Vignette:
Thirty-six year old Russell awakened one morning to find that he could not hear the sound of his wife's voice as she attempted to awaken him for work. As he lurched out of bed he felt an unsteadiness and fell backward onto the covers. A loud roar from inside his head was the only sound he could "hear". Later, Russell was diagnosed with an acute bilateral Meniere's episode resulting in complete deafness. As a marketing director for a regional telecommunications company, he now had to take a leave-of-absence for an undetermined period of time. The shock of facing an impenetrable invisible barrier, one so complete as to disconnect his career, his social life, and his family life, brought Russell's life as he knew it suddenly and firmly to a halt.
Diagnosis and Treatment:
Russell suffers from bilateral episodic endolymphatic hydrops, resulting in near-complete outer hair cell hair cell destruction in both cochleae. Functional MRI, auditory brainstem response (ABR) and promontory electrostimulus reveal otherwise normal cochleae, spiral ganglia, auditory (Cranial VIII) nerve, and central auditory function. Audiometric thresholds are consistent with a bilateral severe to profound sensorineural loss. Binaural hearing-only speech discrimination in best-aided condition is within the range of chance (8%). After the neurotology and audiological evaluation, it is recommended that Russell undergo surgical implantation for a unilateral multichannel cochlear implant as quickly as possible.
Thereafter, he will begin auditory rehabilitation. From date of evaluation to the ultimate implant hook-up and mapping there will be a two-month period. During this long, lonely time Russell could become overwhelmed with hopelessness and negative expectations about his future. Instead, an insightful neurotologist refers Russell to an audiologist with psychological counseling expertise for medical crisis counseling (MCC) as described by Pollin (1995).
A form of brief therapy, MCC therapy consists of ten sessions. These will take place over the eight weeks while Russell awaits reimbursement approval, surgery, healing, and cochlear implant hook-up and mapping. To overcome communication difficulties during counseling sessions, a real-time caption interpreter is utilized. Counseling will involve Russell and his wife, Ann, separately and together. One session will involve the entire family.
Below, each of the eight objectives of MCC will be addressed within the context of Russell's case. For our purposes in this paper, each objective will be adapted to help Russell overcome his fears, and hopefully to help him to look forward to the changed paradigm that can potentially provide new opportunities for him and his family.
Although treatment for Russell's condition--which will be a combination of cochlear implant, assistive technology, and training for effective coping strategies--will enable him to learn to lead a full, productive life, such will not come easily. In fact, even the best of treatment outcomes will leave much to be desired in terms of ease of communication and psychosocial function.
- To Reestablish Control of One's Life- Russell can no longer function on the job, nor communicate effectively with his wife, children, or others. He feels a complete loss of independence, going from father-husband-provider to near-helpless dependent for even the simplest of communications. In practical terms this means that the person or persons at hand to assist him will be making many decisions on his behalf. They will decide whether or not a given communication or detail is important. They will answer the telephone, respond to strangers at the door, and otherwise control many aspects of social interaction. In effect, they become his veritable "alter ego". Our goal for Russell is for him to embrace any and all available compensating technologies and strategies, so that he can regain a productive livelihood and to regain a degree of communicative and decision-making independence (Metz, 2005).
- To Grieve Losses and Redefine Self- Losing one's sense of audition is indeed a substantial loss. The fact that the onset of deafness is sudden creates a greater sense of loss--akin to losing a loved one or losing a part of one¡¦s own self. As the reality of the changed situation sinks in he will fall deeper into each stage of mourning, plunging him into an emotional mosaic of feelings of fear and hopelessness unlike any he has ever experienced. Hence, our objective here is to help Russell travel through the stages of mourning, including those of numbness, denial, despair, and acceptance (Bauman, 2005; Chartrand, 1999). In bringing out those fears in the light of day, Russell can confront and, in turn, conquer each one as they manifest.
- To Combine Maximum Self-Reliance with Acceptance of a Level of Physical Dependence- As stated earlier, Russell will be undergoing cochlear implantation. By itself, we can expect a speech discrimination ability that may be as little as 50% of that of normal hearing individuals in quiet listening environments. In noisy circumstances, however, speech understanding can plunge no matter how successful the cochlear implant performance (Beck, 2005; Namasivayan, 2004). Of course, the fact that his loss is post-linguistic and occurred recently will aid significantly in restoring closer to normal central auditory processing than for an individual whose loss is long-standing. To bring our patient closer to normality--or communicative wholeness--will require extensive auditory rehabilitation (Chartrand, 1999). Developing self-reliance will require utilization of assistive technology to fill the gaps where auditory compensation (via cochlear implantation) leaves off (Diles and Diles, 2005). Russell will need to plan toward optimal self-reliance, but also be willing to accept assistance from his family, friends, and others, when necessary.
- To Develop the Self-Acceptance and Social Skills Needed to Deal with Others' Attitudes- Deafness is an invisible handicap. That is, it is not readily apparent to others when encountering a deaf or impaired individual. Too often deafness is perceived as a mental, psychosocial, or cognitive weakness. Frequent repetition causes loss of patience; having to speak louder than is comfortable or customary adds a negatively emotional dimension to otherwise casual conversation; misunderstandings can be construed as intentional contrariness or lack of cooperation. Certainly, lack of spontaneity makes for awkwardness and impedes bonding in relationships. Our goal here for Russell is to prepare to accept awkward, halting communication, and the misperceptions on the part of others as well-meaning and unintentional, to not take offense to naturally occurring social awkwardness during communication breakdowns.
