Samuel Trychin, PhD
In response to an article on hearing loss and social pain (Trychin, 2012) one woman recently wrote the following. “Some days I just want to crawl in a hole and never come out. But I am a teacher at heart, a people person, and a nurturer. So I keep on suffering the embarrassing moments and I pray that God will continue to give me the strength not to hide from the world.” Another woman’s response to the same article was, “…I was questioning why I seem to invite rejection and social ostracism within my family and with some friends.”
A middle-aged vice-president of a large international company resigned his job after having worked for the company for 30 years. He was quite despondent saying that he had worked hard and finally achieved a position that paid six figures annually, but felt that his hearing loss had become a liability to the company and that he felt he had to resign. The major difficulty was that the majority of information he needed in order to do his work was gained informally in brief conversations in hallways, work areas in the manufacturing sector, and around the coffee pot in the lounge. His hearing loss caused him to miss or misunderstand much of what was said in these encounters, leading him to feel incompetent.
Stories such as these are frequently encountered among people who have hearing loss and illustrate that loss of hearing presents a number of obstacles and challenges. For the majority of people with hearing loss, these are problems in living issues, and the difficulties faced can wreak havoc in a person’s life.
Hearing loss can also present communication difficulties during treatment sessions, sometimes being reflected in a person’s failure to return after the first appointment, missing appointments at later times, or failing to comply with treatment recommendations. Any of these may be due to the patient’s misunderstanding what was said. Otherwise, if the psychologist is unaware of the general problems and issues related to hearing loss, there may be failure to collect salient information resulting in critical factors being overlooked or disregarded. The consequence could be failure to adopt appropriate treatment strategies and/or recommend available community resources. Misdiagnosis is also a possibility. A difficulty for the professional is that many people who have hearing loss are not aware of it, do not accept the fact of it, or are unwilling to discuss their hearing loss. Then it is up to the psychologist to determine if hearing loss may be a factor. The signs and symptoms of hearing loss presented may be helpful in recognizing the possibility that hearing loss is an issue, but ultimately an audiologist’s assessment is required.
A provider’s hearing loss can also interfere with effective treatment if important information is missed or misunderstood or if the person is forced to frequently repeat what was said to the professional. Typically, when people talk about intimate, sometimes embarrassing personal information, they drop the volume level of their voices, producing even greater difficulty for a provider who has hearing loss. As people age, the likelihood of developing hearing loss increases. Usually this develops gradually so that the person may habituate to the increasing decrement, therefore, there may not be a point where it suddenly becomes obvious. There are probably psychologists who know they have hearing loss and decide to retire or do some other kind of work due to concern about becoming ineffective in their practice. It is important that these people become aware of assistive technology and communication behavior strategies that can enable them to continue providing effective services even with hearing loss.
The term people who have hearing loss describes those people who have some degree of less than normal hearing, but do not rely on sign language for communication. In the past these people have been described as hard of hearing. Sometimes, those with hearing loss arelooked upon as simply being less deafand therefore, not experiencing significant difficulties. The barriers to functioning produced by hearing loss may be seen as trivial when they are, in fact, major causal factors in emotional distress, behavior dysfunction, and/or relationship difficulties. This is probably due to the lack of information about the psychosocial dynamics related to hearing loss in graduate and post-graduate training. Some psychologists have had training and/or experience in deafness—serving that subpopulation that relies on sign language for communication.
Because of this general lack of information this article outlines the health-related issues seen among those who have hearing loss and do not rely on sign language for communication. The number of people who have hearing loss in the United States is about 36 million according to the National Institute on Deafness and Other Communication Disorders (NIDCD). Less than one million of the 35 million rely on sign language for communication. The article also includes information about strategies for increasing the ability to live long fulfilling lives with hearing loss. The majority of people experiencing the onset of hearing loss are adults over the age of 45, but we are now seeing many more young people who are affected; the NIDCD estimates that one in five teenagers has hearing loss. Additionally, early intervention screening is detecting more babies who are born with less than normal hearing.
