1. “You Never Listen to Me” and Other Hearing Loss-Related Stories
Samuel Trychin, Ph.D.
Janet Trychin, Au.D.

2. Thanks for inviting us to Beautiful Fresno

3. The importance of putting hearing loss in a larger context.
Part 1
The importance of putting hearing loss in a larger context.

4. Two basic things we need to do in order to survive
1. Avoid or escape from harmful or dangerous things or events—those that threaten physical and psychological health and integrity,
2. Approach beneficial or renewing things or events—those that promote physical and psychological health and integrity.

5. Survival requires several abilities
1. Ability to detect those harmful and beneficial things and events.
2. Ability to learn ways to avoid or approach those harmful and beneficial things and events.
3. Ability to consolidate that learning in memory for dealing with future similar things and events.

6. Adding hearing loss to the equation
Hearing loss, our most basic and important sense, affects two levels of human functioning:
1. External, physical and social , and
2. Internal, physiological, emotional, and cognitive.

7. Hearing loss is a systems issue affecting…
The external social system—hearing loss affects what we are able to detect that has important influence on our sense of acceptance or belonging: Examples:
The person speaking is angry and voice level is:
Loud Soft (pick one)
The person speaking delivers a loving message and the voice level is: Loud Soft (pick one)

8. Hearing loss is a systems issue affecting…
The external environmental system—hearing loss also affects a person’s ability to detect important environmental sounds:
Katrina, car horns, alarms clock, sirens, telephone ringing, kettle whistling, microwave timer, etc.
Question: What is the influence on one’s sense of competence and control or influence over events?

9. Hearing loss is a systems issue affecting…
The internal, physiological systems, such as, the nervous, hormonal, cardiovascular, respiratory, immune, and digestive systems.
Two internal system issues to consider are:
a. Negative emotional arousal, and
b. Unrealistic, dysfunctional attitudes and expectations

10. Hearing loss is a systems issue affecting…
The interactions between the external and internal systems, as occurs when:
Difficulty understanding discussion at a business meeting (external) produces…
Anxiety (internal) which lessens the ability to focus attention and use judgment (micro) which causes…
Increased inability to understand what others are saying (external) which increases anxiety further and also…
Prevents effective problem-solving (internal) and then
Communication problem persists/worsens(external).

11. In order to break these cycles people need to learn to do two things
1. Manage communication situations in order to prevent or reduce those communication difficulties that are due to hearing loss.
Failure to do so can result in feeling:
Less acceptable to others,
Less competent in work and everyday functioning,
Less influence or control over social and other events.

12. People also need to learn to…
2. Manage themselves because even when they
learn and regularly practice tactics and strategies for preventing or reducing communication breakdowns, they will not always be successful because:
a. Other people refuse to cooperate, and/or
b. It is not possible to modify the environment

13. Learning to manage communication situations involves
Recognizing situations that produce problems and those that don’t,
Knowing the causes of communication breakdowns:
Knowing what to do to prevent/reduce communication problems.
Practicing until new behaviors becomes habitual.
Anticipating difficulties in upcoming events.

14. One Problem
Most people who have hearing loss don’t recognize it, or admit to having it, or take steps to deal with it.
For example, of the estimated million people who have hearing loss in the United States:
Less than 1 in 10 with mild hearing loss use amplification, and
Less than 4 in 10 with moderate to severe hearing loss use amplification.
Kochkin,S. MarkeTrak VIII: Hearing Review. 2009:16 (11):

15. A Second Problem
Many of those who know they have hearing loss attempt to hide it from others. Problems…
1. Behaviors signal that something is wrong.
2. Others make assumptions that are not in that individual’s best interest.
3. Additional anxiety from fear of being found out.

16. Some reasons why people hide their hearing loss
Pragmatic reasons, e.g., afraid of being fired
Cosmetic reasons, e.g., will be less attractive
Social reasons, e.g., don’t want to appear different
Cultural reasons, e.g., are aware of negative stigma and don’t want to be devalued

17. 1. General social/cultural stigmatizing:
Stigma—A major factor that interferes with accepting the fact of, or admitting to having, hearing loss
1. General social/cultural stigmatizing:
Old, weak, deteriorating, incompetent, dependent, burden, stupid, etc.
2. Communication partner stigmatizing:
Spouse/lover, “Your hearing is fine…”
Parent/child, “It’s not a problem; he/she’s ok.”
Spillover--Concern about reflection on themselves
3. Self-stigmatizing:
Oneself—buys into the negative stereotype of self

18. A Third Problem
Misinformation about hearing loss and about those who have it contributes to failure to take effective action.
Misinformation about hearing loss also contributes to relationship difficulties as in, “Why don’t you pay attention?” or “How many times do I have to tell you to slow down when talking?”