- To Be Able to Face Difficult Decisions with Realism and Sensitivity to Others' Needs- An aspect of the psychology of the hearing impaired that makes cognizance of others' needs difficult is the fact that deafness naturally causes a drawing into ones self, a form of social disconnect, which I consider to be a form of "social autism" (Chartrand, 1999). Even with cochlear implantation, assistive technology, and coping strategies, the reality is that one is still deaf. Coping with a life of deafness requires a certain level of humility and understanding toward the feelings of others, lest the stress and strains of deafness --coupled with isolation and frustration--inhibit all social interactions. Such can result in a loss of the sense of belonging to a larger community. Here, our goal for Russell is to think in terms of anothers' point of view, to enlarge his perception and to empathize with others' wants, needs, and aspirations. His will be a need to stay in "circulation", to preserve past relationships and build upon them for an ever-growing social circle.
- To Identify and Redirect Anger, and Thereby Release Constructive Energy- One of the strongest manifestations of newly experienced deafness is anger and frustration (Bauman, 2005; Chartrand, 1999). Anger may not be directed toward any one individual. Nevertheless, uncontrolled anger affects all who live, work, or play around the afflicted individual. Channeled in a positive way, anger and frustration can be utilized to propel the sufferer toward auditory rehabilitative guide-posts, thereby shortening the time it takes him to learn to speechread, to master the complexities of assistive devices, and to learn better how to repair communication breakdowns. Our goal in this aspect is to help Russell direct the energy of his anger and frustration toward mastering those skills necessary for leading as normal a lifestyle as possible (Pollin, 1995).
- To Sustain an Appropriate Level of Meaningful Contact with Others- As mentioned above, the natural tendency is to pull inward, to reduce exposure to and avoid social situations, and to diminish the size of one's social circle. A great deal of Russell's success in maintaining social contacts and involvement will depend largely upon assistance from his wife. She will often be his link to past relationships, particularly in the family. Therefore, she will also need counseling in how to deal with her husband's deafness, yet at the same time, overcome the tendency to jump in and take over all aspects of social interaction. Both Russell and his wife will have to learn to master the delicate balance between too much and too little, between overdependence and abandonment.
- To Promote Existential Acceptance with an Emphasis on the Quality of Life in the Here and Now- An existential viewpoint rises above a personally involved viewpoint. It rises above the trees to reveal a forest. A certain amount of emotional detachment must accompany the rehabilitative process, lest one become obsessed with limitations over which there is no control. In fact, obsessing over a hearing handicap will only make things worse; obsessing can stifle a return to relative normality. Humor, on the other hand, can break up awkward moments, it brings perspective and differentiates between consequence and tragedy. Building on already-developed talents and strengths can serve as a bridge to a more happy and productive future. Learning a new skill or trade, more attuned to the changed sensory paradigm, preserves earning-power and job satisfaction. Reliance upon civil rights empowerment, such as the Americans with Disabilities Act of 1990 (ADA) and associated legislation, helps level the playing field in the public arena. Our goal for Russell in this regard is for him to learn to be positive, to resist negativity, to strive for equilibrium and homeostasis; to increase the use of humor and to learn to put others at ease. And whereas deafness started out as his bane, it can potentially become, in a sense, a boon for a new life and for living on a deeper plane. While many precious elements of past activities were taken for granted, he now can appreciate the nuances of love, friend, and the generosity and kindnesses of others.
Everyday hearing health practice rarely encounters cases such as Russell's. Most cases occur gradually over a significant period of time. Therefore, it can be difficult to fathom the trauma accompanying a sudden hearing loss. Also rare is accessibility to the kind of counseling model needed in such cases.
Only a collaborative multidisciplinary approach, comprising an audiologist, the physician, and a mental health therapist, can provide an effective safety net for patients experiencing such a traumatic life change. Utilization of an MCC counseling approach in the chronic condition of deafness, informed in all the particulars that apply to extreme auditory rehabilitation, can also be an effective therapy for those suddenly entering the hearing health care system.
References
Bauman, N., (2005). Grieving Your Hearing Loss. Hearing Health, 21(3): 34-37.
Beck, D., (2005, July 25). Interview with Jay T. Rubinstein, M.D., Ph.D. Healthy Hearing, retrieved on October 16, 2005, from www.healthyhearing.com/library/interview_content. asp?interview_id=723.
Chartrand, M.S., (2005, April 18). Tinnitus Loudness Perception in Precipitous HF Losses. AudiologyOnline, Archives. Retrieved on August 26, 2005, from www.audiologyonline.com/articles/pf_arc_disp.asp?id=1359.
Chartrand, M.S., (1999). Hearing Instrument Counseling: Practical Applications in Counseling the Hearing Impaired, 2nd edition. Livonia, MI: International Institute for Hearing Instruments Studies.
Diles, C.G., and Diles, W.S., (2005, August 8). Staying in the Loop: When Hearing Aids Are Not Enough. AudiologyOnline. Retrieved on August 26, 2005, from /articles/pf_arc_disp.asp?id=1423.
Gatchel, R.J., and Oordt, M.S., (2003). Clinical Health Psychology and Primary Care: Practical Advice and Clinical Guidance for Successful Collaboration. Washington, D.C.: American Psychological Association. ISBN: 1-55798-989-3.
Metz, D., (2005, May 9). The Road Back. AudiologyOnline, Archives. Retrieved on August 26, 2005, from www.audiologyonline.com/articles/pf_arc_disp.asp?id=1370.
Namasivayan, A.K., (2004, June 21). Cochlear Implant Technical Issues: Electrodes, Channels, Stimulation Modes and More. AudiologyOnline, Archives. www.audiologyonline.com/articles/pf_arc_disp.asp?id=782.
Pollin, I., (1995). Medical Crisis Counseling: Short-Term Therapy for Long-Term Illness. New York: W.W. Norton.
