While I can attest to the benefits of aural rehabilitation (AR), it continues to surprise me how many people with hearing loss either do not know about it, have no access to it, or have not become involved in AR. I had the chance to sit down and talk to Geoff about what I believe are highly important questions about his work and aural rehabilitation in general.
Stu: Can you provide a short history of hearing or aural rehabilitation and what it originally involved?
Geoff: Aural Rehabilitation started with the pioneering lip reading teachers of the early 20th century who developed their approaches at a time when lipreading was the only rehabilitative approach available. There were no hearing aids available for everyday use, and that meant that even people with moderate-to-severe hearing losses were forced to depend primarily upon the visual signal to understand what was being said. It was an imperfect solution to the problem of hearing loss and many people floundered and were cut off from access to everyday conversation.
Stu: When did AR begin to show some promise?
Geoff: The biggest single step occurred during World War II, and coincided with the development of “wearable” hearing aids. “Wearable” then meant a large body-worn box powered by a separate battery pack with a single earphone.
The US military at that time was dismayed by the loss of service personnel due to hearing loss resulting from noise exposure and/or trauma experienced in war. So, the goverment established four retraining centers to provide service personnel with hearing aids along with Communication Training consisting of lip reading training, the newly developed auricular training that is now called auditory training, and speech conservation training, which was intended to prevent the individual’s speech deteriorating following hearing loss. It was out of these retraining centers that the new science of audiology came, and in those days audiology had a very strong rehabilitative component.
Stu: What about hearing aids?
Geoff: Back then, hearing aids were not seen then as the answer to the problems of hearing loss. They were, instead, part of an overall process that “treated the man, not the ear,” a process that unfortunately could not be sustained because of the enormous cost of providing such services.
Stu: What does AR mean today?
Geoff: Aural rehabilitation today is very different from how it was envisaged by those first pioneering audiologists. Audiology now has its primary focus on diagnosis and hearing aid selection and fitting.
Stu: What else should be involved?
Geoff: Aural rehabilitation should be more than diagnosis and hearing aid fitting, and there are some audiologists who go well beyond it and provide counselling and other support in groups or on a one-on-one basis. These are the exceptions, however, and there are few providers who give any form of communication training, other than recommending the use of online resources such as “LACE” and “Hear My Quips.” Both of these programs are excellent, by the way, but they are a supplement, not a substitute for direct one-on-one training that focuses on the special needs of the individual client.
Stu: How has AR changed in the past decades?
Geoff: Rehabilitation changed a great deal when cochlear implants (CI) were introduced in the 1970’s. The first CIs were crude single-channel devices that provided access to the time and intensity cues of speech, and were, at best, supplements to lipreading. Many of those who first received these devices had long-standing hearing losses, and had been without access to the acoustic signal for many years, or decades in some cases. Training was seen as a critical part of the approach adopted. The introduction of multi-channel devices in the 1980’s meant that CI users now had access to a more complex acoustic signal, and this was seen by some as reducing the need for extensive training. This attitude seems to have been reinforced as improvements in technology have led to enhanced performance, and we now have the situation where most CI users receive little direct training with their device.
Stu: What role has changing technology played in altering/assisting the AR you conduct with your clients?
Geoff: The changes in technology since 1974 when I started have been astonishing. Consider that back then most adults with an acquired profound hearing loss had very few options. Hearing aids at that time were usually body worn, and provided marginal benefit, and the lipreading training provided to a very small group of deafened people was often ineffective, and, even worse, frustrating. I met many people in the 1970’s who had endured, and there is no other word I can think of to describe their situation, great difficulties in every aspect of their lives following the onset of deafness. Some would say to me that they had “accepted” their deafness, but the reality was that they were grimly resigned to it. The development of CIs has meant that such people now have access to speech to a degree that was unimaginable in the 1970’s. Similarly, HAs have seen huge improvements over my period working in this fascinating field. On a personal note, I have a high frequency loss in both ears, and without my HAs I cannot reliably pick up speech sounds such as [s] and [t], but, thanks to frequency lowering, I now have access to these important speech cues.
Stu: Talk about the purpose and scope of your work in AR?
Geoff: Improved speech communication skills. People seek help because they are having trouble understanding speech and optimizing a person’s speech understanding skills should be the focus.
