the dishwasher behind you rather than in front of you.

Install assistive listening technology that allows you to hear the television or use the telephone.

Learning to Make Use of Visual, Contextual, and Linguistic Cues

There will be situations in which the conversation you hear through your hearing aids is incomplete because of poor listening conditions, the distortion caused by your hearing loss, the imperfect fidelity of hearing

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aids, or some combination of those factors. In these situations, you must apply yourself and use all the cues that are available to supplement aided hearing.

Visual cues are available through lip reading, facial expressions, body language, and gestures. Combining these cues to understand speech is called speechreading (discussed later).

Contextual cues are related to the situation and the people involved in it; for example, someone at a potluck dinner is more likely to be talking about baking a cake than raking a fake. To demonstrate, ask someone to say any five words without using their voice. Without context, you probably won’t be able to speechread all five words correctly. Now ask them to say the names of five numbers (or colors, or fruits). The task will be easier because the words have some context.

Linguistic cues are the duplicate and overlapping cues embedded in our language that give speech messages some predictability. For instance, the sentence, “The girls are taking their lunches to school” includes several cues about plurality (girls, are, their, and lunches). If you miss one cue, there’s a chance you’ll get one or more of the others; in other words, you can afford to miss some information and still understand that there’s more than one girl. And knowing that makes understanding the rest of the message easier.

For someone with hearing loss, listening must be active rather than passive. The successful listener learns to use all available cues to fill in what’s missed through hearing. A hearing rehabilitation group is the perfect place to practice combining various types of cues.

Speechreading

Speechreading combines lip reading (the use of cues that come from watching the speaker’s mouth) with those that come from facial expressions, gestures, and body language. We all rely on speechreading, especially when hearing is difficult. The more challenging the listening situation, the harder we work to see the speaker’s face. Experts estimate that combining vision with hearing improves speech understanding by 30 percent or more in difficult listening situations. We’ve all developed some degree of speechreading skill, although some of us have more talent for it than others.

Speechreading complements aided hearing. For example, even people with very limited hearing report that wearing hearing aids improves their ability to speechread. Combining what they hear (even if it’s only the rhythm of speech) with what they see improves their ability to understand. Some severely hard of hearing and deaf people successfully rely on speechreading and aided hearing for communication. However, as important as speechreading is to listeners with hearing loss, it can’t substitute for hearing. In fact, only 30 to 40 percent of the speech signal can be

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understood through speechreading alone. There are several reasons for this:

First, 60 to 70 percent of English speech sounds can’t be seen on the lips; for example, the production of /h/, /k/, and /r/ are not visible.

Second, among the sounds that can be seen, many look alike (for example, /f/ looks like /v/ and /t/ looks like /d/). As a result, approximately half of all English words look like one or more other words (for example, the words “man,” “pan,” and “ban” can’t be distinguished visually).

Third, the way sounds are formed depends on which sounds precede and follow them.

Fourth, unless there’s a visible pause between words (which rarely happens), sounds run together and become one long, uninterrupted series of lip movements.

Some speakers make speechreading even more challenging. For example, speakers sometimes talk with their mouths obscured: they put their hands in front of their faces, they talk while chewing or smoking, or they talk with their faces turned away. In some situations the lighting is poor, or the speaker is too far away to be seen clearly. There are also people who barely move their mouths when they talk.

In years past, speechreading drill and practice was a primary focus of hearing rehabilitation programs. Today, it’s more likely to be part of a broader program designed to enhance overall communication, maximize the benefits of hearing aids, and promote personal and family adjustment to hearing loss. Practicing speechreading during conversations that occur naturally in group hearing rehabilitation sessions is more effective than doing speechreading exercises in isolation. See Appendix F for speechreading tips.