One somewhat surprising fact is that the majority of people who have hearing loss (80%) do not take any steps to accommodate it, such as getting a hearing evaluation and, if necessary, hearing aids (NIDCD). The tendency of people to deny or ignore their hearing loss presents a challenge for health service psychologists who may be dealing with a person’s lack of basic information as well as lack of acceptance of her or his own hearing loss. Two sources of information can be very helpful for both the people seeking and providing help. First, the Hearing Loss Association of America (HLAA) provides information on a variety of topics related to hearing loss, including assistive technology and effective communication behavior tactics and strategies (HLAA.org). HLAA produces six bi-monthly magazines each year covering a variety of topics and also has an annual convention with many useful workshops. The second resource is the Ida Institute (IdaInstitute.org) that produces useful information and tools for audiologists and other professionals who work with people who have hearing loss. (Particularly helpful information can be accessed by going to the Ida Institute website and clicking on the tools section.)
Some basic issues related to hearing loss
Hearing loss affects people in two ways, each contributing to health concerns. First, hearing loss interferes with access to important physical environmental information. It can interfere with receiving auditory signals important for survival, e.g., alarm signals, car horns, or shouts of warning. It also interferes with receiving other important information such as the sounds from telephones, doorbells, or alarm clocks. Second, it interferes with social communication and relationships. Communication breakdowns, especially when frequent, often result in weakening relationships and creating distance between people. Hearing loss creates varying degrees of emotional arousal related to decrements in both physical environment attunement and individual/group relationships. The degree of interference depends in part on the severity and type of hearing loss, whether assistive listening equipment is used, the person’s knowledge and use of effective communication behaviors, and the communication demands in particular situations.
It is important to recognize the distinction between hearing and understanding. Many people who have normal hearing think that if a person hears someone talking, he or she will also understand what is being said. Unfortunately, for most people who have hearing loss, this is not the case. They have hearing decrements in certain sound frequencies that make it difficult to hear specific speech sounds, especially the consonants f, s, sh, th, t, p, k, ch and h. They usually can hear the vowel sounds that carry the volume and duration of speech (a, e., i, o, and u). The result is that they may hear the vowel sounds and know someone is talking, yet be unable to hear certain consonants, making it difficult to determine the words spoken.
Missing or misunderstanding speech sounds can result in changing the meaning for the listener of what is said. . For example, years ago I was listening to a radio newscaster discuss results of an election poll. I heard the man say, “Voters don’t like politicians who take aspirin.” That statement startled me, so I listened more carefully and determined that what he had said was. “Voters don’t like politicians who take action.” not aspirin. My brain had heard the a and the n, but missed the middle speech sounds and automatically and involuntarily filled in the gap with a word from my lexicon. Fortunately, the result did not fit the context, so I checked it out. However, there are many occasions in which the word does fit the context but is wrong, resulting in confusion or worse. If the boss says don’t go over $15,000 on that contract and the employee hears $50,000, there is a potential for problems. Knowledge of this difference between hearing and understanding can help in reducing the confusion resulting when a person is able to understand some things but not others. This information is helpful in reducing accusations that are not helpful in relationships, such as, “You can hear me when you want to” or “She has selective hearing.”
People may not relate difficulties they are experiencing to their hearing loss. They may not relate their fatigue, anxious or depressed feelings, or tendency to withdraw from others to the hearing loss. Sometimes, as stated previously, the person is unaware of or chooses not to discuss his or her hearing loss and the provider is left to pick up the signals that it is present and may be a factor in the patient’s difficulties. Some signs or signals indicating the presence of hearing loss might be evident to observers. Other signs can be quite subtle, but are recognizable to the discerning eye. Any one alone may or may not point to hearing loss, but several occurring together are probably reliable indicators of hearing loss, especially when they occur with some frequency. The following is a list of these indicators.
- Frequently misunderstanding words
- Frequently asking people to repeat
- Inappropriately responding to what is said
- Failing to respond to what is said
- Difficulty understanding in groups
- Avoiding social situations
- Blaming people for not speaking clearly
- Being defensive about communication problems
- Turning up radio or TV much too loud
- Having a puzzled expression when listening
- Intently watching the speaker’s mouth
- Having a strained expression around the eyes
- Turning the head to one side to hear better
- Talking too loudly or very softly
- Hearing loss and age-related major life-tasks
The time of onset of hearing loss in a person’s life is an important variable. The impact can be especially large in earlier development. For children/adolescents their major life-tasks are education and training, job/career, relationships, self respect/confidence. Difficulty acquiring language affects educational achievement and ultimately employment opportunities. The effects of being bullied or rejected by peers can have lifelong negative effects that may no longer be in conscious awareness, but still exert powerful negative social and emotional effects (Knack, J.M., Gomez, H.L. & Jensen-Campbell, L.A. 2010).
