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Effectively Utilizing Third Party Psychology
In the Evaluation Process
By Max Stanley Chartrand
Far too many first-time hearing instrument fittings are
lost due to factors clearly within the control of the
Hearing Instrument Specialist. Part of the problem may
simply be a lack of appreciation of the importance of
family and loved ones’ involvement in the rehabilitative
process.
But, probably more common is that the specialist may not
always recognize the psychosocial idiosyncrasies between
the patient and third party, which have resulted from
years of deteriorating interpersonal communication1. It
is the purpose of this course to introduce how these
idiosyncrasies may be recognized and ameliorated during
the process of the hearing evaluation.
When a prospective patient comes to the hearing
evaluation without their spouse or close loved one, the
law of averages has proven time and again that they may
not be prepared to make a positive decision. Nor are
they usually able to assess the need for or potential
quality of life impact of corrective amplification,
assistive technology or aural rehabilitation2.
At the same time, when third parties do accompany the
patient to the hearing evaluation, too often they are
not included (enough) during the case history and
audiometric evaluation. Hence, if they are not
sufficiently involved they may not themselves experience
the needed emotional sense of closure. Worse, they may
withhold or withdraw their active support of the
sometimes-arduous process of helping the patient
overcome psychosocial barriers that inhibit their
acceptance of hearing help.
Furthermore, the third party, during the gradual decline
of the patient’s hearing acuity, may have adjusted their
own lifestyle, and personal relationships to,
accommodate the patient’s hearing loss3. As one
specialist put it to a hearing impaired patient who was
in deep denial, “Your wife has become your hearing aid.”
Truisms Learned from Experience
Normal-hearing loved ones closest to the patient will be
those most affected by the insidious yet marked
psychosocial, emotional, and lifestyle effects of the
uncorrected impairment. One or more of these parties,
then, needs to be directly involved in the process of
rehabilitation, from beginning to end. Instead of being
mildly interested observers, the specialist must enlist
them to become a vital part of the process4. Because of
a virtual mountain of internal psychosocial obstacles,
most nonuser sufferers require third party support in
not only the decision to take the first major step
forward to accept amplification, but also to
successfully make the needed changes during the
acclimatization process.
We understand from the psychology of the hearing
impaired that it is common not to recognize the impact a
hearing impairment is having on one’s life5, 6. What is
less understood are the effects upon the normal hearing
spouse and other close loved ones who may attribute
changes in behavior, relationships, and waning ambitions
to causes other than hearing impairment. In other words,
those closest to the patient may not be able to
objectively assess or properly attribute these changes
as a consequence of the patient’s declining hearing
acuity.
Home Alone?
From the moment that an appointment time is established
it should be understood by all that a married patient
should be accompanied by their spouse, with few
exceptions. If they are not married, another family
member or close friend who is willing to assist them
throughout the rehabilitative process can attend.
When the patient insists that the spouse not attend the
hearing evaluation it is usually an indication of denial
or an implicit intention to not move forward in
resolving their communicative difficulties. Of course,
there may be notable exceptions to the rule, requiring
the specialist or the person making the appointment to
be sensitive in such cases. Certainly, one would not
want to place undue burdens on the process, if such was
the case. An experienced hearing instrument user may
also be the exception.
However, it is nearly always advisable to utilize an
interested third party in every step of the evaluative,
fitting and post-fitting process, so that they may
overcome their own derivative effects of their loved
one’s hearing loss, as well as assist the patient in
that all-important rehabilitative journey (see Figure
1).
The Spouse May Mirror…
Patient’s Behavior Their Response
Denial (I hear OK”) “Hears when he wants to”
Selectively attentive “Just not paying attention”
Frustration/indecision “Backs off/gives space”
Avoids S/N situations “Limits own activities”
Feigns understanding “I do his talking for him”
Figure 1
A More Effective Case History
The most critical time to include the third party is
during the case history portion of the evaluation. For
it is during this time that perceptions and vantage
points are explored. Often the new patient has been in
denial for so long that it is difficult to frankly
express how they really feel about their communicative
difficulties. Conversely, the third party may have
experienced the tearing of bonds during the
deterioration in personal communication so that they,
too, may tend to frame the discussion in terms of
victimization and personal affront rather than in strict
objectivity (“He hears me when he wants to”).
By bringing both parties together, with the specialist
acting as facilitator, they may compare notes, and come
to a better sense of understanding of their
communicative difficulties. Many “He said/she said”
interchanges have been written about in the literature7.
And while perhaps framed in humorous tones, these real
life discussions too often represent tragic barriers
holding back the patient (and the third party) from
moving forward, sometimes for years at a time.
Therefore, it is important that this critical stage of
the evaluation involve both parties when possible.
