Section #1 – Aural Rehab 4300 Notes

From "Foundations of Aural Rehabilitation" by Nany Tye-Murray (1998)

Communication Training

• Instruction to help a hearing impaired person maximize their potential for communication

• Communication Strategies are actions taken to facilitate communication or rectify problems that occur during communication

CONVERSATION

• Why do we engage in conversation?
• Rules of Conversation
• Agree to share one another’s interests
• ensure that no single person does all the talking
• participate in choosing and developing the topic
• take turns in an orderly fashion
• try to be relevant to the topic of conversation
• provide enough information to convey a message without being verbose

Hearing Loss and the Rules of Conversation

• Erber (1996) outlined these problems that people who have hearing loss often exhibit in their conversations:
• Disrupted taking of turns
• Modified speaking style
• Inappropriate topic shifts
• Superficial content
• Frequent clarification

Key Factors in Conversations

• TALKER
• What the talker does and how the talker delivers a message has a big impact
• MESSAGE
• The construction and form of the message is important
• ENVIRONMENT
• Can enhance or detract from the conversation
• PATIENT - THE LISTENER
• The most important role in the conversation

Communication Strategies for the Person With Hearing Loss

• Rules often need to be bent for hearing impaired listeners
• May result in modifications in communication
• Facilitative Strategies
• designed to prepare things so that communication has the greatest chance of success
• Repair Strategies
• implemented when there has been a breakdown in communication

Facilitative Strategies

• Instructional Strategies - designed to help the talker know how to deliver the message in the best possible way

• Message-tailoring Strategies - changes in how the message is delivered to optimize the chances the message will be understood by the listener

Facilitative Strategies (cont.)

• Constructive Strategies - designed to modify the environment to be more conducive to communication

• Attending Strategies - focus efforts by the patient to succeed in obtaining the message

• Anticipatory Strategies - preparing to understand based on context or experiences

Maladaptive Strategies

• Bluffing - acting as if you understood the message
• Become outgoing with exaggerated jovial behavior
• there is tremendous emphasis on talking which presents no problems and is used as an escape from listening
• Retreat from society

Maladaptive Strategies (cont.)

• Displacement of anxiety- for example, may become preoccupied with somatic complaints
• Anxiety about future or present conversations
• Exploitation of loss - become an invalid
• May become cantankerous due to anger, hostility, and/or self-pity

REPAIR STRATEGIES

• Receptive Repair Strategies - used by someone when they have not understood the message of their conversation partner

• Expressive Repair Strategy - used by someone when their conversation partner has not understood their message

Repair Strategies People Use

• Non-specific
• "What?", "Huh?", and "Pardon?"
• Specific - asks for:
• repetition of all or part of the message
• rephrasing of the message
• Elaboration of the message
• Simplification of the message
• Indication of the topic of conversation
• Confirmation of the message
• The message in written or fingerspelled form

Factors that influence the choice of a repair strategy

• How well you know the communication partner
• How useful a strategy has been in the past
• How much of the message was understood
• How well and/or willing you think the communication partner will be in following the instructions you give

Three Stages of Communication Repair

• Detection of the breakdown in communication
• Choosing a course of action
• The course of action
• using a repair strategy
• disregarding the utterance
• bluffing

Motivations Behind the Choices

• People generally use a repair strategy because they are interested in the conversation and are aware that this is how to fix the breakdown
• People ignore the message or bluff as if they have understood the message for a variety of reasons:

Why do people bluff or disregard statements in conversation?

• (let’s assume that the person is not merely uninterested by the conversation)

• Do not wish to reveal hearing loss
• Do not want to disrupt conversation
• Do not have the skills to use repairs
• Do not have the energy to make an effort
• Do not know the conversation partner

Research into Communication Repair Strategies

• Non-specific (most common) requests usually result in repetition of what was said
• Frequent interruptions by a person can lead to negative feelings towards that person by people who communicate with him/her
• A person is more likely to understand when an idea is rephrased rather than simply repeated

Research into Communication Repair Strategies (cont.)

• People who use non-specific requests are often viewed unfavorably by their communication partners
• Non-specific repair strategies are the least effective and yet still can be effective
• Non-specific requests can be minimally disruptive to the flow of a conversation

Conversational Styles

• No one style is always right, but some are more appropriate more of the time
• There are three styles according to Kaplan, Bally, and Garretson (1985)
• PASSIVE
• AGGRESSIVE
• ASSERTIVE

Passive Conversation Styles

• Withdraws from conversations
• frequently bluffs and pretends to understand
• avoids group and social interactions
• use non-interactive communication behaviors that detract from their communication interchanges with others

Aggressive Conversation Styles

• Can be hostile
• can be belligerent
• have a general bad attitude - blaming others
• May take dominating communication behaviors that make them undesirable communication partners

Assertive Communication Styles

• Respect the rights of their communication partners
• Honestly and openly express their own needs and emotions
• Take responsibility for managing their communication difficulties in ways that are considerate of their conversation partners
• Often exhibit interactive communication behaviors that encourage and foster communication
• Most people are not aware of the communication style that they predominantly use (never thought about it)
• Individuals use different communication styles at various times and in various places
• It is important to help people realize the importance of communication style and the behaviors they encompass

ASSESSMENT OF CONVERSATIONAL ABILITIES

• Goals of the initial assessment
• Determine the communication demands placed upon individuals in their everyday life
• Evaluate impact of hearing loss on daily activities
• Identify settings where problems arise
• Document the social activities in which a person is likely to engage
• Assess how effectively they use communication strategies in a variety of settings
• Chronicle their employment responsibilities

Conversational Fluency

• Relates to how smoothly conversation takes place
• three factors define conversational fluency
• Time spent in repairing communication breakdowns
• Exchange of information and ideas
• Speaking time is shared

