Everyday conversation is the most common site of activity limitation/participation restriction (previously disability and handicap) arising from acquired hearing impairment. It is a premise of this paper that aural rehabilitation (AR) therapy aimed at addressing everyday activity is best designed to mimic the key elements of the activity that it aims to address, thus increasing the likelihood of generalisation of the skill taught in the clinic to the daily activity. The less the need to generalise (i.e., the closer the therapy task is to the real life activity) the more readily clients will be able to use the tasks learned in therapy in their daily lives. It is the aim of conversation based therapy to bring under some level of conscious control many of the behaviours that occur in conversation that clients may not have been fully aware of and thus not able to respond to as effectively.
The primary focus of this paper is the adult who has an acquired hearing impairment (and by extension his or her frequent communication partner(s)) although the principles outlined here may well be applied for others with hearing impairment. In this context, I distinguish this form of therapy from auditory perceptual models of intervention on the one hand and from psychosocial models on the other. These are not mutually exclusive approaches to AR therapy, but rather they do function on different premises and should be viewed as addressing different aspects of the communicative and psychological consequences of acquired hearing impairment.
Hearing clinicians (audiologists, speech pathologists, audiometrists, hearing therapists and others - depending on where you are in the world) have focussed on speech reception training for 60 years or so and are yet to show everyday life benefits from this training. The first main reason for this is that there remains a great distance for the client to generalize the auditory visual skills trained in the clinic to the complexity of everyday conversations. The second reason for this is that supposing the therapy is successful, we do not share a sufficient understanding of how conversation works nor how we might best assess it in order to evaluate the success of our intervention.
As mentioned above, these therapy models are not mutually exclusive;rather, audiovisual speech reception training is better placed in a context of everyday conversation and the elements that influence it may be better understood and addressed. Thus I suggest clinicians replace the idea of improved speech reception with the idea(l) of "intelligibility". This serves several purposes: first, it includes all elements of the conversation setting (speaker, message, environment as well as the hearing impaired listener);second, it focuses on the role of the conversation partner and ultimately gives equal weighting to the role of communication partner;and third, it implies the active participation in conversation activities by the hearing impaired adult and thus his/her ability to control the content, sequence and flow of talk.
So, how do we understand intelligibility in the context of everyday conversation? I would like to suggest we look to the current theories of conversation as well as our understanding of the vein of research into intelligibility in acquired hearing impairment. Four questions then, take our attention: how does conversation work?;how might we apply the theories of conversation to acquired hearing impairment?;what might the therapy tasks look like that derive from this understanding?;and finally, how might we assess the outcome of therapy in a conversationally relevant manner? This paper aims to address briefly each of these questions.
What is conversation and how does it work?
From the point of view of the listener, spoken communication is simultaneously a sensory/perceptual task, a linguistic code and a social activity. More specifically, conversation is fundamentally a sensory/perceptual task that is mediated by linguistic structures but is ultimately a social activity. In order to expand on these points in the context of various theories of conversation, it should be noted that there is no overarching theory of conversational behaviour that has currency over others at this time. In the world of syntax and sentence structure, Chomsky's (1957) generative grammar remains the keystone of syntactic theory and a guiding theory in our understanding of sentence based audiovisual speech reception. No similarly accepted model of conversational behaviour exists. Clinicians still understand relatively little of the processes that underpin everyday conversation and we are hampered in doing so as we have no widely held theoretical stance on which to base this understanding. It is beyond the scope of this article to address the full range of conversation theories in full;rather, I would like to pull out some of the ideas and theories that seem to be most pertinent in the design of AR therapy. For reviews of the current theories in conversation, interested readers may access Nofsinger (1991) and/or Eggins and Slade (1997). What follows is simply a collection of models that I have found to be relevant to the design of rehabilitation exercises for adults with acquired HI.
Let us start at the broadest level, in which we consider the purpose of conversations. The anthropologist and philosopher Bronislaw Malinowski (1923 - 1975) suggested that there were different social "purposes" of interaction and that the patterns of interaction differed between them. He identified four types: phatic communication, that is, conversation purely for the purpose of maintaining social connections;speech-in-action, or talk that mediates task-oriented activity for people working together;story-telling, or narrative, often long periods of monologue in which talk is used to unfold a story;and formal logic, which he saw as restricted to those trained in formal philosophical argument (and which I will leave out of this article).
Implications for AR: Clinicians might wish to engage clients in different genres of conversation. Most often when asked to converse in clinic, and left to their own devices, clients tend to talk about social matters, essentially Malinowski's phatic conversation. Tasks designed to solve a dilemma, or to plan or conduct an activity may well raise different types of communicative issues. The need for increased accuracy of understanding is often implied by these speech-in-action tasks and thus the need of clarification is often greater than in purely social conversation.