19. Myths and Misconceptions about Hearing Loss
Hearing aid myth
Lip-reading myth
Sign language is for everyone
Professionals understand hearing loss
People who are hard of hearing understand their own hearing loss and its effects
Communication partners understand hearing loss
Trychin, 1987

20. Hearing loss considered as a communication disorder
Part 2
Hearing loss considered as a communication disorder

21. Rationale for including communication partners
Hearing loss is primarily a communication disorder for most people who experience it.
As a communication disorder hearing loss affects:
The person with hearing loss who is listening, and
The person/people who is/are speaking to him/her.
Good perspective: “It is our hearing loss.”

22. Examples
Beryl,
Minister’s wife,
Grandpa,

23. Hearing loss challenges
That subgroup of people who have hearing loss who come to audiologists for help in accommodating their hearing loss do so because:
1. They are experiencing hearing loss-related difficulties in their daily lives, or
2. Someone close to them, e.g., spouse, friend, employer, etc., has urged them to do something about their hearing condition.

24. Hearing Loss As a Communication Disorder
CPs are physiologically affected by their partner’s reactions to hearing loss-related problems via overt /verbal distress signals, mirror neurons, and electromagnetic transmission.
CPs are emotionally, cognitively and behaviorally affected by the difficulties they encounter in being understood when speaking.

25. Hearing Loss As a Communication Disorder
The perspective and experiences of CPs should be taken into consideration during assessment, treatment, and follow-up because:
CPs can facilitate or inhibit the tendency of a person who has hearing loss to take effective action to deal with it.
CPs may report problems that the person who has the hearing loss is unaware of or is unwilling to discuss.

26. Who are these communication partners?
In the past we have used the term significant others.
Usually, we think of significant others as a person’s spouse, lover, child, or parent.
However, most people communicate with a large variety of people in the course of a day, week, month, or year.

27. YOU

28. Who are these communication partners?
The most important communication partner at any given time is that person with whom the individual with hearing loss is conversing at that moment.
Example: Physician’s office
(both ways)

29. Ease of communication
When the communication partners in one’s inner circle, i.e., those with whom the person communicates most frequently (family, friends, coworkers, etc.) and the person with hearing loss use strategies and tactics for preventing or reducing communication problems, interactions proceed rather smoothly, and relationships benefit.

30. Dis-ease of communication
However, if there are frequent communication breakdowns, the result is often a weakening of the bonds that hold relationships together.
Then, there are emotional, cognitive, and behavioral effects on both the person who has hearing loss and the communication partner(s).

31. Three major problems for person who has hearing loss
1. Didn’t realize someone was speaking to her (didn’t get her attention before speaking)
2. Not understanding:
3. Misunderstanding:
Examples: Riverside, Aspirin, Obama

32. Effects of hearing loss on those who have it and on their communication partners
The following specific problems have been reported by many of those people with whom I have worked.
It is likely that these problems are also present in the lives of those people who have hearing loss but who have not yet recognized it, admitted to having it, or taken steps to deal with it.

33. Problem situations frequently reported by people who have hearing loss
Hearing alarm signals, at home/in a car
Someone talking to you from another room
Can’t see speaker’s face
Poor illumination
People whispering

34. Problem Situations Reported by HOH
Voice’s on TV or radio
Conversations in a moving car
Family dinners at holidays
Understanding conversations on the phone
Several people talking at once
Medical situations/reports
Outdoors-wind, traffic, etc.

35. Problem Situations Reported by HOH
Person who’s speech is not clear
Misinterpretation of mistakes
Unaware that the person is talking to me
Movies, plays, lectures, classes
Stopped for traffic violations
Dancing and talking

36. Extent of effects of hearing loss
It should be apparent that hearing loss can affect virtually everything a person does from the time he/she arises until going to sleep—and even thereafter.
Communication partners are also affected when their attempt to communicate orally with the person who has hearing loss fails or they ar uncertain that the message has been correctly received.