Stu: How did you develop your unique AR approach?
Geoff: My approach in the 1970’s and 1980’s concentrated on using auditory and tactile cues to supplement lipreading, so the bulk of my work focused on auditory-visual training approaches. During the ’80s, I also started to develop approaches that aimed at improving auditory access to speech, and, by the turn of the century, I was doing more and more aimed at enhancing listening only performance. Lately, however, I have been looking, once again, at auditory-visual training as part of my approach.
Stu: Why have you made those adjustments to your approach?
Geoff: My reasoning for this change is simple; Phones are, of course, a very important part of modern interactions, but face-to-face communication, where both auditory and visual cues are available, is still the most common situation. Auditory-visual training and testing provides me with a good picture of a client’s “optimal performance level” and gives a benchmark against which I can compare her/his auditory only performance. I also feel that this approach provides the client with the opportunity to see just how much vision can improve her/his performance.
Stu: How important are these visual cues?
Geoff: I prefer the use of “lip reading” to “speech reading” and visual cues are sometimes not emphasized enough by other professionals, and I want clients to be able to experience and compare their performance in the auditory only and auditory-visual conditions. Hearing materials may be very challenging in the auditory only condition yet are often much easier when visual cues are available, and clients need to experience this important change so that they can seek to optimize its use in their everyday lives. This is especially true in adverse listening condition, such as where noise and/or reverberation make the task so much harder.
Stu: Do you have a preference for digital or analog technology?
Geoff: First and foremost, I want people with hearing loss to have the best possible amplification.. Carol Flexer always emphasizes that “we hear with our brain,” and I want the person’s brain to have access to the best possible auditory (and visual) signal. In almost all cases, I would want the person to have some form of amplification as a first-step in the rehabilitative process. The “distortions” and “omissions” that hearing loss imposes means an increase in “cognitive load” in order to derive understanding and this can make conversations hard work. If amplification makes the speech signal(s) even a little clearer and less ambiguous, the task of understanding speech becomes easier, and reduces the effort that the person needs to expend.
Stu: What are the different rehab challenges for those who wear hearing aids and CI’s?
Geoff: It depends more on the degree of hearing loss. The bulk of hearing aids users are people with mild-to-moderate hearing loss, and they typically don’t seem to require a great deal of additional speech communication training beyond being fitted with a HA. Nevertheless, I believe that almost all HA users would derive some benefit from some speech communication testing and training.
Stu: What is involved?
Geoff: I’m thinking here of a session or two that looks at the person’s hearing skills using a variety of materials – words, sentences, connected speech – and provides the client with verification that s/he is able to handle most or all of these tasks well. I find that many clients are very pleasantly surprised to find that they can understand speech very well, even when it is presented by someone with an Australian accent!
Stu: How is it different for CI users?
Geoff: CI users are confronted with a new signal that is often very different from what they experienced when they used hearing aids. In many cases, the client is confronted with a signal that is high frequency “rich” compared to the predominately low frequency signal they were receiving with their hearing aids. This takes some time to adapt to, and the process of using this new and much richer signal can be accelerated and enhanced with direct one-on-one training.
Stu: Talk about how new research into the brain’s neural-plasticity has altered your thinking about your work in AR?
Geoff: When I started in this field, there was general consensus that neural plasticity faded in childhood, and there seemed to be a belief that adult brains were not at all flexible and adaptive. I often felt that that “neural concrete” was the general view of the adult brain. The growing awareness of the ways in which the brain can reprogram itself has led people working in rehabilitation to take bigger and bigger “risks,” and, in many cases, this has led to performance levels that would have been unthinkable even two or three decades ago.
Stu: What have been the critical factors?
Geoff: Part of this is obviously related to better technology, but these technological advances have led people to push harder and harder towards higher goals. I now present profoundly deaf clients with tasks that would have been unthinkable in the ’70s and ’80s. There are CI users who can understand speech at levels that approach those of people with normal hearing, at least in quiet listening conditions. There are also some CI users who are able to follow speech relatively easily even in noisy conditions.
Stu: What sets these exceptional people apart?
Geoff: They have been willing to undertake long-term and intensive training. Many of them supplement such training by listening to recorded books, use online programs such as “Angel Sound” aimed at improving listening skills, and push themselves to get better and better
Stu: What do you do in your work that is unconventional?
