The psychosocial challenges that arise as a result of unresolved hearing impairment

Max Stanley Chartrand, PhD, serves as director of Digi-Care Hearing Research & Rehabilitation, Colorado City, Colo, and adjunct professor of behavioral medicine at Northcentral University. He is a long-time author, educator, and researcher in the hearing health field and, as a person with profound hearing loss, uses a cochlear implant and assistive technology for communication.

Helen Keller, upon being asked whether she considered vision or hearing more important, replied:

The problems of deafness are deeper and more complex, if not more important, than those of blindness. Deafness is a much worse misfortune. For it means the loss of the most vital stimulus—the sound of the voice that brings language, sets thoughts astir and keeps us in the intellectual company of man.^1,2

What Keller knew, and what popular thought has often overlooked, is that the human sense of hearing represents the primary cognitive window into life itself. "Blindness cuts us off from things; deafness cuts us off from people … to be cut off from hearing [people] is to be isolated indeed."³

To one who hears normally, it may seem a strange concept that one can stand amidst a room full of fellow human beings—engaged in excited conversation, bonding, and enjoying each other's company—and yet feel awkward and terribly alone.

The Real Effects of Hearing Loss

Years after Keller's exposé on the psychosocial effects of hearing impairment, audiology researcher Ramsdell⁴ published his 1968 thesis suggesting that the most pronounced effects of hearing loss are emotional and psychological. Out of his groundbreaking work came several models of human behavior relative to the human sense of hearing. One of those, used by this author, involves "The Three Psycho-emotional Levels of Hearing"^4,5:

1. Primitive (background) level. This level involves the auditory background of life, much of it indiscernible, that is nevertheless crucial for one's sense of security in a noisy world.

   A newborn baby recognizes, but does not understand, the voice of its mother. But that's all right: it knows that it is home, cared for, and safe in familiar and loving surroundings. Another background noise might be the radio or television playing in the background as we read a book, or soft music playing while visiting over the dinner table. It might be the never-ending drone of traffic from a nearby freeway, or the cheerful chirping of birds, a trickling stream, the ebb and flow of waves on the beach, or wind in the trees above … or all of this together. Any and all of these sounds, as part of our natural or everyday environment, form the ambient backdrop of life and living.

   Remove these suddenly, and the feeling can be that of isolation, despair, emptiness, and insecurity. Changing the intensity of background noises relative to the rest of life's signals (eg, communication) can give rise to an invited signal level of hearing (described below), bringing constant disruption and emotional disturbance to the unfortunate listener.^6,7 Most background sounds are in the low frequency domain, the area where the majority of hearing-impaired individuals maintain near-normal hearing function.

2. Signal (alerting) level. We are all born with innate and acquired knowledge about what to approach and what to avoid. Like the newborn kitten that immediately rears up and hisses upon encountering the friendly family dog, many signals and our perceptions of them are stored in the amygdala or other primal centers of the brain. Our first exposure to fire, thunder, lightning, crashing waves, and ferocious growls all represent warning signals that have been learned and stored up in the human subconscious over hundreds of generations. No learning is required to provide emotional responses to these signals.

   In contrast, almost from birth, we acquire through experience a whole new nomenclature of warning and alerting signals: the ring of the telephone, the doorbell, the sirens of emergency vehicles, the baby's cry, the waking signal of alarm clocks, and timers on microwaves. Whether sound asleep or wide awake, with normal auditory ability no one needs to draw our attention or interpret these signals for us. They garner involuntary attention to the point of distraction until responded to.⁸

3. Symbolic (communication) level. This level of human hearing is most associated with language and verbal communication. So important is this level of perception to one's psychosocial well-being that an average 5-year-old child, with no formal training and little or no ability to read, already demonstrates a working vocabulary of up to 5,000 words. A high school graduate's working vocabulary zooms to 80,000 words, while the average doctoral learner must demonstrate vocabularies of 250,000 words or more. Words help us organize patterns of thought, express emotions, and gain or exchange knowledge. Words help us relate and bond with our fellow beings.