The second useful theory in designing AR is the perspective by Cheepen (1988) and Sperber and Wilson (1986) concerning 'transactional' versus 'interactional' conversation styles and by extension equal versus unequal speaker rights in everyday talk. Interactional talk is that in which talk is conducted for mainly social purposes and in which speakers perceive each participant to have equal speaker rights, that is, equal rights to commence, continue and change topics. Interactional talk is that most often carried out in Malinowski's phatic conversation. Transactional talk is that in which a purposeful talk is undertaken and in which often one talker takes the lead, "has the floor", or otherwise has greater "power" than the other(s). As such there is commonly an asymmetry in power relations and unequal speaker rights. Transactional talk is that most commonly undertaken in Malinowski's speech-in-action.
Implications for AR: Clinicians might frame conversation tasks in which one person has information to be passed to another (e.g., barrier activities) or in which one is more informed about a topic than the other. Otherwise it is often useful to set up simulated conversations in which there are unequal speaker rights, such as a job interview, medical appointment or travel agent for instance. Erber's (2002) QUEST?AR is a useful version of this type of task. It is often the case that clients have difficulty with transactional settings, that is, it is harder to request clarification, or seek cooperation for their hearing impairment. Discussion of the interpersonal or pragmatics of these various settings makes a good therapy task.
The third theory of use in our understanding of conversation and to the planning of AR therapy is the work of Searle (1965) and Grice (1975). Searle and Grice belonged to a group of conversation theorists known as the logical philosophical school of language, who worked towards a set of rules by which conversation might be structured and conducted. Two important elements of potential use to us arose from this school. First, Grice postulated that while we understand that correct grammar /syntactic usage follows a set of (reasonably) well-defined rules, no such set of rules governs conversation behaviour. That is, there is no right or wrong. Rather he postulated that there were "maxims" or guidelines by which we might cooperate in conversation. Further he suggested that when we break these maxims, we do so to make a conversational point, rather than simply doing so in error. From the same school of thought, Searle postulated that there were three distinct events in a turn at conversation, which he labelled as speech acts, that is the mental and behavioural manifestations of one's talk. These speech acts were labelled as illocutionary (the speaker's intention), locutionary (the speech signal), and perlocutionary (listener's interpretation). This allows us to talk about the essentially indeterminate nature of the 'meaning" of turns at talk and the potential sources of misunderstanding that may arise.
Implications for AR: It is useful to commence discussion with clients about conversation by indicating that turns in a conversation are not to be judged as "right" or "wrong" and are not governed by "correctness", the way that word order or grammatical agreement are, for instance. Secondly, clinicians might discuss that turns at talk do not have a prescribed meaning. What one person means is not always what the other understands the turn to mean. This "indeterminacy" is often the source of breakdown (leading to repair) in probably every conversation, regardless of whether one person has a hearing impairment or not.
The psycholinguist Herbert Clark has added some further thoughts to this by suggesting that one's speech may be mis-communicated for several reasons (that is, the difference between the perlocutionary and illocutionary acts may differ) associated with the transmission and the understanding of the message (Clark & Schaefer, 1987, 1989;Clark & Wilkes-Gibbs, 1986). Clark and colleagues indicated that a turn may be miscommunicated when: the listener is not aware that the speaker speaking;the listener is aware that the speaker is speaking but does not hear some or all of the talk;the listener hears the talk, but does not understand the people or events to which they refer;or, the listener hears the talk and understands the references, but does not understand the pragmatic intent or purpose of the turn.
Implications for AR: We should not assume that because there is a breakdown in conversation involving an adult with hearing impairment, and a portion of talk is miscommunicated, that it results from the imposition of the hearing impairment on the conversation. Miscommunications arise for many reasons and they are a common part of everyday interaction regardless of the participants' hearing status. We should always "measure" miscommunication and repair in conversations involving hearing impaired adults against the normal mishaps in everyday interaction. Normal everyday conversation does not equate with perfect conversation.
