Andragogy and Aural Rehabilitation

Introduction:

The profession of audiology started with the aural rehabilitation needs of those with hearing loss. Raymond Carhart and Norton Canfield developed the profession after rehabilitating the auditory abilities of military personnel coming back from WWII. The primary focus of audiology was managing hearing loss, so people with hearing loss could lead more normal lives.

As audiology progressed in the 1970's, audiologists expanded their role to include the evaluation and fitting of hearing aids. As such, issues related to hearing aid amplification dominate most audiologists' clinical time, whereas relatively few audiologists focus clinical time on formal aural rehabilitation (AR) programs and the psychosocial impact of hearing loss.
Group-based aural rehabilitation is used by a minority of audiologists to help individuals with hearing loss cope with the day-to-day issues related to hearing loss.

Adult education, also called "andragogy" offers principles relating to facilitating change in an individual. We should not act as lecture-based agents of change. Rather, to affect a meaningful outcome, we should act as facilitative andragogical audiologists, to permit individuals to become self-directed learners.

PART A
Review of Literature:

Aural rehabilitation groups that are supportive and educational in nature have been advocated in the literature (Lesner, 1992, p. 11-12, Binnie et al., 1990, p. 37-41, Abrahamson, 1997, 19-22), yet few audiologists use group intervention as a way to facilitate change in individuals.

Kochkin (1993, p. 47-54) noted the scarcity of post-hearing instrument fitting rehabilitative services and suggested this may be a limiting factor to the perceived benefit from amplification by the individual. Stika et al. (2002) found that only 7.7% of hearing aid users were invited to a group AR program. Kricos (1996) noted group AR can have greater efficacy if it targets global instruction on the tasks of daily communication, versus being more content-oriented. Non-professional counselors (for example, audiologists) who dispense hearing aids should be prepared to provide ongoing and effective support to those requiring more than content counseling (Garstecki, 1997, pg 14).

Abrams, et al. (1992, 371-377) examined the perception of hearing handicap in three groups using the written version of the Hearing Handicap Inventory for the Elderly (HHIE). Individuals were assessed using the HHIE prior to their first audiometric testing session, and then after two months of hearing aid use. A significant reduction in the degree of perceived hearing handicap was demonstrated for those who received amplification in tandem with a three-week AR program. The people in the group receiving hearing aids only (without an AR program) also showed a reduction in perceived handicap, but to a lesser extent than those receiving hearing instruments with AR.

Abrahamson (1997, p 20) suggested that participation in an aural rehabilitation group can serve several functions, for example;

1. Provide a support network during adjustment to amplification.
   
   
2. Encourage individuals to acknowledge hearing loss.
   
   
3. Encourage individuals to assume responsibility for managing their hearing loss and using amplification.
   
   
4. Allow hearing impaired individuals to explore realistic expectations and limits of amplification.
   
   
5. Minimize the negative effects of hearing loss on communication, especially in vocational and interpersonal relationships.
   
   
6. Educate family members about hearing loss and hearing instruments.
   
   
7. Allow family members to be involved in and supportive of, the patient's adjustment to amplification and use of coping strategies.
   
   
8. Teach skills to family members to reduce the quantity of communication breakdowns.
   
   
9. Promote improved satisfaction with hearing instruments and audiology services.

Purpose Statement:

The purpose of this article is to address basic AR issues, with a focus on methodology appropriate for eliciting change in adults with hearing loss. If we appreciate how adult learning occurs, and how to best facilitate andragogy, we can maximize meaningful change for individuals with hearing loss through an adult-based group aural rehabilitation process.

Andragogy:

In the 1960's adult education was evolving. In the 1970's, educators began to appreciate that adults learned quite differently from children. Malcolm Knowles first used the term "andragogy" to describe adult education in 1968 (Knowles, 1990). Knowles blended the work of many researchers, educators and psychologists in an approach defined as "the art and science of teaching adults" (Knowles, 1980, p. 43-44).