For adults their major life-tasks are continuing their education or training and maintaining job/career, relationships, self-respect/confidence. Problems for working adults are interference with keeping employed or advancing in their careers. Problems for older people are loss of family and friends due to illness/death accompanied by difficulty in making/keeping new friends, resulting in loneliness and its attendant problems (Cacioppo, 2003).
At any age, if hearing loss-related problems are overlaid on other difficulties, e.g., adverse physical, financial, employment, relationship issues, the problems are compounded, but the specific effects of the hearing loss may be difficult to determine. There are three possibilities when considering the effects of hearing loss on a life’s challenges. First, the hearing loss may not be a factor at all, e.g., the person would be just as depressed if she had no hearing loss. Second, the hearing loss may exacerbate a preexisting condition, e.g., even without the hearing loss the person would still be depressed, but not as depressed as she is with it. Third, the hearing loss may be the cause, e.g., if she didn’t have the hearing loss she would not be depressed.
In an effort to make such a determination it can be most helpful to have information about the general effects of hearing loss and how people often respond to communication situations when hearing loss is present. The following sections outline the types of information that are found useful in this regard.
1. Frequently held myths and misconceptions about hearing loss
A. The hearing aid misconception is so widely held that I call it a myth. This is the mistaken idea that hearing aids function much like eye-glasses, returning the user to something close to the equivalent of 20-20 hearing. Hearing aids only amplify sounds—all sounds including those the listener does not want to hear. Hearing aids also lose their effectiveness as distance increases between the source of the sound and the user. Unfortunately, when someone is seen wearing a hearing aid, the erroneous assumption is that that person’s hearing ability is returned to normal or close to it. Then unhelpful, sometimes caustic, comments are made, such as, “What’s the matter; isn’t your hearing aid working?” This being said, it is most important that everyone who can benefit from hearing aids have and use them.
B. The lip-reading misconception is the mistaken belief that when hearing is diminished there is an automatic compensation by improved vision and/or that people with hearing loss are expert lip-readers. In reality people vary in their ability to read lips; some are fairly good (understanding maybe 40%) and others not good at all. There are many speech sounds that look alike on the lips and as age-related hearing loss increases, vision also decreases, resulting in poorer acuity in both. Another problem is that many people who have hearing loss suffer a decrement in their ability to pay attention. Nonetheless, we recommend that people take speech-reading classes because every additional skill adds some help in successful coping.
C. The sign language misconception is the mistaken idea that an easy alternative to spoken language is relying on sign or manual communication. One problem with this view is that sign language is not that easy to learn; it requires time and lots of opportunity to practice on a regular basis. The second problem is that one’s family, friends, and coworkers are unlikely to also learn sign language, so what is the point of the effort? We do recommend that people who communicate on a regular basis learn some basic signs and perhaps finger-spelling that can prove helpful in some situations.
D. They understand hearing loss and its psychosocial effects misconception is the mistaken assumption that professionals, e.g., physicians, health service psychologists, educators, audiologists, etc. are cognizant of the psychosocial effects of hearing loss. They are not, generally, and there is no reason they should be unless they picked up the information through direct experience. Again, the information is generally not taught in most university programs. It is also the mistaken assumption that the people who have hearing loss themselves and their communication partners understand the psychosocial dynamics of hearing loss and the majority of them also do not.
2. Considering hearing loss as a communication disorder
Because hearing loss is a communication disorder, it affects both the individual who has it and those who are attempting to speak to him or her—the communication partners (CPs). The perspectives and experiences of both must be taken into consideration for assessment, treatment, and follow-up for several reasons. First, CPs can facilitate or inhibit the tendency of a person who has hearing loss to take effective action to deal with it. Second, hearing loss places an extra burden on those who are attempting to communicate because they have to change some aspect of their communication behavior in order to be understood. If not, they will be put in the position of needing to repeat a lot of what they had said. Third, CPs may be able to report information that the patient who has hearing loss either doesn’t know or is unwilling to discuss.