37. Problem Situations frequently reported by communication partners
Having to repeat often
Having to interpret frequently
When we become frustrated or irritated
When she/he doesn’t pay attention
Not talking as much as before
When he/she is not understanding someone else
Difficulty remembering what to do
Not knowing whether she/he understands
Trychin & Albright, 1993

38. Problem Situations for Communication Partners
The variability in his/her ability to understand
Hard to get her/him to understand me
TV or radio is much too loud
Becoming too dependent on me
Being isolated from friends and family
Not doing things we enjoyed previously
Having to repeat in pressure situations
Not traveling or going new places

39. Problems for students/trainees
In each kind of situation that the person who has hearing loss encounters there are a variety of problems and concerns that arise and need to be anticipated and planned for ahead of time.
Schools and other training programs, for example, have many ways of producing difficulties for students and trainees who have hearing loss.

40. Problem Situations for Students/Trainees Who Are HOH
Teacher does not understand the effects of hearing loss in classroom settings
Teacher talks while facing the blackboard
Other students ask questions from behind
Teacher talks while walking around room
Teacher uses microphone as a pointer

41. Problem Situations for Students/Trainees Who Are HOH
Use of uncaptioned TV, videos, or films
Recorded as absent, didn’t hear name
Examine time announced from rear of room
Air conditioning drones on during lecture
Teacher has heavy foreign accent
Teacher not open for suggestions

42. Problem Situations for Student/Trainees Who Are HOH
Teacher lectures while students take notes
Teacher does not provide written outline
Student is unable to follow other student’s comments in work groups
Teacher comments on films, slides, or videos when lights are out
Difficulty understanding PA announcements

43. Major life-tasks
The impact of hearing loss on one’s life can be enormous—especially in earlier development.
For adults: Continuing their education or training and Maintaining job/career, relationships, self-respect/confidence.
For children/adolescents: Establishing education/training, job/career, relationships, self respect/confidence

44. Preventing/reducing communication problems
As stated, the major problem for most people who have hearing loss and for their communication partners is the breakdown in communication.
Both the person who has hearing loss and his/her communication partner(s) contribute to difficulties in communication, and both need to cooperate in attempting to prevent or reduce these problems.

45. Preventing/reducing communication problems
In order to begin to minimize communication problems both the person speaking and the person listening must know the major causes of communication problems.
They also need to understand that hearing loss is only one causal factor and that most of the other causal factors can be prevented or reduced.

46. Factors that influence understanding what is being said
Speaker factors-the person who is talking.
Environmental factors-the place/situation in which the message is being delivered.
Listener factors-the person receiving the message

47. Speaker Factors that Influence Understanding
Does not first get the listener’s attention
Does not face the listener while talking
Covers face while talking
Talks too rapidly/too slowly
Talks too softly/too loudly
Does not enunciate clearly
Uses too little/too much facial expression or body language

48. Speaker Factors that Influence Understanding
Has a foreign accent/regional dialect
Has distracting mannerisms
Has an untrimmed beard or mustache
Has a boring delivery or message
Is impatient with the listener
Is irritated with having to repeat

49. Environmental Factors that Influence Understanding
Background noise
Poor lighting
Poor room acoustics
Too far from source of sound
Visual or auditory distractions
Objects interfere with seeing speaker

50. Environmental Factors that Influence Understanding
Poor seating arrangements
Inadequate ventilation
Lack of assistive listening systems
Lack of alerting systems
Lack of visual aids-overheads, CART, etc.
Illegible visual aids

51. Listener Factors that Influence Understanding
Severity of hearing loss
Type of hearing loss
Use of hearing aids
Use of assistive listening devices
Attention level
Emotional status

52. Listener Factors that Influence Understanding
Distracting sensations
Distracting thoughts
Fatigue level
Motivation to hear
Expectations about ability to understand
Has low self-esteem and/or self-efficacy

53. Listener Factors that Influence Understanding
Familiarity with the terminology used
Familiarity with speaker’s voice
Speech-reading skills
Tinnitus status
Other physical symptoms-vertigo, pain
Manual communication skills

54. Part 3 Reactions to Communication Breakdowns and
Mental health risks associated with hearing loss

55. What happens next—after the communication problem has occurred?
Once a communication breakdown has been perceived, the people involved will react to it in some way:
1. Some reactions are productive, i.e., they help to resolve the problem.
2. Other reactions are unproductive, i.e., they fail to resolve the problem and often make it worse.
The following are some frequently reported reactions that often make the situation worse.