Andragogy is a humanistic theoretical framework applied to adult education (Elias, 1980, p. 131) based on concepts of humanistic education and psychology. Carl Rogers and Malcolm Knowles believed in the humanistic paradigm which espouses that; the student is at the center of the experience; the teacher is the facilitator; learning is a personal, internal process; and that group activities are valued (Elias, 1980, p. 135). All these components allow the ultimate goal of humanistic education: the process of changing an individual into a fully-developed person.

Knowles (1980, p. 43-44) described andragogy as "simply another model of assumptions about learners to be used alongside the pedagogical model of assumptions." The four assumptions of andragogy as stated by Knowles (1980) include:

1. Adults desire and enact a tendency toward self-directedness as they mature, though they may be dependent in certain situations.
   
   
2. Adults' experiences are a rich resource for learning. Adults learn more effectively through experiential techniques of education such as discussion or problem-solving.
   
   
3. Adults are aware of specific learning needs generated by real life tasks or problems. Adult education programs, therefore, should be organized around "life application" categories and sequenced according to learners' readiness to learn.
   
   
4. Adults are competency-based learners and they wish to apply newly acquired skills or knowledge to their immediate circumstances.

Adults, therefore, are "performance-centered" in their orientation to learning.
In contrast, adult education is whatever pedagogy is not (McWhinney, 1990, p. 15). Standard pedagogical methods assume children-learners are dependent, conceptual, disciplined, and directed. Andragogy, on the other hand assumes that an adult is independent, autonomous, responsible, self directed, purposive, performance-centered, oriented to experience and capable of working with ambiguities (McWhinney, 1990, p. 16).

McWhinney (1990) noted that early adulthood education reinforces intuitive and rational modes of thought. This efficient educational process provides a relatively stable intellectual world in which we attain mastery of our specific field of study (McWhinney, 1990, p. 16).

Tough (1979, p. 183) identified four characteristics of ideal facilitators in andragogy. Facilitators are generally warm, loving, caring and accepting of learners. Only by showing unconditional positive regard for learners can we be at peace with the didactic nature of our efforts to elicit change in an individual.

In andragogy, the individual learner(s) should be allowed to plan their goals and the facilitator should not trespass on these goals. An ideal facilitator should view him-herself as participating in an open dialogue with the adult learners in a cooperative peer relationship. The underlying theme is that we are "all in this together." Tough (1979) noted the ideal facilitator is completely open to change and new experiences and seeks to learn from his/her helping activities.

As audiologists, we should not attempt to "fix" a person's problems. Rather, our goal should be to help facilitate the process of change in an individual. Andragogical teaching helps elicit change in the individual, and in the group, by harnessing self-directed learning. In aural rehabilitation, as in counseling in general, the individual needs to be the person defining what help is needed and when it is needed.

Andragological Learning Processes:

Self-Directed Learning

Self-directed learning is a process in which individuals take the initiative in designing learning experiences, diagnosing needs, locating resources and evaluating learning (Knowles, 1975). Rogers (1969) described the process of learning in general as existing on a continuum of meaning from meaningless memorization to experiential learning. Self-directed learning is an active process sharing qualities with the humanistic perspective of psychology (Cavaliere et al., 1992, p. 8).

At the core of self-directed learning is the concept of autonomy. Brookfield (1986, p. 58) viewed autonomy as an individual's understanding and awareness of the range of possibilities present. Therefore, self-directed learning is dependent upon leaners' awareness of their personal power, and their power to change their situation.

When adults take action to acquire skills and knowledge to cause a change, they exemplify the principles of self-directed learning (Brookfield, 1986). Brookfield (1986, p. 58) stated that in the process, adults are "realizing their autonomy in the act of learning and investing...with a sense of personal meaning." Self-directed learning can be seen as complete when the process and reflection are married in the adult's pursuit of meaning (Brookfield, 1986, p. 58).

The way we approach the learning process provides a conduit for effective change in an individual. In order to help adults enhance their capability to function as self-directed learners, the educator must do the following (Suanmali, 1981, pp. 31-32.):

1. Progressively decrease the learner's dependency on the educators.
   
   
2. Help the learner understand learning resources, i.e.; experiences of others, and how to engage others in reciprocal learning relations.
   