My Dad

People who can’t hear well depend especially on their eyesight, and people who can’t see well depend especially on their hearing. Unfortunately, my dad has trouble with both. He suffers from macular degeneration, a condition that’s taking away his vision. He misses the critically important speechreading cues that most people use to help them understand speech. With poor vision and only one usable ear,

it’s hard for him to determine where sounds are coming from or who’s talking in a group. Because he has difficulty recognizing faces, he has to rely on hearing to recognize voices (but, of course, he has trouble hearing voices too). It’s amazing to me that he remains so engaged, so fun, and so cheerful, given his double disability. Anybody in his little town will tell you that if you ask him how he is, he always says, “Terrific!” with a big smile. He’s my hero.

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Auditory Training

Hearing aids enable people to hear (detect) softer sounds, but they don’t necessarily make them better listeners. Unlike hearing, listening requires effort and concentration. It’s focused and deliberate. Auditory training is formal listening training. Along with speechreading, it was once a primary focus of hearing rehabilitation programs. In more recent years, both have been integrated into broader programs designed to improve communication in real-life situations. New insights based on research in neuroscience have renewed interest in auditory training, however. We’ve learned that when input from the ears to the brain is reduced by hearing loss, areas of the brain devoted to certain hearing functions get reassigned (as mentioned earlier, this is known as brain plasticity). We’ve also learned that with properly structured practice, brain resources can be reclaimed for functions important to listening and communication. Properly structured practice involves short, frequent training sessions rather than longer, lessfrequent ones; active listener participation, as opposed to passive learning (tasks must be interactive); immediate feedback about the accuracy of a listener’s responses; and a level of difficulty that “adapts” to keep the listener challenged yet motivated.

Participating in a concentrated (daily), adaptive auditory training program with an audiologist tends to be inconvenient and costly. In contrast, a home-based, interactive computer program enables listeners to do intensive training at their own pace and in the comfort of their own homes. An example of such a program is Listening and Communication Enhancement (LACE).2 More information about LACE can be found in Appendix G. Your audiologist can assist you in selecting the most appropriate program, setting it up, establishing personal goals, and monitoring progress.

Learning New Strategies for Communication

As mentioned, the focus of hearing rehabilitation programs has shifted from an emphasis on speechreading and auditory training lessons to an emphasis on building confidence and improving communication in a variety of situations. This has been called communication strategies training.3

All such strategies fundamentally begin with taking responsibility for your hearing difficulty. People are likely to be more helpful if they know that you have a hearing loss than if they believe you’re not paying attention. Telling people about your hearing problem also gives you an opportunity to provide specific suggestions about what they can do to help you understand (for example, “Please speak more slowly; Don’t cover your mouth; Face me; Use shorter sentences; Tell me when the topic changes.”). Of course, that means knowing enough about your hearing

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loss to be able to tell others what would be helpful. It also means reminding people (more than once) about what you need—something that might feel uncomfortable. Communication habits are deeply ingrained, and people easily lapse back into old patterns until new ones have been learned.

Participants also learn how to repair communication when it breaks down. Most often, when a person hasn’t understood, she says, “What?” or “Huh?” This is usually understood as a request for repetition, and the response is often exactly that—the speaker repeats the message word for word. Whichever word(s) or phrase(s) the listener didn’t understand the first time, she probably won’t understand the second or third time either. It’s the least effective repair strategy but the one most commonly used. A better strategy is to ask the speaker to say the message differently: to rephrase it, elaborate on it, or simplify it. Another effective strategy is for the listener to use the information he did understand to get the information he missed (for example, “Your sister lives in which city?”). This allows the listener to confirm the part of the message he heard and clarify the part he didn’t. Requests for repetition that are less open ended make it more likely that the listener will understand quickly, minimizing disruption to the conversation. For example, asking “Did you say ?” usually works better than asking, “What did you say?” In other cases, the best strategy may be to ask for a key word, especially when the topic changes (for example, “Tell me what you’re talking about”). When all else fails, it may be necessary to ask the speaker to write part of a message. A hearing rehabilitation group is the perfect place for participants to develop new strategies and practice using them with one another.