A typical example of an interchange during a few case
history questions might go something like this:
Specialist: “Mr. Smith, do you hear but experience
difficulty understanding some of the words?”
Patient: “Oh, I hear fine…I hear things she can’t hear.”
Specialist: “Is that right, Mrs. Smith? Do you feel your
husband can hear things that you can’t?”
Third Party: “Oh, no. He keeps saying that the noise in
the car bothers him so much. But, it doesn’t bother me.”
Patient: “I hear all right, but people just don’t talk
as plain as they used to…you know, they mumble a lot…if
they would just speak out a little bit more, not down in
their throat, I’d do just fine.”
Specialist: “Now tell me, Mr. Smith…do you have a
problem on the telephone?”
Third Party: ”He sure does!”
Patient: “No, I don’t. Not unless there’s a bad
connection or they’re not talking into the mouthpiece.”
Third Party: “Then, how come I hear them just fine?”
Patient: “Well, I don’t know…you’re just used to talking
on the phone a lot, I guess.”
Specialist: “Mrs. Smith, if your husband is suffering
from a high frequency hearing loss, he would think that
it’s only a matter of clarity, because he can hear the
vowel sounds of speech that make up the tone of one’s
voice. However, he would miss the more important
consonant sounds so vital for speech understanding.”
The interchange goes on, but an excellent preclose that
helps the specialist assess the progress made during
this stage is: “Mr. Smith, if we can help address the
communication problems we’ve talked about today, would
you want to explore some of the available options that
may meet your needs?” And to the third party: “How about
you, Mrs. Smith, would you like us to explore those
options, as well, to see what can be done to help your
husband?”
Of course, we are not asking for a commitment at this
time, but we are trying to establish that there is a
common understanding between both parties. We want to
confirm that 1) all agree that there are communication
problems, and that 2) the next logical step would be to
explore the available options for the resolution of
those problems, whether it be hearing instruments,
coping strategies, assistive devices or cochlear
implants. With a more open mind, then, we are ready to
proceed to the next critical stage.
The Inclusive Audiometric Evaluation
One of the challenges we encounter in the test booth
situation is the awkwardness of involving the third
party. They are often made to feel like the “fifth
wheel.” And their natural response may be, “You go ahead
with the hearing test. I’ll be waiting outside.” But, in
light of the psychosocial barriers still lingering, this
can be deadly to the success of all parties involved.
Therefore, this author has long espoused the need to
help the third party to become more actively involved
during each step of the evaluation. In fact, we must
make the third party a partner in the evaluation. Here
are some ways this may be accomplished when the
professional is faced with a sound booth setting where
only a small window is between the specialist and the
patient:
· Seat the third party beside you so that you can
explain to them what you are doing at each stage of the
evaluation, and so that they may visually see the
responses of the patient.
· Make verbal comments during the pure-tone test, such
as, “No wonder he feels he doesn’t have a hearing
problem. He hears the low frequencies almost normally,
but look at these high frequencies that are so necessary
for speech understanding…they’re practically off the
chart!”
· Explain the patient’s audiogram so that they may have
a better understanding of what is unfolding in the
discovery process of the evaluation. If there is clearly
a serious hearing impairment and the third party appears
to take it lightly comments such as, “How long has
he/she been suffering with this problem?” (Stress the
word suffering.)
· Make the third party aware of the speech test results.
Explain the Speech Reception Threshold (SRT) and aided
Speech Discrimination tests and their significance.
· After completing the standard speech tests ask them,
in their own voice over the microphone, to read a list
of aided speech understanding questions so that the
patient and third party may assess improvement with a
familiar voice.
If you have a master hearing aid, this is an excellent
time to demonstrate how the patient may hear the third
party with appropriately shaped amplification in quiet
environments. Speech-in-Noise (SiN) demonstrations may
also be appropriate.
In short, make the third party, a partner in helping the
patient make an informed decision. Help them to
understand the kinds of changes that may occur, relative
to the previous case history, through correction and
counseling.8 Keep expectations realistic (“Even after
all we can do, he/she will still have a hearing loss,
albeit a milder one).
When Third Parties “Jump Ship”
Sometimes the specialist is caught off-guard by an
otherwise supportive third party. Perhaps at the point
of decision, they surprise us with, “Maybe we ought to
think about his some more.”
Now, experience tells us that many patients will take
another five years to “think about it” or “wait until it
gets worse” (see Figure 2). In fact, they’ve probably
already been “thinking about it” for the past fifteen
years, and have been “waiting for it to get worse” for
nearly as long.
It is not the purpose of this article to explore how
this objection may be effectively overcome. However,
there are some important considerations that may help
the specialist in this situation, and the author
suggests that the place to start is with the third
party. What makes a seemingly supportive third party
“jump ship” at the crucial moment of decision? There
are, of course, the obvious reasons: the specialist did
not handle him/herself professionally, the ambient noise
environment was not conducive for an accurate test, or
there is a genuine financial limitation.