   
3. Assist learners to define their learning needs.
   
   
4. Assist learners to assume increasing responsibility for defining their learning objectives, planning their own learning programs and evaluating their progress.
   
   
5. Organize what is to be learned in a meaningful way.
   
   
6. Foster learner decision making to expand the learner's range of options and to facilitate alternative ways of understanding.
   
   
7. Encourage the use of criteria for judging performance, which are increasingly inclusive and differentiating.
   
   
8. Facilitate problem-posing and problem-solving.
   
   
9. Reinforce the self-concept of the learner by providing for progressive mastery through a supportive climate with feedback to encourage provisional efforts to change.
   
   
10. Emphasize experiential, participative and instructional methods.

Collaborative Inquiry

Collaborative inquiry is a facilitative andragogical method described as a process that provides a systematic structure for learning from experience (Yorks (2002), p. 3). The participants of collaborative inquiry organize themselves into small groups to address a question(s) of interest. Through cycles of reflection and action, collaborative inquirers attempt to develop new meanings related to the question of interest.

In group aural rehabilitation the question of interest may be ... "Why does society place a stigma on hearing loss?" The collaborative inquiry question in the aural rehabilitation group may involve a question relevant to any aspect of the psychosocial implications of hearing loss.

Through the collaborative inquiry experience, participants explore the inner meanings the topic has for them personally and they devise ways to put their new construct into action in their lives. This process is appropriate when the content is socially controversial or requires social or personal healing (Yorks, 2002, p.3).

Collaborative inquiry is one of many inquiry methodologies that are experience- based and action-oriented (Yorks, 2002, p. 3). In the process, participants assume primary responsibility for making decisions together about the design and implementation of their learning (Yorks, 2002, p. 19). The group facilitator is often the collaborative inquirer, who simply asks the group what main concern or concerns they have and then the facilitator moves into the role of a peer within the group (Yorks, 2002, p. 19).

The underlying themes of collaborative inquiry that should be present during the inquiry process include:

1. Learning is experienced as a striving for equilibrium between the individual and the group.
   
   
2. Learning is experienced as enhanced access to nonlinguistic knowing.
   
   
3. Learning is experienced as an empowering process.
   
   
4. Learning is experienced as energizing.
   
   
5. Learning is experienced as a change in critical subjectivity and critical inter-subjectivity.
   
   
6. Learning is experienced as having a boundary-less quality, like having a good conversation with a friend. Having confidence in one another, in thought and action, is critical (Yorks, 2002, p. 40).

Transformational Learning:

Transformational learning is the primary goal of all adult education, but not the only goal (Mezirow, 1991, p. 64). Transformational learning theory fits into the larger framework of the three basic types of knowledge; instrumental, communicative, and emancipatory. (Habermas, 1971).
The three types of knowledge are further explained by Ross-Gordon (2002, p. 64):

"Instrumental knowledge is cause and effect-type, objective knowledge derived from scientific methodologies. The acquisition of instrumental knowledge is a goal of education in the trades, technologies and sciences. Communicative knowledge is the understanding of us, others, and the social norms of the community or society in which we live. It is derived through language and validated by consensus among people. The acquisition of communicative knowledge is a goal in the study of human relations, political and social systems, and education. Emanicipatory knowledge, the self-awareness that frees us from constraints, is a product of critical reflection and critical self-reflection. Gaining emancipatory knowledge can be a goal in all facets of adult education, as we critically question, for example, the role of technology, which is itself instrumental knowledge, or the underlying assumptions of a political system, which is in itself communicative knowledge. It is an explicit goal in life skills learning, literacy programs, self-help groups, women's studies courses, and community action groups. The acquisition of emanicipatory knowledge is transformative."

Emancipatory knowledge is a common goal of self-help groups and group aural rehabilitation processes falls into this category. An example of transformative knowledge is when something happens in someone's life, such as losing a job or losing the ability to hear, and then the person becomes aware of holding a limiting or distorted view of the world (Ross-Gordon, 2002, p. 64). When the individual examines his point of view critically, and opens himself up to alternatives and consequently changes the way he sees things, the person has transformed some part of how he makes sense (meaning) of the world (Ross-Gordon, 2002, p. 64).

