Changes in several domains over the last decade have had a profound effect on how we conceive, organize, provide, and evaluate audiologic rehabilitation (AR) services. Tremendous advances in hearing instrument technologies have made it possible to include digital components of amplification systems in commercial devices that are readily accessible to individuals with hearing loss. Notwithstanding these developments, the hearing aid industry is very aware that services provided to people with hearing loss must extend beyond the fitting of amplification systems. Hearing aid fitting must be accompanied by patient education, counseling, and other non-technological AR services.
Three innovative components of AR are having a dramatic impact on the services provided to adults with hearing loss:
- The World Health Organization's (WHO) International Classification of Functioning, Disability and Health (ICF).
- A client-centered approach to rehabilitation treatment.
- A problem-solving approach to AR and goal setting.
When these three aspects of AR are integrated into a comprehensive and cohesive package, the result is a dramatic shift in how AR services are provided to adults of all ages with hearing loss.
The ICF: A Conceptual Framework
The ICF is considered a biopsychosocial approach to health in that it accounts for health issues that occur not only at the level of the body (body structures and functions) but also at the levels of the person (activities that individuals perform) and society (the individual involved in life situations that involve other people). The ICF (WHO, 2001) and its nomenclature have been adopted by more than 190 countries and its principles have been incorporated by all disciplines of health rehabilitation.
ASHA incorporated the ICF into its Scope of Practice in Audiology in 2003. The model is particularly well-suited as a conceptual framework for health conditions in which a disease/ailment/disorder is chronic and thus, by definition, involves impaired body structures or functions that cannot be returned to normalcy. For example, sensorineural hearing loss constitutes a chronic health condition for which no known treatment can restore normal hearing function. Consequently, at least one aspect of a treatment program for people with a permanent hearing loss should be the provision of AR services that will allow an individual to eliminate or minimize the activity limitations and participation restrictions associated with the disorder.
The main elements of the ICF are displayed in Figure 1 [PDF] (for a more detailed discussion of this conceptual framework and its application to AR, see Gagné & Jennings, 2008; Gagné, Jennings, & Southall, 2009). The classification system has two domains. One domain incorporates aspects of functioning and disability and includes body functions and body structures as well as activities and participation. The other domain includes contextual—environmental and personal—factors. According to the ICF, an individual's state of health is determined by the dimensions of functioning and disability and is influenced by how these dimensions interact with one another. Clinical applications of the ICF combine activities and participation into one domain. The schematic representation of the model indicates that the dimensions of health (body functions/structures and activities/participation) may influence one another. The model also indicates that contextual factors (environmental and personal factors) may influence or be influenced by those dimensions of health.
Several authors have discussed how the ICF can be applied clinically (e.g., Gagné, Jennings, & Southall, 2009; Smiley, Threats, Mowry, & Peterson, 2005; Worrall & Hickson, 2003). Gagné et al. (2009) discussed several advantages of using the ICF as a conceptual framework for AR. One of the pertinent advantages is that the ICF provides a functional description of the difficulties experienced by individuals with hearing loss, all of which can be described as an activity limitation/participation restriction that occurs within a specific physical, social, or attitudinal environment. For example, Mrs. Smith (see the case study online), who has a sensorineural hearing loss (i.e., an impairment at the level of body structures and functions), reported difficulties conversing with her granddaughter (an activity limitation/participation restriction) because the little girl has a tendency to speak softly and does not always look at her grandmother when she speaks.
Using ICF nomenclature, AR may be defined as intervention procedures designed "to restore or
optimize participation in activities considered limitative by persons with hearing loss or by other individuals who partake in activities that include persons with hearing impairment" (see Gagné, Jennings, & Southall, 2009, pp. 49–50). Moreover, adapting the ICF as a conceptual framework will naturally lead to an intervention approach that is client-centered and based on goal-setting and problem-solving. In the case example, Mrs. Smith's rehabilitation program should include the identification and application of solutions that will allow her to overcome the specific activity limitations/participation restrictions that she reported to the audiologist (difficulty communicating with her granddaughter).
As indicated, using the ICF as a conceptual framework for AR leads to a functional approach based on identifying and setting specific goals and applying solutions that will overcome (or minimize or alleviate) the client's difficulties. An approach to AR based on the ICF leads naturally to the application of two other principles of intervention that can be incorporated into a contemporary AR service delivery model: the use of an approach that is focused on the client's needs and involves the application of a systematic problem-solving approach to AR and goal-setting.
Adopting a Client-Centered Practice
The use of the term "client-centered practice" began with Carl Rogers (1939), who described a nondirective therapeutic approach that focused on creating an atmosphere within which the client was inclined toward positive growth and realizing his or her potential. Rogers believed that people receiving services are capable of playing an active role in defining and solving their problems. This approach differs considerably from more traditional medical (curative) approaches to health in which the diagnosis of the disease or disorder is made and the treatment regimen prescribed solely by the professional. In medical models of health, the expert is the treating professional and the decision-making process is unidirectional and non-consultative.