Learning to deal effectively with communication problems discourages participants from resorting to negative coping behaviors like bluffing (pretending to hear when you don’t), dominating the conversation (as long as you have the floor, there’s no need to understand anyone else), blaming (you’d hear fine if everyone would just quit mumbling), and social withdrawal.

Conversational Styles

A primary goal of communication strategies training is to help listeners become assertive communicators.4

The passive communicator avoids conversations, pretends to hear when he doesn’t, or is overly dependent on others. The passive communicator would rather miss out than acknowledge the problem and ask for help.

The aggressive communicator is belligerent or blames others for her communication difficulty. She might dominate the conversation or insist on hearing everything.

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The assertive communicator shows respect for the rights of conversational partners while honestly and openly expressing his own needs. He takes responsibility for managing communication problems in a considerate way, which might mean reminding people (more than once) about what he needs if he is to understand them.

A hearing rehabilitation group is a good place to practice assertive communication behavior.

Assertive Communication

Assertive communication means:

Standing up for yourself without being insensitive or disrespectful to others.

Taking responsibility by acknowledging your hearing loss.

Not blaming others when they unintentionally make communication difficult for you.

Telling people how they can help you to understand them.

Being willing to remind people about what you need (again and again).

Showing conversational partners appreciation for their efforts.

Making adjustments to your surroundings (for example, rearranging the seating in a meeting room).

Responding to problems with a sense of humor.

Personal Adjustment Counseling

The average person waits 7 years before seeking help for hearing loss. During those years, feelings of anger, resentment, isolation, vulnerability, loneliness, or depression can develop. Some people begin using inappropriate coping behaviors like bluffing, blaming others, withdrawing, or monopolizing conversations. Important relationships (within the family and beyond it) can be damaged. Even when the hearing loss is finally addressed, problems like these aren’t resolved overnight. When negative feelings and damaged relationships affect a person’s self-concept and feelings of self-worth, it can be more harmful than the hearing loss itself. It can be helpful to talk with an audiologist or professional counselor who understands the social, emotional, and psychological ramifications of hearing loss.

Most people lose their hearing gradually; however, people who lose their hearing suddenly are particularly vulnerable to adjustment problems. The abrupt transition from “hearing person” to “deaf person” can set off an

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emotional crisis. If the services of a professional counselor are needed, an audiologist may know of someone with an understanding of hearing loss.

Counseling Family Members about Your Hearing Loss

Hearing loss never affects just one family member; it affects all family members. Rehabilitation is therefore most successful when family members (or other significant others) are also involved. Family members can begin by learning what it’s like to have a hearing loss. Your audiologist should be able to demonstrate this with a recorded simulation.

Equally important, family members (particularly spouses) often need support themselves. Everyday conversations with you now require special effort. You might be less interested in socializing than you once were. Communication might make you feel tired and irritable. Better-hearing husbands and wives tend to feel more regret about these changes than their partners with hearing loss. A part of hearing rehabilitation is recognizing when you or your significant others are experiencing feelings of sadness, resentment, or frustration, and exploring ways to resolve them.

People who are important in your life need to learn how to improve their communication with you. Research has shown that speech understanding improves when a communication partner is asked to speak more clearly, and it improves even more when she is formally trained to use “clear speech.” An example of the difference between typical speech and clear speech is the difference between “Thekids’r swim’n inthepool” and “The kids [pause] are swimming [pause] in the pool.”5 In a recent study, people with sensorineural hearing loss listened to a speaker who had been trained to use clear speech and a second speaker who had been asked to speak more clearly. Speech understanding improved in both cases. When listening to the speaker who had been trained, however, listeners recognized sentences in background noise as well as listeners with normal hearing (that is, scores approached 100 percent). And this was after the talker had received less than 1 hour of training! These results suggest that communication can be dramatically improved when family members are provided with clear speech training (as opposed to simply receiving written or verbal instructions).6

Clear Speech

Clear speech is characterized by

Slowed speaking rate

More pauses

Longer pauses

Precise (but not exaggerated) enunciation

Emphasis on key words