   Many studies over the years have demonstrated a strong correlation between vocabulary size and social, emotional, vocational, and financial development. In fact, the heart of societal and language development depends mightily upon the development of verbal and written vocabulary. However, it is in the interchange—both giving and receiving—that symbolic communication provides us with these benefits.⁹

Hearing Loss: Reactions and Relationships

Keeping in mind the three levels of human hearing, we then need to understand what transpires—in terms of human relationships, educational/vocational progress, and psycho-emotional well-being—when one's sense of hearing diminishes over time.

First, we find that there is a role reversal between the primitive and signal levels of hearing as hearing loss advances. As the background of life becomes distorted or not clear enough for interpretation at the subconscious level, background noise rises into the signal level, where sounds become alarming and distracting. This means that everyday sounds—including traffic, multiple speakers, machinery, etc—no longer can be shuffled into the background of one's subconscious, but now are thrust rudely into the foreground of one's attention.

Most common in this development are losses where the high frequencies plummet, making more audible background-laden low frequencies. Of course, this is highly dependent upon the degree of hearing loss and the period of time over which it progresses. Generally, the worse the high frequency loss, the more disruptive become the background sounds and the more aversive they are to one's emotional well-being.⁵ Some hearing-impaired individuals claim that background noises have become louder, when in fact all that has happened is that nonbackground sounds (eg, the critical high frequencies needed for speech communication) have become softer!

In cases of rapid decline of hearing, sufferers sense a profound loss not unlike losing a close loved one. Such losses can evoke the same emotions of mourning—denial, despair, frustration, anger, and finally acceptance—that transpire when they actually lose a loved one, but often without recognizing the source of such feelings. Reports of sudden hearing loss repeatedly present an almost crippling form of emotional and psychosocial debilitation.¹⁰

It has often been said that normal hearing individuals should experience a simulated hearing loss (wearing totally occluding earplugs, for instance) to understand what hearing-impaired individuals are going through. But, of course, this experience is more aligned to cases of sudden deafness equivalent to moderate to moderately severe conductive hearing loss. Losses that occur over, say, 20 to 30 years bring feelings of loss, but more subtly, with depression, anxiety, and a loss of self-confidence being the most common responses. Offsetting the emotional impact also is that those with gradually progressing losses have time to compensate by using visual cues, focusing harder on the speaker, and turning up stress levels in an effort to fill in the blanks. But the emotional effects are just as sure and profound.

If the background or primitive level of hearing rises to the signal level, where does the signal level go? Since signal levels may become distorted, softer, and possibly not even heard, their usefulness in the scheme of personal security becomes less defined. That is why it can be unsafe to function in the hustle and bustle of life with poor hearing. Assistive devices, including flashing lights instead of sounds, tactile (vibration) signals, and amplified signals, become critical for safe function of hearing-impaired individuals.

Within the context of normal healthy human relationships, the preservation of the symbolic level of hearing, or verbal communication, is important to one's social-emotional well-being. The "voice that brings language, sets thoughts astir, keeps us in the intellectual company of man," as so ably stated by Helen Keller, adds up to the ability to function and advance unfettered within society. It means bonding in relationships—friendships, romance, marriage, family, intimacy, interaction and cooperation, giving and receiving encouragement, developing empathy for others' plights. These are the markers of social and emotional homeostasis. It also means advancement in education and vocation, and innumerable life pursuits.¹¹

The loss of the symbolic (speech communication) level of hearing, on the other hand, also means the loss of what this author calls "intimate communication." The loss of intimate communication means the loss of encouragement, hearing "I love you" in tones that demonstrate felicity, and the nuances of speech that signal empathy or sympathy.¹² As uncorrected hearing loss approaches the severe stage of loss, not only do the softened tones that express empathy and sensitivity disappear for the impaired individual, they begin to disappear from their own voice, as well.

Indeed, one whose mode of verbal interchange is of raised voices, repetition, and pained facial expressions is one who feels estranged and isolated from larger society. They become invisible in social circles, fail to advance in vocational tasks, require coaching and supervision by others, and often lead a life of loneliness.