Ross-Gordon (2002, p.65) points out how transformational learning is not a linear process, yet there is a progression that culminates in a greater level of understanding. The component steps of the progression may include:

1. An event that exposes a discrepancy between what a person assumed to be true and what has just been experienced, heard, or read.
   
   
2. Articulating and recognizing underlying assumptions that have been non-critically assimilated and which are largely unconscious.
   
   
3. Critical self-reflection; questioning and examining assumptions in terms of where they came from, the consequences of holding them and why they are important.
   
   
4. Being open to alternative viewpoints.
   
   
5. Engaging in discourse in which evidence is weighed, arguments assessed, alternative perspectives explored and knowledge constructed by consensus.
   
   
6. Revising and transforming assumptions and perspectives.
   
   
7. Acting on revisions: behaving, talking and thinking in a way that is congruent with transformed assumptions or perspectives.

Part B
Andragogy Applied to Group Aural Rehabilitation:

The tenets of andragogy can be applied to individual and group aural rehabilitation processes. The following are examples of how each of the philosophical components of andragogy can be applied to AR.

1. As a person matures, self-concept moves from that of a dependent personality towards one of a self-directing human being.

When adults come to our clinics seeking help with their hearing difficulties, they have made a cognitive step towards change. Adults have the ability to be self-directing in nature, and it is not our duty to define what their hearing loss should mean to them, or how they should best handle it. It is their choice, and their families' choice as to when hearing help is needed, although we can facilitate recognition of that need.

We must work to facilitate an individual's constructive decision making. With support and input from peers and significant others, we can hope that change is facilitated in a self-directed manner. We are not facilitating autonomy in the individual if we are trying to own their hearing loss and rehabilitative process. By allowing them to act as self-directed learners, we are revealing our appreciation that individuals have the power of self-actualization. Transformational learning will most likely occur if we allow individuals to work with their peers to form a new mental construct as to what their world means to them as people.

2. An adult accumulates a growing reservoir of experiences, which is a rich resource for learning.

All adults in aural rehabilitation bring with them unique backgrounds, knowledge, and baggage that only they possess. If we do not appreciate this uniqueness, we might see all group members as an audiogram. We need to allow individuals to use their unique life experiences to come to grips with what a new construct might look like for them. Reflection of the impact of hearing loss on one's life through a hearing loss self-assessment tool can be a valuable means of facilitating development of this new construct. Throughout peer interaction in the group aural rehabilitation process, we allow individuals to share unique experiences and learn from each other's struggles and triumphs. Interplay between peers facilitates group learning, providing fertile ground for transformational learning.

3. The readiness of an adult to learn is closely related to the developmental tasks of his or her social role.

Individuals who come to us for help have taken the first step to learn more about how to help themselves. If we provide a group AR process, we allow people an avenue through which to grow. Individuals attending group AR programs may initially find it difficult to integrate the knowledge gained from others into their personal mental construct. One's personal situation, as defined by social and emotional circumstances, defines what one sees as their self concept. If individuals see their personal situation as being quite far removed from the other group members, it becomes quite difficult for the individual to recognize commonalities they share with the group. Readiness to learn can be affected by such factors which cloud an individual's judgment as to whether to accept help from others. If people are not accepting of growing, then they will not grow. Adult learners will be ready to learn when their emotional ties allow them to do so.

4. There is a change in time perspective as people mature; from future application of knowledge, to immediate application.

The focus of our efforts regarding people with hearing loss should be the problems they are facing in their own lives. The problems the group identifies as pertinent to its members' need for growth should be applicable topics throughout the group AR process. As self-directed learners, adults can take knowledge gained through the group process, and apply it to their daily lives. If the content of the group AR process is not directly applicable to the individuals' current construct, the curriculum may be viewed as lecture material, i.e.; neither applicable nor interesting.

5. Adults are motivated to learn by internal factors rather than external ones.

The motivation to make a life change or attend a learning environment, such as a group AR meeting, is inspired by the adult's need for fulfillment. When adults "self-seek" hearing help they are self-directed learners facilitating change in their lives. When adults are pressured to seek help by external forces such as family members, they may not have the internal motivation to learn.