Finally, we look at the body of linguistic theory that is the most compelling for me, the sociolinguistic perspective known as Conversation Analysis (CA). The early proponents of CA, Harvey Sacks, Gail Jefferson and Emmanuel Schegloff, published a series of seminal papers together in the 1970s that remain the foundation of this theory and research method. This theory looks at the observable sequential aspects of everyday conversation and has provided us with several important concepts. First, they considered how conversations are started and finished and how these actions differ from the content of a conversation. They distinguished openings and closings in which predictability is high and talk is often formulaic from the relatively low predictability of the content of the conversation. This variability has consequences for the frequency of repair. Second, they suggest we might consider how we know that the person we are speaking to has understood our turn at talk. This becomes a very hard thing to define yet we seem to manage this in everyday talk without any effort. They suggested that talkers establish, maintain and monitor a level of mutual understanding sufficient or adequate for the interaction at hand. That is, talkers decide for themselves whether they are following what each other is saying. There is no formal or common yardstick for this. As this monitoring occurs at each turn at talk, any instances of miscommunication are addressed immediately. That is, violations of mutual understanding commonly lead to repairs;sequences of talk in which miscommunications occur are addressed and resolved prior to the continuation of the talk. Third, the authors suggest that repair is a powerful conversation process, in which when one participant recognizes the need to repair, ongoing talk ceases almost immediately and the miscommunication is addressed in the vicinity of its occurrence. They also comment that repair is not a matter of error correction or of one participant getting something "wrong" and thus there is no inference about "Who is to blame?" for breakdowns requiring repair.
Implications for AR: CA provides clinicians with some views of the flow of conversation and the observable behaviours that comprise the sequential organization of conversation that are of great use in clinic. First, we can discuss with clients how there is no objective standard for the content, or turn taking in a conversation. These things are organized between participants and are mutually (if tacitly) agreed upon in each conversation we undertake. There are times we might not bother to initiate a repair as miscommunication is not judged to be of sufficient importance to do so. When repair is initiated it tends to occur very close to the site of the problem that requires repair, that is, people don't hold off undertaking repair until later. However, the KEY issue is that no one should be "blamed" for uttering a turn that needs repair nor mishearing a turn and thus needing repair. It is a common phenomenon, it occurs in all daily conversations and it should be seen as a "self-righting mechanism" for a conversation, rather than as a problem requiring correction.
In summary, conversation theories give clinicians useful guidelines for understanding some of the principles by which everyday conversation works, and in turn allows us to talk to clients to alleviate some of their concerns, misbeliefs and fears about conversation "failure". These principles stand apart from those we have tended to report from (at least, traditional) models of sensory-perceptual skill development. However, the research and clinical activity into "intelligibility", which casts much of these more traditional models of therapy, offers some very useful additional insights into how everyday conversation might be made more fluent, more successful, or just plain easier.
What is intelligibility?
Since the mid-1980s, research findings have led to the understanding that talkers all talk differently, and there is no clear or consistent relationship between talkers' visual speech characteristics. In the 1980s, Kricos and Lesner (1982, 1985) demonstrated that talkers were likely to produce different and quite individual patterns of visual speech sounds, varying in the number of distinctly identifiable viseme groups. Further, they found that the overall intelligibility of each speaker's speech was reported to vary with the number of viseme groups into which their speech sounds fell. Erber (2002) noted that every interaction comprises a speaker and listener (indeed, participants taking turns as each of these roles), a spoken message and an environment in which it occurs. Gagné, Masterton, Munhall, Bilida and Querengesser (1994) demonstrated that intelligibility cannot be separated out from message and environment.
Implications for AR: Speech sound visibility is not the unitary and consistent concept we have taken it to be in clinical practice and some talkers are easier to understand than others. That is, intelligibility of the visual speech signal varies across talkers and across settings. Further, it is a reasonable therapy goal to alter the speech characteristics of communication partner(s), by giving them practice to approach clear speech when conversational circumstances require it.
In a particularly important body of research, Picheny and colleagues (Picheny, Durlach & Braida, 1985, 1986) undertook to investigate the differences in 'clear' versus 'conversational' speech from both perceptual and acoustic perspectives. The results indicated firstly that the listeners perceived the "clear" speech to be more intelligible than the "conversational" speech across all other variables (i.e., volume, frequency gain of hearing aid, talker). The "clear" versions of speech were spoken over twice the length of time of their "conversational" counterparts. The authors noted this is due to: increases in number of pauses;more accurate production of certain speech sounds;increasing duration of longer consonants;greater intensity of consonants relative to adjacent vowels;and formant frequencies more closely matching target values. Schum (1996) also identified that speakers are able to improve the intelligibility of their speech on demand. Further, Michael, Seigel & Pick (1995) and Pedlow and Wales (1987) found that speakers will increase the intensity of their voices proportionally to the increase in distance from the listener as well as in response to perceived changes in the complexity of their talk, and in both cases without instruction to do so.