But more often than not, the problem lies in one or more
of the following:
1. Too much was taken for granted earlier in the
evaluation.
2. You thought they were with you, but actually it was
only “personal” for them.
3. They’ve suffered a great deal because of the
patient’s unmitigated loss; they need closure too.
4. You simply did not give them enough information so
that they may be an effective partner in the
rehabilitative process.
Why waiting “until it gets worse” is not plausible
Insidiousness
Gradual decline over many years
Transparency
Spectral, threshold changes prevent self-assessment
Loss of Spontaneity
Absolutely essential for bonding in relationships
Communicative Paradoxes
Tend to mask real nature of problem
Continued Denial
Becomes more personal, less objective
Figure 2
Applying the “Stages of Mourning”
The specialist may be keen on the need of the patient to
travel through the “four stages of mourning” (Numbness,
Denial, Despair, Acceptance) to reach the point where
they are ready to begin the road to rehabilitation 9.
But, what about the third party whose quality of life
has also been turned upside down as a result of the
patient’s problem? Must they not also travel, albeit in
a different way, the same road, to find some sense of
emotional closure?
Let’s review the four stages and how the third party
might fit into this scenario:
1. Numbness upon hearing the unpleasant news that it’s
actually a hearing loss that causes the patient to
appear to be less interested, more distracted and
overall not as warm and caring as they once were. On
first hearing this news it is difficult to emotionally
switch gears so suddenly, which can leave a feeling of
emotional suspension.
2. Denial of the loss may cause the third party to
continue searching for another more plausible
explanation. “He doesn’t love me any more. We’ve grown
apart. We no longer enjoy the same things. He just uses
his hearing as a way to avoid me.”
3. Despair sets in when the truth begins to sink in. “I
didn’t realize that he really does have a hearing
problem. If only I’d been more understanding. Maybe if
we had checked his hearing sooner we could have avoided
so many heated arguments, saying things we really didn’t
mean.”
4. Acceptance of the situation and the available
solutions to the problem that would allow life to go on,
“to pick up where we left off. He deserves to hear
better, and I’m going to help him.”
Summary
The objective of this course has been to explore the
psychosocial interaction between prospective hearing
instrument patients and their significant others during
the decision-making process. The ultimate success for
the new user often hinges on the active support and
understanding of close loved ones, whose lives may also
be positively enhanced during the course of hearing
correction.
A successful hearing instrument fitting is best defined,
not so much by improved pure-tone thresholds or
monosyllabic discrim score, but by the lives it changes
for the better. And while hearing instruments may
provide only part of the solution, coupled with
appropriate and frank counseling during the hearing
evaluation, it can serve as the foundation from which to
rebuild relationships, expand opportunities and enhance
the lives of all those involved…especially for that
all-important third party.
References
1. Chartrand, M. S., “Psycho-Social Principles of
Hearing Impairment”, in ed., R. Sandlin, Hearing
Instrument Science & Fitting Practices, National
Institute for Hearing Instruments Studies, Livonia, MI,
1996, pp. 741-792.
2. Chartrand, M. S., “Fundamentals in Counseling in the
Dispensing Practice,” Audecibel, Fall, 1990, pp. 24-29.
3. Oja, G. L., and Schow, R. L., “Hearing aid evaluation
based on measures of benefit, use and satisfaction,” Ear
and Hearing, 5, pp. 77-78.
4. Ross, M., Brackett, D., and Maxon, A. B., Assessment
and Management of Mainstreamed Hearing-Impaired
Children: Principles and Practices, Pro-Ed, Inc.:
Austin, TX, 1991. (Note: Although this book is written
about children, it contains many psychosocial principles
applicable to families with hearing impaired adults.)
5. Chartrand, M. S., “Working with the psychology of the
hearing impaired”, Hearing Instruments, 41:11, 1990, pp.
22-24.
6. Hull, R. H., “Assisting the Elderly Client”, Katz,
J., ed., in Handbook of Clinical Audiology, Williams &
Wilkens Co.,: Baltimore, MD, 1978, pp. 596-604.
7. Chartrand, M. S., “He said…she said…,” Hearing
Instruments, 45:10, 1994, pg. 44.
8. Gatehouse, S., and Killion, M., “HABRAT: Hearing Aid
Brain Rewiring Accommodation Time,” Hearing Instruments,
44:10, 1993, pp. 29-32.
9. Bowlby, J., and Parkes, C. M., “Separation and Loss
within the Family,” in E. J. Anthony and C. Koupernik
(Eds.) The Child in his Family, Vol. 1, NY: John Wiley &
Sons, Inc., 1970. |
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