Who are these communication partners? In the past we have focused on significant others when referring to those people with whom the person with hearing loss communicates. Usually, we think of significant others as a person’s spouse, lover, child, parent, other family member, and/or close friend. However, most people communicate with a variety of people in the course of a day, week, month, or year. The most important communication partner at any given time is that person with whom the individual with hearing loss is conversing at that moment. You may be in face-to-face communication with your physician only once a year, but at that moment, she is a very important communication partner and you need to understand what she is saying to you. Also, she needs to know that you understand the information she is trying to tell you.
3. Examples of types of problem- situations frequently reported by:
a. People who have hearing loss: hearing alarm signals, voices from another room, cannot see speaker’s face, poor illumination, person talks too fast or too softly, loneliness.
b. Communication Partners: difficulty remembering what to do, not knowing whether she/he understands what I say, the variability in his ability to understand, not going out to new places or seeing new faces, loneliness.
The purpose of including this information is twofold. First, the people who have hearing loss and their communication partners learn that many of the difficulties they encounter simply go with hearing loss; these experiences are not due to some imagined imperfection or flaw in themselves or their personality—there is no need to feel guilty. Second, the person with hearing loss clearly sees the difficulties that the hearing loss produces for his or her partner and vice versa. Then, the door is opened for viewing hearing loss as being our problem, rather than my or your problem, and we can begin to work on it together. Third, people begin to see the relationship of the hearing loss to some issues and concerns in their lives that they had not previously considered being related to the hearing loss, opening the door for possible improvement in those areas.
4. Causes of communication problems
There are three major categories of communication problems faced by people who have hearing loss and their communication partners. The first type of problem occurs when the person speaking doesn’t first get the attention of the person who has hearing loss before beginning to speak. The listener isn’t aware someone is talking, so will not understand what is said. The second type occurs when the listener doesn’t understand what is being said and knows it. The third type of communication problem occurs when the person who has hearing loss thinks he has understood, but has misunderstood what was said. Then the person who has the hearing loss and the communication partner are both under the misapprehension that what was said had been correctly understood, only to find out at a later time that was not the case, sometimes with disastrous results.
If you ask most people who have hearing loss and their communication partners what the cause of a communication breakdown had been, the typical answer is my (or his) hearing loss. Now, if the person already has up-to-date hearing aids and wears them, that answer is somewhat depressing because it indicates that everything that could be done has already been done and that there are still problems—one is somewhat helpless. However, there are at least forty other causes of communication breakdowns, and most of those causes are correctable once identified. The causes of communication breakdowns generally come from three sources: the person talking-the speaker, the person who has hearing loss-the listener, and the environment in which the message is being delivered-the environment.
Some examples of speaker factors that influence understanding: does not first get the listener’s attention, does not face the listener while talking, covers face while talking, talks too rapidly/too slowly, or talks too softly/too loudly. Examples of listener factors that influence understanding: severity and type of hearing loss, use of hearing aids and other assistive listening devices, ability to pay attention, and emotional status. Examples of environmental factors that influence understanding: background noise, poor lighting, poor room acoustics, too far from source of sound, visual or auditory distractions, objects interfere with seeing the speaker.
Training people to recognize the presence of these factors in difficult listening situations and providing instruction on what can be done to eliminate or reduce their effects goes a long way toward increasing mood, self-efficacy, and self-confidence.
5. Reactions to communication problems
What happens next—after the communication breaks down? Some reactions are productive; they help to resolve the problem. Other reactions are unproductive; they fail to resolve the problem and often make the situation even worse. If upon failing to understand what you just said, I angrily say, “How many times have I told you to speak up!?” the chances are good that you no longer want to continue the conversation. I may not use those specific words, but I can convey my anger toward you via facial expression and body language and still get the same message across. If asked why this relationship is not going so well, the person with hearing loss may say, “Because of my hearing loss.” However, it is the reaction to the hearing loss-related problem that is the cause, and that is correctable.
People react in several different ways, i.e., physiologically, emotionally, cognitively, behaviorally, and socially. Helping people alter their negative reactions in communication situations can be a major step in helping them adjust to hearing loss and improve their relationships and health. In this regard it is necessary to pinpoint their typical unproductive reactions when communication breakdowns occur or are anticipated and then practice more productive alternative reactions.
