As we enter the 21st century, it is encouraging to see an expanded interest among audiologists in providing organized programs of support for new hearing aid users and their families.
Schow and his co-authors conducted a survey of clinically active audiologists and found 94% reported doing some form of audiologic rehabilitation (AR), ranging from individual hearing aid orientations to auditory training to counseling with family and friends (Schow, Balsara, Smedley, & Whitcomb, 1993). These authors found that although traditional AR in the form of lipreading and auditory training drills had declined from previous years, the surveyed audiologists reported a huge increase in provision of systematic hearing aid orientations (HAOs) for new hearing aid users.
The conventional HAO consisting of an explanation of how to use and care for hearing aids also appears to be undergoing a transformation. Several authors have described group support programs for new hearing aid users that focus not only on the hearing aids, but also 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, counseling-based support groups, or perhaps most commonly, both.
The purpose of this article is to offer a contemporary view of AR, while emphasizing the audiologist's role 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 audiologist serving as an effective support group facilitator.
There are a number of benefits of AR support groups for new hearing aid users, their SOs, and there are benefits for the practitioners. Tables 1 and 2 highlight some of these advantages. An important consideration when deciding whether to offer group support programs is the increasing research indications regarding the impact of psychological and social variables on successful hearing aid use. Kricos (2000) described a number of non-audiological variables that may influence hearing aid and AR outcomes. These variables included race/ethnicity, gender, age, personality, self-efficacy, and social support, among others. In particular, several research investigations have revealed the powerful impact of personality variables (e.g., anxiety, depression, locus of control) and social support on successful adjustment to hearing aid use and to living with hearing loss (for a thorough review of these studies, see Kricos, 2000).
A significant relationship between satisfaction with and availability of social support and hours of hearing aid use has been found by several researchers (see Kricos, 2000, for a review). Why would social support have such a marked effect on the new hearing aid user? The answer lies in the myriad of ways that 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 adjusting to hearing aid amplification. . In turn, the availability of social contacts, may in itself, provide powerful motivation for the new hearing aid user. Clearly a reciprocal relationship exists between new hearing aid users and their social milieus.
In view of this relationship between adaptation to hearing aids and availability of social support, it seems extremely important for audiologists to utilize the patient's social networks in a systematic manner.
Hallberg (1999) suggests three ways that AR can enhance the magnitude and quality of social support. First, SOs can be provided with knowledge about hearing impairment and its consequences, as well as technical information regarding amplification via hearing aids and other assistive devices. Second, the AR program can provide psychosocial support for mutual acceptance of the hearing impairment by both the new hearing aid user and his/her SOs. Third, both the SO and the new hearing aid user can be taught effective coping strategies.
There are numerous ways to provide knowledge, support, and coping strategies to new hearing aid users and their SOs. Audiologic rehabilitation support programs might be incorporated into individual counseling at the time of fitting, and/or offered in organized, well-planned printed materials which are given to the patient at the time of the fitting. New hearing aid users and their SOs can be referred to consumer groups such as Self Help for Hard of Hearing, the Association for Late Deafened Adults, or the Internet group known as the Say What Club. These groups focus on positive coping strategies for dealing with hearing loss. An effective way of providing knowledge, support, and coping strategies to new hearing aid users is through the provision of programs that focus on group interaction for collaborative problem solving. A number of group AR models contain 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). Most of these models lay out the content of group orientation sessions, which will help keep the busy audiologist's preparation time to a minimum. In addition to carefully planning the content, the audiologist must be skilled in facilitating group discussion and interaction.
Facilitation has less to do with content (i.e., what you actually do during the group meetings) and has more to do with the process or movement toward a destination. Facilitation refers to making something easy or more convenient (Hunter, Bailey, & Taylor, 1995). Within the context of group AR, the 'something' is probably several things: acceptance of the hearing loss, adjustment to using hearing aids and the ability to manage troublesome communication situations.
Most likely a major goal of the AR group facilitator will be to encourage change: changes in attitude, changes in knowledge regarding hearing loss and hearing aids and changes in communication protocols. As noted previously, the group setting for AR offers a number of advantages for enhancing the probability of change, including peer support and the inclusion of SOs in the learning process. Even greater, more meaningful changes may occur when the audiologists serving as facilitators, view themselves as catalysts, rather than experts. By serving as catalyst, the audiologist lays the groundwork for group members to assume responsibility for discovering solutions to their problems, rather than relying on the audiologist for the answers.
It is probably safe to say that the majority of audiologists have had little or no training in how to successfully facilitate group interaction. The same audiologist who is effective in one-on-one counseling may be frustrated and confused when group work does not initially proceed as comfortably as individual work. There are several key requirements for effective group facilitation. These include understanding the difference between facilitating and leading, the use of active listening, and possession of a number of interpersonal and technical skills.
As noted in the introduction, the group program provided to new hearing aid users and their SOs may likely be both content-based (e.g., how to maintain and insert the hearing aids) and counseling-based (e.g., accepting the hearing loss, dealing with the frustrations of difficult communication situations).
Most audiologists are comfortable providing information to their patients about hearing loss and hearing aids, and frequently use a directive approach to a patient's rehabilitative program. 'This is what your audiogram means,' 'The best type of hearing aid for you will be the....', 'Here's how you insert/remove the hearing aids', etc.