MEAN LENGTH TURN RATIO

• Equal to the mean length speaking turn (MLT) of one individual as compared to the MLT of his/her conversational partner
• Know what is meant by a conversational turn
• highly fluent exchanges are often characterized by relatively equal MLT ratios (close to 1.0)
• Relation of fluency evals to WRS

Communication Handicap and Communication Disability

• Communication handicap is the amount of psychosocial disadvantage that results from a person’s hearing loss - how much it affects them in functioning
• Communication disability is how much a person’s hearing loss results in a loss of normal performance (i.e. when a person cannot distinguish between "sat" & "that")

Communication handicap & Conversational fluency - problems

• both vary as a function of the conversational setting, situation, and partner
• Both vary by the topic of conversation
• Communication difficulties do not always arise during a conversation
• Both are difficult concepts to define and both include many factors - not simple concepts to grasp

Assessments of CF and CH

• INTERVIEWS
• very effective in obtaining info specific to the individual (what concerns them most, examples of difficulties they are having, etc.)
• Not very quantifiable - how do you measure progress or show benefit from the intervention?

Assessments of CF and CH

• QUESTIONNAIRES
• Gather general information quickly and easily
• Can’t cover everything on them
• Often do not provide info about what is important or most devastating to the individual

Questionnaires

• Used much more commonly now since the audiogram does not provide the info necessary to determine actual handicap
• can be composed of open-ended or closed-ended questions (qualitative or quantitative)
• Qualitative VS quantitative information

Assessments of CF and CH

• DAILY LOGS
• provide general idea of CF and CH and may provide info about aural rehab needs
• The very act of completing a daily log may influence the persons CF and CH
• can be used as baseline and final evaluation of treatment but must be careful - why?

Assessments of CF and CH

• GROUP DISCUSSIONS
• members of the class determine content largely
• encourage all to participate
• record remarks on chalkboard
• make sure all are comfortable contributing
• ask guiding and engaging questions
• come prepared to draw specific info from the participants

Assessments of CF and CH

• STRUCTURED COMMUNICATION INTERACTIONS
• TOPICON & Quest?AR are examples of programs
• a structured conversation is had between the client and clinician and then difficulties are discussed afterwards

COMMUNICATION STRATEGIES TRAINING

• Many ways of going about it
• Should try to meet the patient’s expectations, age, socioeconomic background, lifestyle, and particular communication difficulties
• excessive sympathy not expressed and personal problems not related to hearing loss are avoided

COMMUNICATION STRATEGIES TRAINING

• May include facilitative and/or repair strategies
• working on affecting the four factors that affect communication: the talker, the environment, the listener, and the message
• learning to rectify breakdowns in communication
• learning to recognize assertive and non-assertive behaviors and to use assertive behaviors

Training Program Issues

• Program Length
• Class Format
• Esprit de Corps
• Gender, age, life stage, culture, motivation, communication demands, specific communication dificulties

MODEL FOR TRAINING

• FORMAL INSTRUCTION
• individuals introduced to the various types of communication strategies
• Lecturing is usually ineffective - brainstorming and/or directed group discussion is a better way
• Can use activities that will illustrate the ideas you would like to get across

MODEL FOR TRAINING

• GUIDED LEARNING
• goal is to get individuals to use strategies in a structured setting
• role-playing
• videotaped scenarios
• continuous discourse tracking
• drill activity

MODEL FOR TRAINING

• REAL-WORLD PRACTICE
• using the skill in everyday life situations
• try to use areas that are highly motivating for the client
• report back on successes and failures and discussion ensues to handle future problems

Short-Term Training

• MATERIALS APPROACH
• provide printed materials, video tapes and other media services to train people about communication strategies
• may even have a library for informational purposes
• onus is on the person with hearing impairment

Short-Term Training

• SHORT TUTORIAL
• the WATCH program (Montgomery, 1994) is a good example of such a program
• W - watch the talker’s mouth, not eyes
• A - ask specific questions
• T - talk about your hearing loss
• C - change the situation
• H - acquire health care knowledge

Training Frequent Communication Partners

• Goals of such training are:
• to foster empathy for how difficult it is to speechread,
• encourage the use of appropriate speaking behaviors
• learn how to tailor messages so they are easy to recognize
• learn how to repair communication breakdowns effectively

Training Frequent Communication Partners

• Generally learn to speak clearly and slowly
• make sure their faces are visible to the person with hearing impairment
• can learn to organize their messages (i.e. avoid verbosity, use semantically simple sentences)
• Can learn to check for comprehension
• Can use repair strategies
• Usually training happens at the same time as training for the person with hearing loss

Communication Partners’ Needs

• many times need support and counseling
• Life quality changes
• stressed by excessive noise
• stressed by communication breakdowns and misunderstandings
• social isolation and loneliness
• can be burdensome

Communication Strategies for Children

• The programs focus on many of the same things the adult programs do but adapted for the child’s level of understanding and needs
• formal instruction - many do not easily generalize the concepts they learn in formal instruction to their behavior
• Guided learning takes place primarily with role-playing and modeling
• real-world practice should be assigned carefully

Guidelines for real-world practice with children

• Assign an activity with which the child has had success during the guided learning stage
• Select a communication situation that is motivating for the child
• Help the child to have success
• Provide simple instructions
• Provide a means for the child to record the experience

Expressive repair strategies for children

• FIVE STEP PLAN (Elfenbein, 1994)
• understand basic communication processes
• understand communication breakdowns
• message formulation
• introduction of repair strategies
• practice using communication repair strategies

How effective is communication strategy training?

• A difficult thing to quantify
• efficacy data with children is almost non-existent
• needs much more research - however, present data suggest effectiveness

effectiveness depends upon the client’s abilities - may need to rely on frequent communication partners to be empathetic