The following are examples of some frequently reported reactions in each of these categories that often make the situation worse. Usual physical reactions are those that are prewired reactions to threat or danger that prepare the body to respond by altering respiration, heart rate, and hormonal activity that, when intense or frequent often result in fatigue and diminish a person’s cognitive abilities. Emotional Reactions to communication problems include anger/irritation, fear/anxiety, depression/sadness, and embarrassment/shame. Frequently reported cognitive reactions to communication problems include can’t think straight, confused, hard to focus attention, easily distracted, difficulty making decisions, and mind goes blank. It’s easy to see why a person might have difficulty finding a solution to a communication problem when this is occurring.
Frequently reported behavioral reactions to communication problems include bluffing or pretending to understand, withdrawing or avoiding/escaping, blaming, e.g., “you mumble.” demanding, e.g., “you better face me.” dominating conversations, and overdependence. None of these are endearing reactions, and it is easy to see why, when resorted to, they damage relationships. Social reactions too often include self-isolation as a result of the embarrassment or shame experienced in difficult communication situations. Self-isolation can lead to loneliness and its attendant morbidity and mortality problems as well as depression (Hawkley, L.C. & Cacioppo, J.T., 2003).
6. Health care issues
There are two ways in which the negative reactions to communication difficulties can result in more serious consequences. The first occurs when there has been a major traumatic event related to hearing difficulties, e.g., loss of a job, marriage/relationship, health, etc. The second can occur when there has been a long series of more minor, but still hurtful, events, such as rejection/ostracism, bullying/abuse, neglect, etc. Either of these can result in health care problems, sometimes contributing to PTSD.
Other examples are becoming chronically nervous/anxious or chronically depressed, feeling frequent anger, feeling marginalized in one’s own family or work situation, avoiding people, and loneliness.
When people become aware of this information and can apply it to themselves, they are ready to make the difficult changes necessary for living well with hearing loss. The most effective and efficient way to have this information presented/uncovered is in a group composed of people who have hearing loss and their communication partners. In a group setting a psychologist can directly observe people’s communication behaviors and reactions and suggest changes to be adopted on the spot. Homework assignments can be given to ensure that the desired changes are also carried over into the real world outside of the group.
To summarize, people who have hearing loss and their communication partners need to learn how to do two things:
1. Manage communication situations by:
- Learning effective communication behaviors
- Using assistive listening/alerting devices
- Anticipating difficult situations and planning strategies for minimizing problems
- Discussing hearing loss-related issues with communication partners
2. Manage their emotional arousal by:
- Learning to identify early warning signals of emotional distress
- Learning and practicing effective emotional regulation techniques/procedures
- Practicing good health guidelines—enough sleep, proper diet, adequate exercise
Both steps require information, practice, and feedback on the adequacy of their performance. Because there are usually multiple behaviors, feelings, attitudes requiring change and because long-standing habits such as bluffing and being dependent are difficult to modify, a considerable number of sessions over an extended period of time is usually necessary. Again, a group setting is probably the best way to accomplish both of these goals.
For further information, go to www.trychin.com.
Samuel Trychin, PhD, is currently in private practice specializing in treatment for people who have hearing loss and their communication partners. He also conducts national and international training programs for people who are hard of hearing, their communication partners, and professionals who provide services to them. Dr. Trychin has hearing loss and was issued his first hearing aid while serving in the United States Air Force. He has been a hearing aid user since that time. Further information about Dr. Trychin’s program for people who have hearing loss, their communication partners, and professionals who provide services to them can be obtained at www.trychin.com.
Cacioppo, J.T. (2003). The anatomy of Loneliness. Current Directions in Psychological Science. 12, No. ??? 371-374.
Hawkley, L.C. & Cacioppo, J.T. (2003). Loneliness and pathways to disease. Brain, Behjavior, and Immunity 17, S98-S105.
Knack, J.M., Gomez, H.L. & Jensen-Campbell, L.A. Bullying and its long-term health implications. In MacDonald, G & Jensen=-Campbell, L.A(2010). Social Pain: Neuropsychological and health Implications of loss and exclusion. Washington, DC: American Psychological Association.
Trychin, S. (June/July, 2012). Hearing Loss and Social Pain. Hearing Loss Magazine. Hearing Loss Association of America, Bethesda, MD.