Imagine standing in a crowded room, everyone engaged in fluid conversation, and feeling all alone. Add denial to advancing hearing loss, and we find additional psychological manifestations in people who have unmitigated hearing loss⁵:

• Anxiety/panic behaviors
• Mild, moderate, and severe depression
• Defensiveness
• Frustration and impatience
• Resentment and anger
• Self-centeredness
• Social paranoia
• Obsessive behavior
• Social aloofness or isolation

Of course, the degree of each manifestation will depend upon other variables, such as personality type, degree of impairment, ability to cope, and the sensitivity and understanding of one's immediate social network. Since hearing loss is invisible, those in one's social network may be at a complete loss in understanding what the person with hearing impairment is experiencing. They may be too distracted by outward manifestations—anxieties, displays of depression and negativism, anger masked in sarcasm, and/or self-centered behaviors—to recognize the underlying cause, which is actually the loss of the above-described levels of hearing.

As a result, relationship difficulties arise many times more in the lives of hearing-impaired individuals than for those with normal or corrected hearing. Divorce rates are higher, as well as estrangement from children and friends. Social dysfunction often leads to higher rates of alcoholism and substance abuse/dependency, including much higher rates of overutilization of psychotropic drugs, as well as medical services.^13-15

In almost every other human challenge, one would expect the sufferer to know and recognize their sensory deficiency. But the truth is that deficiencies in the hearing and communicative domains are difficult to detect for what they are. Instead, life can become a treadmill of embarrassments, feelings of inadequacy, misunderstandings, rationalizations, and blame-games, until deeper psychosocial barriers prevent the person from seeking help.

Those in the hearing care professions find it a rare instance when individuals with hearing impairment visit their offices on their own volition. It usually requires encouragement from loved ones for the individual to take the first and final steps toward auditory rehabilitation. As detailed previously, much more is at stake than merely amplifying missed sounds.⁵

For that reason, hearing rehabilitation will usually not begin, nor can it be completed, until at least someone in the person's social network is involved in the process of bringing the loved one fully back into the hearing world.

An Auditory Rehabilitative Pathway

The road to "normal hearing" is longer and more arduous than just about any other handicap, requiring most people perhaps 60 to 90 days to overcome a condition of forgotten speech sounds called phonemic regression, and another 6 to 9 months (or more) to mend themselves emotionally or change social relationships, regaining one's bearings on personal ambitions in education, vocation, and personal interests.

Probably the most insidious losses, in terms of elusive rehabilitative pathways, are those that are related to the predominantly high frequencies in hearing.^16,17 Not surprisingly, these also may comprise the largest number of uncorrected cases.

Below, we will advance through stages of auditory rehabilitation, keeping in mind that each hearing loss will be as unique as the individual involved. For that reason, each program should be custom-tailored by a caring, knowledgeable hearing care professional.

It is important to keep in mind that those with severe to profound losses may likely be referred for a cochlear implant evaluation. However, even in such cases, a hearing aid trial to demonstrate best aided condition will nearly always be required. The following sequence represents a typical hearing aid exam, delivery, and aftercare for those who require hearing instruments:

1. Pre-counseling. Hearing care professionals often view their waiting rooms as educational experiences for waiting patients, and tend to equip them as such. In addition, there will be questionnaires asking about the life quality effects of one's loss, their health history, and past experience at receiving hearing services, if any. (The author offers a review of hearing loss at www.digicare.org/abouthearing.asp, as well as information about the societal importance of seeking help for hearing problems at www.digicare.org/Depression.asp.)

2. Hearing evaluation. A hearing evaluation begins with a thorough exploration of how one's hearing has diminished and brought effects upon one's life. This is called the "case history" and is not to be taken lightly. During this crucial time, a caring professional, the patient, and a loving third party lay out on the table how their lives have been affected by diminished hearing, as well as their hopes and aspirations for the future.