56. Types of Reactions Physical Emotional Behavioral Cognitive Social
Trychin, 2001

57. Physical reactions to communication problems
Preparation to freeze, fight, flee, faint:
Changes in heart rate
Increased blood pressure
Blood shunting
Shallow, rapid breathing
Hormonal activation—adrenalin, cortisol, etc.
Muscle tension
Fatigue

58. Emotional reactions to communication problems
Anger
Fear/Anxiety
Depression
Embarrassment
Guilt
Shame
Loneliness

60. High
Excitement
Elation
Happiness
Anger
Anxiety
Fear
Cortosol
DHEA
Relaxation
Contentment
Calmness
Sadness
Depression
Hopelessness
Low

61. Effects of embarrassment and shame
Posture—reflexive
Signals remorse
Survival value--serves to motivate repairing the rift or
Produces longer-term social pain and resulting self-isolation

62. Salience (importance) of stimuli and events
Negative or harmful stimuli ordinarily have greater salience for survival than positive or beneficial stimuli or events because:
You must avoid or escape from harm now.
You can always find something to eat later.
Our memories for negative events are more vivid, intense, and longer lasting than our memory for positive events.

63. Cognitive reactions to communication problems
Can’t think straight-confused
Hard to focus attention
Easily distracted
Difficulty making decisions
Mind goes blank
Decreased self esteem
Reduced risk-taking
Trychin, 1991

64. Behavioral reactions to communication problems
Bluffing—pretending to understand
Withdrawing—avoiding/escaping
Blaming, e.g., “You mumble.”
Demanding, e.g., “ You’d better…”
Dominating conversations
Guilt tripping “If you really loved me,,,” 1

65. Social reactions to communication problems
Many people who have hearing loss report the experience of being or feeling rejected due to communication problems resulting from their hearing loss.
The rejection may be obvious and deliberate such as being divorced, fired from a job, or overtly put down/devalued .
The rejection may also take a more subtle form such as being ignored, passed over, or left out.

66. Social pain
Social pain is experienced when a person feels a threat of loss of attachment to a valued person or group.
There is a pre-wired, genetically determined predisposition to form and maintain attachments to other people.
This reflexive predisposition has survival value and is quite powerful.

67. Social Pain
Follows the same neural pathway as physical pain—degree of distress (psychological) circuit.
Is believed to derive from the same source as physical pain--protection from threat or danger.
Therein lies social pain’s survival value.
Produces escape/avoidance behaviors.
People who have hearing loss are vulnerable.
Communication partners are also vulnerable.

68. Genetic/social support factors
People vary along a continuum in terms of their sensitivity to social pain.
There is a high correlation between sensitivity to social pain and sensitivity to physical pain.
Social support modulates the sensitivity to social pain; family/friends support is essential.
National and local organizations such as HLAA and AR groups also provide helpful social support.

69. Major difference between physical and social pain
When the experience of physical pain is over (the tooth has been pulled), recalling the event or anticipating the next extraction does not elicit the same intensity as the experienced pain.
However, with social pain, recalling the event or anticipating its recurrence can elicit the same degree or intensity of distress—sometimes, even greater.

70. Recent brief survey-What is your estimate of the number of people you serve who report the experience of being rejected
Audiologists: 15%, 50%, 58%, 90%
State services for deaf and hard of hearing: 90% , 90+%, 92%, 100%
Psychiatrist who works with deaf/person who is hard of hearing-100%
Either they are serving different populations or are asking different questions.
What is your experience in regard to rejection?

71. Sequence of events Communication breakdown
Actual or imagined negative reaction in a listener
Fear of being rejected in some way and fear that the relationship is weakened or lost and/or embarrassment, guilt, or shame
Social pain
Desire to repair or escape from the situation 
Desire to avoid such situations in the future 
Social isolation
Loneliness, depression, health problems.

72. Mental health issues

73. Mental health issues
There are two ways in which negative reactions to communication difficulties can result in more serious consequences:
1. When there has been a major, traumatic event, e.g., loss of a job, marriage/relationship, health, etc.
2. When there has been a long series of less severe, but still hurtful, events, e.g., rejection, abuse, neglect, etc.
Either of these experiences can result in PTSD.

