This article is fourth in a series highlighting the work of master clinicians in audiologic/aural rehabilitation, contributed by ASHA Special Interest Division 7, Aural Rehabilitation and its Instrumentation. Jerome Alpiner, whose textbooks about aural rehabilitation (AR) have been a professional mainstay for 30 years, is featured in this interview. Alpiner, who taught for many years at the University of Denver, lives in Centennial, Colorado, and continues to contribute to the audiology profession. He is co-author of the new publication, The Hearing Aid Decision (Your Answer to Many Questions), designed for individuals with hearing loss; it is currently available online from Amazon and Barnes & Noble. Alpiner says, "The book attempts to fill a gap, but I still believe that personal one-on-one contact is best."
Q: It has been said that to predict the future, you must look to the past. In view of your distinguished career in rehabilitative audiology, what do you foresee as critical for the future of aural rehabilitation (AR)?
For years, many perceived AR as the provision of lipreading and auditory training exercises. With the exception of audiologists in military and veterans' hospitals, audiologists did not dispense hearing aids. They conducted audiologic and hearing aid evaluations to determine the rehabilitative needs of patients. Then, based on the results obtained with selected hearing aids, they referred their patients to hearing aid dealers for purchase of the prescribed instrument(s). The extent to which patients returned to the prescribing audiologist for follow-up varied considerably. During that time, I invited hearing aid dealers to discuss their procedures with my classes. Students frequently asked dealers why they did not provide AR services or advise patients to return to their audiologists for AR. Typically, hearing aid dealers maintained that AR was unnecessary because the hearing aid was sufficient. Some would acknowledge that they did not recommend AR because their patients might decide against purchasing a hearing aid because it "was not going to resolve the hearing problem anyway."
To some extent that attitude still prevails, even when the dispenser is an audiologist. Greater emphasis by university training programs on the value of AR and more evidence by researchers of AR's effectiveness will help persuade more audiologists that AR is the foundation of hearing health care and not simply an add-on. Traditional AR does not exist as a separate entity as it did in the early years of the profession. AR today consists of an audiologic evaluation, hearing aid evaluation, consideration of hearing assistive technology systems, counseling, and training procedures to maximize hearing rehabilitation. Expansion of academic programs that confer a doctor of audiology degree and programs provided by ASHA, the Academy of Rehabilitative Audiology (ARA), the American Academy of Audiology (AAA), and other professional societies for audiologists reveal increased emphasis on AR and its evolution. The decision that allowed audiologists to dispense hearing aids afforded us this opportunity and challenge. We would not even be discussing this issue if audiologists were not dispensing hearing aids.
The Denver Scale of Communication Function has been one of the premier self-assessment tools in audiology. It was part of the original protocols for adult cochlear implant evaluations and has a history of clinical applicability. A number of scales and profiles have been developed since, but audiologists seem to resist including them in diagnostic and rehabilitative test batteries. What are your feelings about this?
The Denver Scale of Communication was developed at the University of Denver after doctoral students asked, "How do we really know how clients feel about their hearing loss when hearing aids are recommended?" The emphasis of this discussion pertained to the effects of hearing loss on social, vocational, and family relationships. It also stressed that we were good at evaluating hearing aids numerically but needed to link amplification with client success in the real world (before and after the use of hearing aids) in a way that reflected our concern for individual clients. Numerous assessment tools have been developed through the years for clinical and research purposes.
Audiologists resist using these instruments for two main reasons—time and economics. It takes time to engage in the task, evaluate the results, and discuss them in detail with clients. Economics is the other, and perhaps major, reason. Most insurance companies will not reimburse for this procedure and clients generally will not pay for it. I volunteer for an organization that provides hearing aid assistance for persons in financial need. I have reviewed hundreds of applications, and have noticed that on the application, the hearing aid vendor recommends one or two hearing aids. In my decision-making, it would be easier to have data from a self-assessment procedure to better know the client's social, vocational, and family needs for communication. So I am still a believer in self-assessment.
Q: How has the ARA been influential in AR?
Several ARA founders felt a need for the organization because, as they stated, "it seems that many in clinical audiology have become preoccupied with diagnostics and research almost to the exclusion of aural rehabilitation and habilitation." Their hope was to stimulate research in the area of AR and provide a forum for the exchange of information and views important to current procedures, case finding, programs for individuals with hearing impairments, relationships with allied professions, relationship of diagnostics to AR findings, and other issues.
The ARA has been extremely influential in promoting AR. That influence has carried over to AAA and ASHA. In reviewing some of the Journal of the Academy of Rehabilitative Audiology articles and programs from Academy meetings, I find numerous topics that have become part of developments and procedures today. A sample of these topics illustrates ARA's influence:
Audiology and the Dispensing of Hearing Aids
Support Personnel in Audiology
Self-Assessment: From Research Focus to Research Tool
A Cooperative Outreach Program for the Elderly
Assistive Devices for the Hearing-Impaired
Many ARA members also have held important positions in other professional organizations, often providing expert information and support for AR within those organizations. Convention programs from these organizations also illustrate ARA's impact—its members are frequent presenters and AR topics continue to increase. ARA's advocacy has been commendable and its role is continuously being evaluated as it moves forward in this century.
Q: You established an AR assessment protocol that included the use of the Denver Quick Test of Lipreading Ability. Do you think speech-reading assessment and training have become a lost art?
After all these years, I am not sure I know the answer to that great question. Let me address this issue in terms of adventitious hearing loss. I used the Quick Test for two reasons—assessment of "natural" lipreading ability and motivation. Numerous studies have evaluated possible predictors of lipreading ability, such as intelligence, degree of hearing loss, age, gender, etc. The resulting correlations have revealed no especially predictive variables. If my clients did well on the Quick Test, the effort was to reinforce this ability by presenting the various visual sound groups. My hope was this would make them better listeners. Regarding motivation, if a client did well, it seemed to enhance his desire to really work at becoming good at total communication. Obviously, I believe that an individual who uses residual hearing and vision will do better than with vision alone. Some clinicians believe that persons will learn to lipread what they can without training. I guess I can say that with good amplification, additional listening training can be very helpful. So I think, in the final analysis, lipreading is an art, not a science.
Q: Self-study auditory training and speech-reading lessons such as Listening and Auditory Communication Enhancement (LACE) and Seeing and Hearing Speech have changed the process of AR services for many. Do you think these programs offer substantial benefit over individualized AR treatments?
I have no personal experience with self-study programs. It appears that many people have benefited from LACE. If an individual cannot have individualized or group sessions, then I believe that self-study may be helpful. Anything that will improve communication in the everyday world is good. I do not know if the program offers substantial benefit over individualized treatment.
In the ideal world, I would prefer the individual treatment supplemented by self-study. I think it would be ideal to have individualized AR, self-study, and instructional printed materials. I am a dreamer in which all of the above are paid for by health insurance. Finally, I am reminded of Carl Binnie, who years ago made the following prediction, "By the year 2000, computer-based instruction will assume a significant role in audiologic rehabilitation." He was correct!
ASHA resources on audiologic/aural rehabilitation are available online.