Implications for AR: The variability among speakers' articulatory patterns and conversational speech styles severely limits the applicability of traditional methods of audio-visual speech reception training in aural rehabilitation. The intelligibility of a message is a complex phenomenon, influenced by any or all elements of a conversational setting. Conversationally-based AR therapy aims to address the areas of conversation that might adversely affect intelligibility. Speakers, and in this case, communication partners, can alter their speech to increase or improve intelligibility. That is, communication partners may well be able to accommodate for their partner's hearing impairment. There are specific phonetic and suprasegmental aspects of speech that might be good candidates for this therapy method, including frequency of pausing and overall speed of speech. Hearing tactics aimed specifically at altering the quality of the speaker's speech may be successfully responded to and clarity can be improved either by general or specific instruction.
So, what might conversation-based therapy look like?
The previous section of this paper has identified some theory- and research-based concepts that might lend themselves to designing conversation-based AR. This therapy has as its focus the use of compensatory strategies to overcome or ameliorate the adverse effects of acquired hearing impairment on conversational success. Essentially, this therapy addresses communication partner intelligibility and the repair of miscommunications. It is important to note that in working on these dual goals, communication partner involvement is critical to therapy success, and that the majority of tasks follow two or three basic clinical "designs".
Assessment and intervention in conversation-based AR therapy
Assessment
In order to establish the clients' (i.e., hearing impaired adult and communication partner) goals for therapy, clinicians may wish to access both conversational data as well as self- and other-reported sources of conversational difficulties. In recent years, one of the most widely used self-reported scales has been the Client Oriented Scale of Improvement (COSI) (Dillon, James & Ginis, 1997). The strengths of the COSI lie in the client's freedom to identify the situations and their specific characteristics that are causing most difficulty for the hearing impaired adult. However, there has not been a tool to offer the communication partner a similar assessment, i.e. one that asks, "What do you, as the communication partner, perceive to be the most difficult situations arising from your partner's hearing impairment?" Recently, at one of the IDA Institute seminars in Copenhagen on communication partnerships, I heard Jill Preminger from the University of Louisville propose the POSI - the Partner Oriented Scale of Improvement. This sparked much discussion about the questions one might like to ask both the hearing impaired adult and the partner until she arrived at the GPS (great acronym!) the Goal-sharing Partnership Scale. This simply asks the hearing impaired adult and communication partner to identify the situations that they each and/or both perceive to be the most problematic and/or easiest for their communication. This allows discussion about the conversational settings that might best be addressed in AR clinic. Jill included the question about the easiest communication settings to help gauge the conditions in which the client and his/her partner find communication to be the most successful, if indeed there are any, as a basis for establishing when communication DOES work. This is a wonderful idea and I do suggest clinicians try this in clinic to help establish therapy goals.
Assessing conversation is best done by having the participants undertake conversation itself. This takes some practice, particularly on behalf of the clinician. During clients' conversational interaction clinicians may want to listen for and note the following: the number of breakdowns and repairs;the speed or ease (usually measured by the number of turns taken to resolve the repair) with which each repair is undertaken and the breakdown resolved;and the communication partner's ability to change speech characteristics (e.g., volume, speed, and pausing) and/or language (e.g., specific versus general content of repair turns) in response to breakdowns and /or to the hearing impaired adult's requests. To this point there are no clinical tasks which mimic everyday conversation sufficiently to allow more structured task analysis. Some recent research of our own has demonstrated that Continuous Discourse Tracking (deFilippo & Scott, 1978) for instance has little conversational reality, limited as it is to repetition of the spoken text segments (Okell & Lind, in preparation). Erber's (2002) Sent-Ident is a useful sentence based assessment for identifying the strategies by which a hearing impaired adult might best perceive another's talk. Its adaptive method, by which the person presenting the stimulus repeats it until it is perceived correctly by the hearing impaired adult, provides a particularly conversationally oriented scoring method.
We have learned from the speech reception studies that no person's speech is inherently intelligible. Intelligibility is (either positively or adversely) influenced by all factors in the interaction. It is at moments when conversation repairs are required that intelligibility might be best assessed. Ask clients what happened at that point. Ask if it is the speech clarity, message clarity, the effect(s) of environmental conditions or some combination of these that resulted in the breakdown. Remember also that not all repairs arise from mishearings (see Lind, Hickson & Erber, 2004, 2006) and as such are not all the focus of our AR clinic.
Intervention
In order to conduct therapy, clinicians need to feel comfortable discussing issues related to the conduct of conversation with clients. To this extent we need to educate a new generation of audiologists whose AR knowledge includes the linguistics of conversation alongside the linguistics of audiovisual speech reception and basic within-sentence lexico-grammar and syntax. As mentioned above, in its simplest form, conversation-based therapy may be seen as exercises in increasing intelligibility and reducing the effect of breakdown by increasing the effectiveness of repair behaviour. The tasks that most readily suit this therapy model are everyday conversations, barrier games/activities, and simulated conversations.