74. Mental Health Risks of Hearing Loss
Becoming chronically nervous, anxious
Becoming chronically sad, depressed
Feeling anger much of the time
Loss of group identity
Feeling marginal in one’s own family
Withdrawing from social contact
Loneliness
Trychin, 1991

75. Mental Health Risks of Hearing Loss
Becoming distrustful of people
Developing poor self-image
Feeling incompetent
Feeling unacceptable to others
Feeling loss of influence or control
Feeling marginal at work/social situations
Trychin, 1991

76. Loneliness Effects
Depression
Morbidity
Mortality

77. Possible relationship between hearing loss and mental health problems
1. Causes or exacerbates pre-existing symptoms: Person is now more anxious or depressed.
2. Adds new symptoms to a pre-existing problem:
Person is now fatigued and has even less energy to cope.
3. Interferes with treatment efforts: Person is unable to understand what is being said in treatment sessions.
4. Interferes with treatment compliance: Person fails to understand or misunderstands what he should be doing in terms of medications, appointments, etc.

78. There are always three possibilities related to mental health issues, e.g.,:
1. The hearing loss causes the depression. Without the hearing loss the person would not be depressed.
2. The hearing loss exacerbates the depression.
Without the hearing loss the person would still be depressed but not as depressed as she is now.
3. The hearing loss is unrelated to the depression. Without the hearing loss the person would still be as depressed as she is now.

79. Mental health and other providers often do not understand the effects of hearing loss so they:
May not recognize its presence,
If the hearing loss is recognized, its significance may not be appreciated, resulting in it being ignored or disregarded it.
If its significance is recognized, therapists may not know what to do about it because…
Education/information regarding hearing loss and its effects is not in their training.

80. Consider how would you feel if you went for help and….
You were unable to understand what people (receptionist, counselor/therapist, physician, or advocate) said to you.
People did not know what to do to help you understand them, or refused to do it, when you informed them about what to do.
People denied that your hearing loss was really a part of your problem.

81. To this point we’ve seen:
1. Problems reported by people who have hearing loss and their communication partners
2. Causes of the communication problems
3. Reactions to communication problems
4. Mental health risks and issues associated with hearing loss

82. Consider all of that again in regard to a person’s major life-tasks
For adult onset it is continuing their education/training and maintaining their job or career, relationships, self-respect/confidence, and health.
For childhood/adolescent onset it is establishing education/training, job or career, relationships, self respect/confidence, and maintaining health.
When these are compromised, there are mental health risks.

83. Communication Partner Guidelines
Pick the best spot to communicate
Get the listener’s attention before talking
Be sure your face can be clearly seen
Do not have objects in your mouth
Speak slowly and clearly
Rephrase if you are not understood

84. Communication Partner Guidelines
Inform listener when changing subject
Don’t shout
Try to be patient, calm, and relaxed
Speak to, not about, the person who is HOH
Use facial expressions and gestures
Ask for tips to improve communication
Trychin & Boone, 1987

85. Listener Guidelines Practice relaxation skills beforehand
Pick the best spot to communicate
Anticipate difficult situations-plan ahead
Inform others how best to talk to you
Pay attention to the speaker
Look for visual cues of what is said

86. Listener Guidelines Do not bluff
Inform the speaker about what you heard
Reinforce speaker’s helpful communication
Set realistic goals for understanding
Ask for key words in writing if needed
Arrange for breaks if meetings are long

87. Other effective communication behaviors
Inform others about your hearing loss
Inform them about what to do
Remind them when they forget
Model the communication behavior you want from them
Reinforce other’s communication efforts
Relax and maintain your composure

88. The Risk of Failure to Inform Others About Your Hearing Loss
You might be blamed for being:
Unfriendly/aloof
Incompetent
Lazy/dodging responsibility
Uncooperative
Stupid/having low intelligence
Weird/having personal problems
Boorish/without social skills

89. When informing others, try to avoid:
Being apologetic
Putting yourself down
Being impolite
Being sarcastic
Expressing anger
Guilt tripping
Being defensive

90. Intervention Two: Learning how to do it effectively requirements
1. Information about what to do,
2. Opportunity to practice doing it, and
3. Feedback about the adequacy of the performance.
A group format is the most effective and efficient way to accomplish this goal.