Viewed historically, audiologic/aural rehabilitation (AR) comprises a rather vague set of paradigms that encompass a wide range of restorative services to people with hearing loss. By definition, paradigms are axiomatic systems characterized by assumptions that emerge out of the entity or system for which they are designed. This definition is correct in relation to AR, since there seem to be as many theories as to what audiologic/aural rehabilitation is—or is not—as there are service providers. Each patient has distinct communicative/interactive/hearing needs, and each paradigm of service on the patient's behalf must also differ accordingly. To be effective, AR services should be tailored to patients' needs in their individualized communicative environments, with their specific communication partners, or in specific situations in which they are required to communicate.

What principles, then, might guide audiologists to address the specific AR needs of adults with hearing loss, and the complexities of their individual communicative challenges? The following principles can guide the planning and execution of AR programs for adult patients. For some readers, they are not new, but they are offered as guidance originally discussed in part by Bode and Tweedie (1982), and later by Hull (1997, 2000, 2001).

1. Audiologic/aural treatment should always address the specific needs of the patient.

Although obvious, this principle appears in many instances to have been ignored. If a patient is having difficulty communicating in a specific environment or with a specific person, then it is critically important that the audiologist work with him or her to develop strategies to address those specific difficulties. The individualized strategies often generalize to other situations as the patient develops the resolve, the self-confidence, and plans of action to overcome the original difficulties.

2. Because older patients with presbycusis can have both peripheral and central auditory involvement, environmental design strategies can be effective in enhancing speech understanding.

This aspect of AR service involves not only development of listening strategies that accommodate auditory decline in the peripheral and central nervous system of aging patients, but also includes environmental design strategies that can enhance speech understanding. Treatment that enhances cognitive function that can otherwise impair auditory/linguistic processing can also be utilized—including strategies for analysis and synthesis of auditory/linguistic information, speed of auditory processing, accuracy of attending behaviors, and auditory sorting behaviors.

3. Empowering patients to become more assertive enhances their ability to improve their communication environment, which is an essential component of treatment.

Assertiveness can be an important treatment objective, and should be a goal in patient counseling. The patient can learn to stage-manage communication events and environments to maximize the probability of successful participation. Reducing background noise levels, decreasing the distance from a talker, optimizing lighting for speech-reading cues, requesting that the talker speak with greater clarity and/or use the microphone (at speaking engagements), and manipulating the design of the environment to one's communicative advantage are examples of how the patient can be a positive catalyst in improving the communication environment.

4. The clinician should model effective communication.

Clear, articulate speech without unnatural over-articulation should be the norm. Appropriate speech intensity levels for maximum intelligibility in a variety of listening situations should be sought. Unintentional masking of visible speech by hand or head movements should be noted and avoided. By being an example of a good communicator, the audiologist demonstrates what patients with hearing loss should expect from their most effective communication partners. Further, the patient can teach others about effective communication skills.

5. The patient and clinician should work together to develop specific auditory training goals and objectives.

Since AR is a learning process, the patient must be made aware of his or her part and responsibility. The patient's active involvement is of paramount importance. Carryover into real-life situations cannot be fully accomplished unless the patient accepts his or her responsibility in the process.

6. Individual and group treatment programs should be available to patients.

Group sessions permit the patient to discuss communication problems with peers who may have similar problems, but each patient must be carefully evaluated as to his or her potential for successful entry into a group environment. Some patients should begin individual treatment before joining a group, either because their communication difficulties may negatively affect their ability to interact in a group environment, or because their communication problems are not conducive to group discussion. For patients who are a good fit for group work, this type of treatment can be a powerful tool for the development of a more positive attitude about their hearing loss, since others in the group may be able to offer successful strategies that they found helpful. In addition, group problem-solving sessions can be extremely beneficial.

7. Treatment activities should offer opportunities for successful communication.

Interesting and challenging activities can be planned; social activities for AR groups at which techniques of successful communication can be practiced in a controlled and nurturing environment can be a positive treatment tool. Developing and maintaining motivation are important potential effects of a relationship wherein humor, active involvement, and dynamic interaction are important parts of treatment.

8. Counseling is essential to the effectiveness of the clinician-patient relationship.

Counseling is one of the most important activities involved in audiologic/aural rehabilitation. In that regard, major attention and effort must be directed toward developing counseling skills in audiology students and clinicians so that they can become effective listeners, provide constructive support, facilitate problem-solving, instill confidence, and be a catalyst in the development of strategies to resolve difficult listening/communicative environments.