   Next, usually come the video otoscopy examination and a determination of whether there might be medically correctable issues (or other issues) that would warrant medical referral. If so, a recommendation is made. If not, the exploration continues with a thorough battery of audiometric tests.

3. Amplification recommendation. Often a demonstration of various technologies and applications is rendered at this point. It is imperative that solutions are explored within the resources of the patient, and yet be able to meet their individual needs optimally.

   Today, digital hearing instruments come with more options and styles than ever before. Discreet hearing is attainable in the vast majority of cases without advertising it to everyone. Even so, the most important benefits are to be found in digital solutions that help one hear better in noise, understand speech more clearly, and enjoy spatial functions in multiple and varied listening environments.

   These three domains—function in noise, speech information, and spatial ability—help patients regain self-confidence and feel more connected to their environment and the people around them. It is at this point that decisions are made for the most appropriate type of amplification solution to be ordered, and impressions are made of the ears, if needed.

4. Preparing for delivery. In preparation for this special day, our clinic asks new patients to use a gentle, botanical solution in their ear canals daily to help restore the often missing or deficient layer of keratin in the ear canals. Keratin is the important layer of tissue that often gets removed when one uses Q-tips or harsh solutions (eg, hydrogen peroxide), or that is often damaged by underlying disease and/or use of many prescription medications. Keratin is needed to shield the neuroreflexes of the external auditory canal so that ears can adapt quickly and successfully to wearing hearing aids.¹⁸

5. Delivery and training. During delivery of instrumentation, a comprehensive checklist of key tasks is followed to assure that the patient is capable of inserting, adjusting, removing, and maintaining their new instruments.

   A wearing schedule is presented that allows for gradual wearing adaptation. Often, the schedule will suggest 1 hour in, 1 hour out throughout the first day; 2 hours in, 1 hour out the second day; 3 hours in, 1 hour out the third day, etc, until one's physiology has accepted the prosthesis without discomfort during all-day wear.

   In addition, it is imperative that important others in the patient's life be involved in the rehabilitative process.

6. Post-fitting counseling. This is where the heavy lifting of auditory rehab takes place. In true Auditory Rehabilitation (AR), hearing instruments serve as the core of the program, but certainly not the end-all.

   Moderate, severe, and especially profound loss will require a combination of coping strategies (speech reading skills, communication repair, and/or cued speech), assistive devices (flashing alarm clock, amplified telephones, door flashers, etc), and understanding of the utilization of an individual's rights under the Americans with Disabilities Act (ADA).

   In each post-fitting visit, the client should notify the dispensing professional of challenges encountered between visits until each has been addressed. This step of the process may require several visits over the ensuing weeks.

7. 3-month and 6-month follow-up visits. In many cases, it is wise to have a check-up at 3- to 6-month intervals to document quality of life improvements and to assure all bases have been covered. The goal is optimal outcomes within one's resources and within the capabilities and resources of the attending professional(s). Often, reprogramming of digital instrumentation is needed to fine-tune to changes in the neurological system.

8. Annual reevaluation. It is advisable that an annual checkup of audiometric status be performed and documented. Then, as hearing thresholds change or individual needs evolve (and they will in most cases), both patient and professional can assure optimal long-term benefits from AR.

Discussion

Helen Keller, in her advancing years, concluded in a letter to a friend that "after a lifetime in silence and darkness to be deaf is a greater affliction than to be blind...Hearing is the soul of knowledge and information of a high order. To be cut off from hearing is to be isolated indeed."¹

The foregoing has been written to present an honest, realistic appraisal of the emotional and psychosocial challenges that beset a huge swath of the general public. The fact that hearing loss has often been called an "invisible handicap" illustrates why so many people fail to recognize its impact on their lives.

Recently, a gentleman who described himself as a "retired professional" came in for a hearing test at one of our offices. He presented with a terrible loss, one of the worst precipitous cases I had seen in awhile. Though he admitted to having "a little bit of trouble hearing," his unaided monosyllabic speech discrimination score in quiet was 32%, and his articulation index (AI) stood at 24%. For years, his wife, children, and numerous colleagues had been begging him to do something about his hearing loss.