Geoff: Probably the most unconventional thing that I do is provide two-hour, 1:1 trainings over an extended period of time. Some come in for weekly sessions for several months, and I have several clients who have opted to continue training over a period of years. I almost always include some Speech Tracking segments in the session in which a story is read line by line to the client and her/his task is to repeat exactly what was said. I see my role with such clients as akin to that of a personal trainer, but I am working on the person’s ear fitness. When we embark upon a fitness program we don’t work at it for a few weeks and then drop it, and expect to maintain the same level of fitness. Similarly, some clients come back every one to two months to monitor their performance and make sure that they are still able to perform at the same level, while others attend farmore often.
Stu: How do most clients do with these tasks?
Geoff: It is a very difficult task for many clients, but each segment requires only five minutes of concentrated listening. The score obtained at the end of each segment is the client’s Tracking Rate expressed in words-per-minute, which represents the number of words presented and correctly repeated during the five minute period. The current Windows-based system I use was developed in collaboration with a research team at Gallaudet University.
Stu: In some ways it sounds very simple what you do with your clients.
Geoff: Almost childishly, so, but I am constantly shocked when clinicians ask me questions such as, “Do you really think people get better with training?” When this happens, I usually bite my tongue and avoid the obvious response, but instead ask them what aspect of human behavior doesn’t benefit from practice. Maybe it’s because most of us acquire speech understanding skills with no apparent effort that we fail to recognize that this ability, like all others, can be improved by practice. To maintain practice requires support, however, and that is an important part of being a listening “personal trainer.” My favorite approach to training involves the use of Speech Tracking, but I also have a large number of analytic and training exercises that I select and use with individual clients.
Stu: What kind of results are you getting?
Geoff: Clients report that they are able to maintain listening focus for extended periods following training. One client, for example, said that she felt that her listening stamina had been improved by the training. Another reported that although she didn’t think her hearing ability had changed, she was a better listener. These observations are supported by ongoing testing across the training period which show steady improvements in a client’s ability to understand speech. The test material that I use primarily is Speech Tracking Rate, but testing with unrelated sentences shows similar improvements in performance.
Stu: How do listening exercise “improve” hearing?
Geoff: Listening is a cmplex process and listening with HL is even more so. Again, as Carol Flexer points out “we hear with our brains,” and I want clients to get as much practice as possible to develop their ability to “decode” what is said over an extended period of time. It’s like the old joke about, “How do I get to Carnegie Hall?” The answer is “practice, practice, practice,” and when people practice they get better at the task.
Stu: Is there a difference between an improvement in hearing as seen on an audiogram and an improvement in one’s experience of hearing?
Geoff: Audiograms provide a great deal of information about how loud a sound of a particular frequency has to be before it is detected. What it doesn’t do is tell us is how well the person is able to understand speech. It is self-obvious, but the only way that can be done is to test and train the person using speech. The person’s audiometric thresholds will not change, but their ability to use their hearing will be improved.
Stu: You work with singers and musicians. How does listening to music alter the brain and hearing? How do listening exercises help them?
Geoff: There is some very interesting work coming out of Northwestern University that shows that music training results in positive neural benefits. For example, listeners with music training have better auditory working memories, and are better able to understand speech presented in noisy backgrounds. Studies indicate that the more musical training the better, but, also indicate that even if a person does not continue to play a musical instrument later in life, the benefits remain. At a time when music education seems to be regarded as an unnecessary “luxury,” these findings provide much food for thought.
Stu: Are the strategies and techniques you use the same for non-musical clients?
Geoff: It depends on what I am doing with the client. For example, some clients, non-musicians, but music lovers, come in requesting help to improve their ability to listen to music. I try to help this group of users to obtain more pleasurable music listening experiences. This includes suggesting types of music that seem to be better suited to the limitations of CIs, and making suggestions for resources. I use the acronym FAVORS (Familiar, Auditory-Visual, Original, Rhythmic, and Simple) to summarize the characteristics of music that seems to be best suited as a starting point for CI users, and, I suspect, hearing aid users. These characteristics should also be considered by musicians with hearing loss. An opera singer for example may find it very difficult, if not impossible to sing with an orchestra, but singing with only a piano accompaniment (a simple setting, if you like) may be much more satisfying.