Everyday conversation.Clinicians should be led by their clients as to the type of interactions that cause most difficulty and mimic these in these clinical activities. Not only does this make the therapy more ecologically valid but it lessens the generalization that needs to occur from clinic to real life settings. Discussion following the exercises might engage participants about the strategies that worked best, how more or less specific requests for repair influenced the speed with which the repair was resolved, and how changes to speech and language patterns increased or decreased intelligibility.
Everyday conversation is the most functional exercise for clients and their communication partners to improve intelligibility and reduce the impact of breakdown and the need for repair. Clients who are able to demonstrate that they can manage unstructured talk in the clinical setting confidently can often work in this format. However, it is often that case that they attend AR clinic because this is exactly what they cannot manage and as such the clinician needs to break down the task into some component parts. There is substantial pressure on the clinicians to make the judgments about intelligibility and repair in the context of a fast moving conversation. This is difficult even with experience and slower moving and more structured clinical tools may well help in analyzing these behaviours.
Barrier tasks.
Barrier tasks are exercises in which clients aim to pass information known to one participant to the other via verbal (and sometimes non-verbal) cues only. Examples of barrier tasks include: giving directions on a map;describing a diagram or picture and having the other participant either reproduce it or select the diagram or picture from amongst a closed set of alternatives;following a set of directions to complete;and answering questions about a picture or body of simple everyday text such as train stations, road signs, or shop signs. The task allows for the communication partner (usually the person with the diagram, etc. in front of them) to practice message intelligibility via speech and language cues and for the hearing impaired adult and communication partner in concert to practice clarification and confirmation strategies. In these cases, the hearing impaired adult may ask a question to confirm or clarify what has been said (essentially a repair initiation turn), which is usually followed by the communication partner responding with a repair turn. Barrier games mimic Malinowski's speech-in-action, as they are based on people talking together to work towards a common goal.
Simulated conversations.
Simulated conversations allow practice of breakdown and repair as well as intelligibility strategies by mimicking a wide range of troublesome conversational settings in which people find themselves. People may want to practice interactions at the post office, the delicatessen, the doctor's office, the bank, or their workplace, for instance. In these settings, we also see speech-in-action type tasks, or phatic communication, and we may well wish to "impose" either equal or unequal speaker rights to reflect a difficulty identified by clients in their assessment. The clinician or the communication partner purposefully causes breakdowns by turning away, dropping their volume, speaking faster, changing topic abruptly, or by taking a long and complex turn at talk, for instance. The hearing impaired adult then gets to practice repair initiation turns in response to the breakdowns that occur. As previously mentioned, Erber's (2002) QUEST?AR is also a very useful version of a structured conversation which allows emphasis on clarification and/or confirmation strategies.
Final words
Two issues are worthy of being raised at the end of this paper, namely generalization and re-inventing the wheel. Generalization is the clients' application of skills learned in therapy to everyday life. This is not an issue we discuss often in the context of AR clinic. A downfall of our speech reception model of the last 60 years or so has been that we have not linked the training and learning that go on in clinic with real world speech reception events. That is, clients have had to work hard (and we still have little or no evidence of their success) to link their new knowledge to the events in their daily lives. We might suggest that, as a general rule, the more "real life" the therapy task the easier it is to apply the learned skills/generalize to the real world. The implication of this is that we need ultimately to assess real world consequences of our intervention. Second, there are many texts in existence that provide clinicians with well worked, conversationally relevant clinical exercises. Clinicians do not have to start from scratch in developing these materials. Several texts are identified in the reference list and in the accompanying presentation which people might wish to access to guide them in this form of AR therapy.
Conclusion
In conclusion, our intervention needs to be based on a clear understanding of the way conversation works, bringing aspects of conversational behaviour under the client's conscious control. Tasks are best planned to be easily/readily generalizable to everyday communication activities and should be measured against the "normal" mishaps of everyday conversation. There is still a lot to be done before this therapy is fully realized. This includes developing: a range of assessments that complement our range of intervention techniques;direct clinical assessment of communication abilities to complement self-reports;a common vocabulary by which we might discuss communication/conversation;and finally, research and evidence-based outcomes for the various rehabilitation intervention techniques.
Acknowledgements
I would like to thank Carolyn Smaka for the invitation to undertake the seminar on AudiologyOnline and to Graham Weir for his support. I would also like to acknowledge Elise Okell for assisting in the development of some of the ideas put forward in this presentation. Finally, I would like to acknowledge Prof. Louise Hickson and Dr. Jill Preminger who have both lent ideas to this presentation.
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