His wife complained that she cannot stay in the same room with him when he watches television or listens to the radio. His children and their families don't come around anymore because he "heads for the workshop or stays glued to the TV set." He gave pretty rough treatment to the hearing care professional during the case history as she struggled to bring into the light of day how his loss was really affecting his quality of life and the lives around him.

When asked if he realized how his uncorrected loss is making life difficult for his wife, he reared his head back and wondered aloud how his hearing ability could possibly affect his wife's happiness and well-being. "After all," he said, "I'm the one who has to live with it." To that, the attending professional offered, "Sir, I'm afraid that is not the case. Your family lives with it every waking hour and would like nothing more than to have their father and husband back."

Tears welled up in his eyes, and he looked at his wife and said, "Dear, I never really thought about how my hearing was making your life miserable. I always thought it was just me, but now I see that if no other reason, I need to do this for you."

"No, dear, let's do this for us," came her tearful reply.

References

1. Love JK. Helen Keller in Scotland: A Personal Record Written by Herself. London: Methuen & Company;1933:68.
2. Grant B. The quiet ear. Deafness in Literature, An Anthology. London: Andre Deutsch; 1987:36-37.
3. Christie J. Helen Keller. In: Gallaudet Encyclopedia of Deaf People and Deafness. Vol 2. New York: McGraw-Hill; 1987:125.
4. Ramsdell DA. The psychology of the hard-of-hearing and deafened adult. In: Davis D, Silverman A, eds. Hearing & Deafness. New York: Holt, Richard & Winston; 1970.
5. Chartrand MS. Hearing Instrument Counseling: Practical Applications for Counseling the Hearing Impaired. 2nd ed. Livonia, Mich: International Institute for Hearing Instruments Studies; 1999:11-47.
6. Ross M. My "Near Deaf" Experience. Available at: www.hearingresearch.org/Dr.Ross/my_near_deaf.htm. Accessed April 21, 2008.
7. Cybertherapy. Sound in VR. Available at: www.cybertherapy.info/pages/sound.htm. Accessed April 21, 2008.
8. Moore BC, Alcantara JI. The use of psychosocial tuning curves to explore dead regions in the cochlea. Ear Hear. 2001;22:268-278.
9. Hodges AV, Balkany TJ. Cochlear implants for sensorineural hearing loss. Available at: www.turner-white.com/pdf/hp_oct02_cochlear.pdf.
10. Bowlby J. Attachment and Loss. Vol 1. New York: Basic Books; 1969.
11. Better Hearing Institute. Hearing loss and its impact on income: a special report on new data generated by the BHI. Alexandria, Va: BHI. Hearing Review. 2005;12(11):16-32,82.
12. Furby RL. Sighs and whispers. Hearing Review. 1996;3(7):21-22.
13. Morton NE. Genetic epidemiology of hearing impairment. Ann New York Acad Sci. 1991;630(1):16-31.
14. Whitehouse A, Sherman RE, Kozlowski K. The needs of deaf substance abusers in Illinois. Am J Alcohol Drug Abuse. 1991;17(1):103-113.
15. Steinberg R. Issues in providing mental health services to hearing-impaired persons. Hosp Comm Psych. 1991;42:380-389.
16. Chartrand MS. Sleep Deprivation and Auditory Rehabilitation: A Patient Primer. DigiCare Hearing Research & Rehabilitation. Available at: www.digicare.org/Sleep-Deprivation.asp. Accessed April 21, 2008.
17. Qian-Jie F, Galvin J, Wang X, Nogaki G. Effects of auditory training on adult cochlear implant patients: a preliminary report. Available at: www.cochlearamericas.com/PDFs/GoodScienceSB.pdf. Accessed April 21, 2008.
18. Chartrand MS, Chartrand GA. Resolving a root cause of failure to fit. Hearing Review. 2006;13(3):100-103.

Correspondence can be addressed to or .