Stu: You’re a musician and wonderful singer yourself. How does your musical background influence what you do?
Geoff: I love music, and when I am working by myself I invariably have music playing in the background. I enjoy singing, and do often sing to clients to demonstrate the value of listening to known songs presented with little or no accompaniment. In my work with children, I often used songs to improve the rhythmic quality of the child’s speech, and I have written and recorded several songs for use with children who are deaf. Thanks for the compliment, even though I regard my voice as being barely adequate. I am, however, prepared to sing for clients without any hesitation, and do so quite often.
Stu: You also have a particular fondness for sea shanties. In fact you and I have sung many of them together during our sessions. What importance do they bring to your clients?
Geoff: I particularly love sea shanties (“What shall we do with a drunken sailor?” and “Donkey Riding” are particular favorites). These simple, familiar, and very rhythmic songs are a wonderful way to illustrate some of the points listed above. My clients have included opera singers, pop singers, and rock musicians, and I find this work extremely interesting and satisfying.
Stu: You feel that access to music is essential to everyone.
Geoff: Hearing loss primarily affects speech understanding, but many people with hearing loss regard the lack of access to music as being a terrible loss. Confucius,believed that music was something that humans cannot live without. Music is important and we need to make it as accessible as possible for people with HL.
Stu: How has the Hearing Rehabilitation Foundation made music more accessible to those with hearing loss?
Geoff: The HRF hosts a number of concerts aimed at CI users over the past few years. These have been very popular, and I hope that we can provide more in the future. I hope that you will be one of our performers Stu!
Note: I’ve already agreed to perform for the HRF and proudly so. .
Stu: Can anyone with a hearing loss benefit from AR?
Geoff: I believe that almost all people with HL would benefit from at least some hearing rehabilitation. For many people with mild to moderate HL the intervention would be short-term, and concentrate on providing information on HL and ways in which people can improve their ability to overcome the problems that the HL creates. I always encourage people with mild and moderate losses to think about being an active listener.LINK SRU The use of recorded books, listening to TED talks, and accessing online training programs are just some of the things that people can do to train their ability to understand speech.
Stu: Who should also consider one-on-one training?
Geoff: People with greater HL should have access to some 1:1 speech perception training but finding places to receive this training is very difficult in many parts of the US. Some CI centers have specialist staff that provide training for people after they have received (a) CI(s), but it is not so easy for HA users who are experiencing difficulties to find appropriate training. Groups such as the Hearing Loss Association of America (HLAA) and the Association of Late Deafened Adults (ALDA) do not provide direct training, but they do act as information sources and members of these groups may know about local AR providers.
Stu: Are your sessions expensive?
Geoff: This type of intensive training is only possible because I volunteer at the HRF and I am not trying to derive my income from this work. All I ask clients to do is make a small donation to the HRF after each session. What the HRF offers is not a viable economic model for hearing aid practices and CI clinics to adopt at this time, but the services the HRF provides are very useful for those who are able to attend for training.
Stu: Many thanks, Geoff.
Please share this interview widely and share with me and our readers your own thoughts about and experiences with aural rehabilitation.
Australian Geoff Plant trained as a Teacher of the Deaf and worked in several schools for the deaf in Melbourne before joining the National Acoustic Laboratories (NAL) in Sydney in 1974, a government audiology service that provided care and hearing aids to children and older adults. It was during his time at NAL that he began working with adults with hearing loss including developing group approaches aimed at clients who had received hearing aids, and designing and implementing one.on-one training programs to improve the ability of people with hearing loss to understand speech.
While at NAL, he conducted research into testing the auditory skills of people with hearing loss, lipreading, tactile aids, and the effects of acquired deafness on speech production. In 1977, he was awarded a WHO Fellowship to study adult aural rehabilitation programs in Sweden and Denmark.
In 1993, Geoff and his family came to the US for a two-year stay but In 1996, he set up the Hearing Rehabilitation Foundation (HRF) in Somerville, MA to “provide and promote speech communication training for children and adults,” now in its 20th year. From 2001 to 2014 he also worked part-time as a rehabilitation specialist for MED-EL, the Austrian-based cochlear implant company. Currently he is greatly enjoying his “retirement,” working as a full-time volunteer for the HRF and hopes to remain in this role for many years to come.