For successful facilitation of a support group, the audiologist needs to re-think their role The audiologist will need to focus on facilitation, rather than leading. Whereas the leader provides knowledge, guidance and support, the facilitator constantly searches for ways to draw out group members in an effort to encourage and inspire the use of self-discovery and problem-solving strategies to learn how to live with hearing loss. Whereas the leader may view the group as being the passive recipient of information, the facilitator views the group as having an active role in finding solutions to frequently occurring problems. Whereas the leader states the desired action plan to manage communication problems, the facilitator asks the group for input regarding problem-solving strategies. And whereas the leader presents information, the facilitator obtains information.
Participation in group discussions can be encouraged by simple statements or questions such as 'Let's go round the group and see how everyone thinks (or feels) about this issue,' or 'Who would like to sum up the issue we've been discussing?'
Schwarz (1994) emphasizes that one of the core values that guide facilitation is the acceptance that group members have free and informed choice as to their objectives and methods for achieving them. Schwarz states '...facilitators do not change peoples' behavior. Facilitators provide information that enables people to decide whether to change their behavior. If they decide to change their behavior, the facilitator helps them learn how to change.' (p. 8)
If I had to single out the one most desirable characteristic of a support group facilitator, it would be active listening skills. Active listening occurs when you listen constructively, with interest and acceptance, to what someone is saying, rather than interrupting, either out loud or in your head, with your own thoughts, opinions, or feelings. One way to immediately start learning what it means to be an active listener is to realize when you are 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, remind yourself to stay in the present. With commitment and practice, you will develop the discipline required for active listening.
Active listeners want to listen. They paraphrase in their minds, what the other person is trying to say. Active listeners convey interest and acceptance, restate what they think they are hearing, reflect on the basic feelings being expressed by the speaker, and try to summarize mentally the major points the speaker is trying to make.
Part of active listening is 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 the speaker's viewpoints. Table 3 contains a checklist that might be used to gauge one's active listening skills.
Another form of communication that is particularly facilitative for group work is reflective listening. As an active listener, you can reflect back the content of what has been said. For example, 'What I heard you say is that people may use their hearing loss as an excuse in some situations. Is that accurate?' Or, you may want to reflect back the feeling of what has been said. For example, 'I sense you feel frustrated about his using his hearing loss as an excuse.' Or you may choose to reflect back the spirit of what has been said, as in 'I can hear that you are concerned about his using his hearing loss as an excuse.' These types of responses encourage group participation as well as a sense of self-value for individual group members.
In addition to active listening skills, Hunter et al. (1995) described a number of other attributes which are desirable in facilitators. For example. facilitators should be comfortable with conflict and should not view disagreement between group members as something that needs to be fixed or avoided. The facilitator should be relaxed and should allow his/her personality to be expressed. The facilitator should keep eyes and ears open all the time to better discern what is happening in the group.
While working with groups, I find it is helpful to periodically scan the group with my mental radar to note body language, facial expression, mood, tone, and temperament of the group. When I am not sure how group members are feeling about the matter under discussion, I will periodically ask them to give me feedback. Group members seem to appreciate these requests for activity and reflection.
According to Hunter and his co-authors (1995), rather than feeling that answers have to be provided to the group, facilitators should use questions and suggestions when group intervention is necessary. For example, rather than saying, 'What you should do is ask the speaker to use the microphone', try 'I suggest that you ask the speaker to use the microphone.' Rather than supplying the group with the answer, the experienced facilitator tries to engage the group to participate in the provision of possibilities and alternatives.
With practice, audiologists will learn the skills and techniques useful for successful group work.
Practical suggestions for serving as an effective group facilitator within an audiologic rehabilitation support group have been delineated in this article. Classic dictionary definitions of the word facilitate usually include statements such as 'to make easier', 'to make more convenient', 'to assist the progress of a person', 'to help forward an action or a process'. The obvious purpose of a support group is to provide support, and thus the facilitator's role is to enable group members both to obtain and to give support to each other. The focus of the facilitator's effort should be:
1. to facilitate the expression of feelings among group members,
2. to foster open communications among the group,
3. to encourage a focus on successful coping strategies,
4. to enable group members to provide useful information to each other,
5. to help establish supportive networks among group members, and
6. to provide opportunities for each group member to assume a sense of self-empowerment in facing many of the problems and dilemmas that may accompany hearing loss.
With these goals and objectives as a framework, the audiologist will be more effective in assisting families in their quest to learn how to better live with and manage 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.
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.
Schow RL, Balsara N, Smedley TC, & Whitcomb C. Aural rehabilitation by ASHA audiologists: 1980-1990. Am J Audiol 1993; 2:28-37.
Schwarz, R. M. The Skilled Facilitator: Practical Wisdom for Developing Effective Groups. San Francisco: Jossey-Bass Publishers, 1994.
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
Table 2. Practitioner advantages for providing AR group support programs
Marketing opportunity (i.e., standing out from competitors)
More satisfied patients
Fitting feedback and modification
Competent hearing aid users
Opportunity to develop rapport with patients
Fun way to interact with patients and their families
Table 3. Checklist for active listening
_____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?
This article was originally published on Healthy Hearing (www.healthyhearing.com) on 10/10/2000 and is reprinted here, based on popular request.