9. Patients should be encouraged to maintain a balance between the give-and-take of communication, and to have realistic expectations.

The patient may need counseling to develop skills in how to be assertive and to listen when communicating. Acceptance of realistic expectations also should be addressed. Not every communicative environment can be changed, nor can all speakers be taught how to communicate effectively. The patient may assume too much personal responsibility for specific communicative failures. Further, clinicians must encourage patients to develop realistic expectations relative to amplification. Despite the continuing technological advances in hearing aid design, hearing aids cannot be expected to match the full range of human hearing, nor can they resolve all the environments in which individuals with hearing loss find themselves. Hearing aids cannot correct for the barriers of poorly delivered speech and difficult communication environments.

10. Clinicians should assist patients in developing alternative behaviors and responses for specific communication events.

Some patients adopt avoidance and/or withdrawal behaviors in situations requiring interactive communication, particularly when they may have had previous frustrating experiences in that place or with that person. Planning for these difficult situations might include activities that involve principles of effective interactive/interpersonal communication that are specific to that environment or with the speaker. These, for example, may include rehearsing participation in a wedding, as a greeter at a social event, or in conducting a business meeting for an organization.

11. Incorporating hearing assistive technology can be an effective part of audiologic/aural rehabilitation.

Technology should be introduced, as appropriate, as a part of an AR program, including such items as telephone amplifiers and commercially available assistive listening devices for specific social or vocational listening situations. The use of new hearing assistive technologies as they become available should be used for instruction and exploration, not to exploit a captive audience for profit.

12. Innovative avenues for audiologic/aural rehabilitation to enhance patients' auditory and visual function can be beneficial.

The speed and efficiency with which clients utilize the auditory and visual information derived from communication can be enhanced. For example, time-compressed speech and interactive laser-video technology are available and useful. Enhancing central auditory function in older adult patients appears to be an efficient avenue for improving speech comprehension, which can be exciting and helpful for patients. Activities emphasizing speed and accuracy of auditory closure, accuracy of very short-term auditory memory, and speed and accuracy of auditory/visual decision-making can also provide benefit to patients.

13. Patients should be taught a variety of listening strategies appropriate for specific communication situations.

The clinician should explain why certain communicative situations are more difficult than others, and discuss why, in certain noisy situations, an alternative strategy might work better-perhaps turning down a hearing aid and relying more on visual clues through speechreading. The patient will become more confident as he or she learns that there are usually several ways to overcome difficult communicative environments, and that most people-not just those with hearing loss-at times have difficulty communicating. And in some situations, there may be no solution. Teach patients to recognize and understand these limitations, rather than to be upset by them.

14. Clinicians should create a catalog of possible methodologies to achieve specific objectives and then review this information during planning of individual treatment.

Varying clinical approaches should be gleaned from the literature (see list of resources on page 16). Novel approaches developed by colleagues should be evaluated for future use, and their contributions appropriately cited.

15. Improving the speech habits of a patient's communication partners can enhance AR treatment.

Clinicians too often focus only on the patient, with little attention given to "significant others" in the patient's communicative environment. When the most important communication partners improve and refine their speech production and vocal expressiveness—including a decrease in the speed of speech and clearer enunciation without over-articulation—the patient's difficulties can be reduced. These changes can be an extremely powerful part of treatment, but diplomacy is a critical factor. Providing tactful instruction on speech production in a diplomatic manner to a patient's spouse, children, and other significant communication partners can be an extremely positive addition to AR treatment.

Speech-language pathologists can also contribute in a number of ways. As an ASHA member certified in both professions, I have worked with local news broadcasters, ministers, and public speakers to improve their manner of speech on behalf of people with hearing loss. For example, one Wichita television news broadcaster spoke at rate of more than 190 words per minute. That articulation speed prevented many viewers—including, of course, those with hearing loss—from understanding his speech. After several treatment sessions, the broadcaster's speech intelligibility improved measurably, as noted by my patients who monitored the broadcasts. Changes in the broadcaster's speed and articulation resulted in higher viewer ratings, and my patients once again tuned into the evening news. In this way, both the viewers and the broadcaster benefited from the service.

We must remain vigilant in identifying the special auditory communicative needs of individual patients, their specific communicative environments, and their communication partners. Above all, audiologists must be insightful and flexible in their approach to AR, offering services that are meaningful to patients.

The original principles that guided the development of this invited article were earlier described by this author in The Hearing Journal (2005).