6. Adults need to know why they need to learn something, before they learn it.

The realization of why a person needs help with hearing loss is the springboard for seeking a change in his life. Adults, as self-actualizing people, can cognitively challenge themselves as to why their paradigm is out of line with their personal rehabilitative goals.

Key Components of Andragogical Facilitation:

Knowles (1984) believed the core of how an andragogical facilitator should act, had several key elements (McWhinney 1990, p. 14-18). He pointed out seven components (below) which can be used for proper facilitation of adult learning in virtually any setting throughout the world.

1. Facilitators must establish a physical and psychological climate conducive to learning. This can be achieved physically through circular seating arrangements. Psychologically, a climate of mutual respect and trust is paramount. Knowles referred to this atmosphere as "a climate of humanness."
   
   
2. Facilitators must involve learners while planning methods and curricular directions. People make stronger commitments to activities in which they have had a participatory and contributory role.
   
   
3. Facilitators must involve participants in diagnosing their own learning needs.
   
   
4. Facilitators must encourage learners to formulate their own learning objectives.
   
   
5. Facilitators must encourage learners to identify resources and to devise strategies for using such resources to accomplish their objectives.
   
   
6. Facilitators must help learners carry out their learning plans.
   
   
7. Facilitators must involve learners in evaluating their learning, principally through the use of qualitative evaluative modes.

Adults have an actualizing tendency (Rogers, 1979, p. 99). Rogers stated "We can say that there is in every organism, at whatever level, an underlying flow of movement toward constructive fulfillment of its inherent possibilities." The basic premise is that an organism (human or not) can be viewed as moving towards the direction of maintaining, enhancing, and reproducing itself.

In group aural rehabilitation proceedings, we need to be aware that members of the group have within themselves "vast resources for self-understanding, for altering their self concept, basic attitudes and their self-directed behavior. These can only be seen if a climate of facilitative psychological attitudes can be provided" (Rogers, 1979, p. 99).

Rogers (1979) stated that as facilitators, we should possess genuineness, an unconditional positive regard for the group members and empathy. Genuineness can be relayed to the members of the group by sharing our "realness" with the group. For example, talking to individuals as a peer member, rather than as a teacher on a podium embodies this concept. Secondly, adult group members need to feel that they are accepted and are free to tell their tales of triumph and woe. Finally, we must possess empathetic understanding, to sense what feelings and meanings are behind statements of the peer group members. As a result, group's members feel increasingly cared for by the facilitator and other group members and members feel comfortable finding ways to fulfill needs they have brought to the group (Rogers, 1979). In fulfilling their needs, members attain a level of transformational learning through which they may envision a new construct of the world around them.

Final Thoughts:

Whenever we consider entering into a helping relationship with an adult, we must be aware of how adult learning is best facilitated. By using the andragogical rehabilitative model presented in this article, we are helping to ensure that the rehabilitative needs of individuals with hearing loss are met more effectively. Other healthcare fields have started to recognize that andragogy is an important concept to consider in the rehabilitative process. Best (2001) noted that an essential part of an orthopedic nurse's role is to provide proper adult education regarding a person's current and future needs. Other fields, such as gerontologic social work have considered these core adult learning principles as key to helping individuals (Whitford, 2001).

The philosophical and practical reasons we should shift our professional focus to rehabilitation, and more specifically to the adult learning process, may have been hinted at in the writings of Jung; "We cannot live in the afternoon of life according to the program of life's morning; for what was great in the morning will be little at evening, and what in the morning was true will at evening have become a lie" (as cited in Campbell, 1971, p. 17).

Consider that what was once true about group aural rehabilitation and how we view the process itself may no longer be true, and further, what may be appropriate for pedagogy may not be appropriate for andragogy. Group interventions are best facilitated through the concepts of andragogy. It is imperative that our field harness what is known to be true about how adults learn best. In doing so, we are ensuring our future stake in the healthcare arena as the primary facilitators of change for individuals with hearing loss.

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