A client-centered approach can be incorporated naturally into a biopsychosocial model of health and is particularly well-suited for the type of rehabilitative health services required by people with chronic health conditions (Erdman, 2009; Laplante-Levesque, Hickson, & Worrall, 2010a, 2010b). According to Erdman (2009), in psychiatry, Engel (1977) was among the first to integrate a client-centered approach into a biopsychosocial model of health. Over the years, several forms of treatment have claimed to be based on a client-centered approach. Consequently, a wide spectrum of services has fallen under the umbrella of what is considered "client-centeredness."
In its most simple form, a client-centered approach actively involves the client in every decision concerning treatment. In reality, the level of client involvement and the considerations given to the client's expressed social and psychological needs can vary considerably as a function of the professional who provides the services. Table 1 [PDF] provides a list of the characteristics typically associated with client-centered approaches to health that have been used in different disciplines of rehabilitation.
Beyond the therapeutic acts implied by the term "client-centered," the underlying philosophy of the approach, the attitude of the professional, the level of involvement of the client, and the counseling approach used distinguish a client-centered approach from the more traditional professional-driven rehabilitation approaches. Several authors have discussed the application of a client-centered approach to AR (Clark, 2007; Erdman, et al., 1994; Laplante-Levesque et al., 2010a).
Counseling is at the heart of rehabilitation programs based on a client-centered approach and is used to establish trust between the client and the professional. It is the tool used to define the goals of the treatment services as well as to establish the course of action throughout the intervention program. Counseling promotes the client's self-confidence and self-efficacy.
The cornerstone of client-centered intervention programs is eliciting the client's narrative, the story the clients tell when asked to talk about themselves and their hearing loss. When solicited in a non-directive way (usually an open-ended question, such as "Tell me about your hearing loss," "What brought you to consult an audiologist?" or "What made you decide to get an appointment with an audiologist?"), and when the client is given all the time needed to reply honestly and thoughtfully, the information obtained during the interview becomes a critical juncture of the intervention program.
The narrative provides factual information about the health condition (e.g., "I noticed that I have difficulty understanding my granddaughter when she comes to visit, especially when she does not look at me directly when she speaks"). It also reveals information about the client's psychological state and psychosocial responses to the disability (e.g., "I don't think my hearing difficulties are that bad. Unlike Clarice, I don't feel that I have to wear my hearing aids at the book club. People talk to her as if she was a senile old lady who is always out of it, in outer space somewhere! I don't want my friends to think of me in the same way"). The narrative provides the professional a comprehensive understanding of the client's own view of the hearing loss, and thus a cognitive and affective understanding of the client's experience. Seabum (2005) reported that when clinicians listen attentively to patients' stories, the biopsychosocial model becomes evident. Many clinicians find it difficult to refrain from interrupting—but the key is for the clinician to listen attentively to the client (taken from Erdman, 2009, p. 176).
In addition to supporting the clinician's empathetic relationship with the client, the narrative helps to identify and set the goals of the intervention program. It becomes the clinician's starting point from which to explore possible treatment options. The emerging partnership between the client and the professional makes it possible for the client to participate fully in choosing the treatment program and eventually to explore the outcome, the effects, and the consequences of the intervention program.
Several studies have shown that a client-centered approach to health care is associated with reduced client psychological distress and improved functional status (Adams & Drake, 2006; Mead & Bower, 2000; Stewart & Brown, 2001). Further, studies indicate that a client-centered approach to treatment is associated with positive psychosocial outcomes, enhanced adherence to treatment regimen, and greater client satisfaction than services emanating from traditional biomedical models of health (Erdman, 2009).
Focus on Solutions
Several authors have proposed the adoption of a problem-solving approach to AR (Gagné & Jennings, 2008; Hickson, Worrall, & Scarinci, 2007; Trychin, 1997). Gagné and Jennings (2008) have defined the sequence of steps typically included in a problem-solving approach to AR (see Table 2 [PDF]). Specifically, a problem-solving process begins with the recognition that a problem/difficulty exists. To set an appropriate AR goal, the problematic activity must be clearly identified and described. This information, as well as all the domains of the ICF (body structures and functions, activity limitations/participation restrictions, environmental factors, and personal factors), should be considered in setting specific rehabilitative goals (i.e., to hear the granddaughter when she visits). The possible solution(s) selected to attain the goal should be based on the desired outcome (i.e., what solutions, acceptable to the client, are the most likely attain a specific goal?). Rehabilitation services may incorporate intervention strategies and activities that will enable the client (and perhaps others involved in the defined activity limitation/participation restriction) to attain the goal.
For example, one AR goal identified for Mrs. Smith was to improve her ability to communicate with her granddaughter. Clinician and client decided that Mrs. Smith would apply two solutions over the course of the following month to reach this goal:
- Request that her granddaughter face Mrs. Smith when speaking.
- Use her hearing aids during the visits.
Because Mrs. Smith found it difficult to remind her granddaughter to face her, client and clinician decided that she would enroll in a group AR program that incorporated self-efficacy training exercises (Jennings, 2005). Both the audiologist and Mrs. Smith ascertained that this type of AR would help Mrs. Smith learn to use assertive strategies appropriately and would increase her self-efficacy, thus increasing the likelihood that she would apply this strategy with her granddaughter.
A comprehensive problem-solving process involves assessing the outcome of the AR services (i.e., whether or not the goal was achieved). Moreover, it should include identifying any impacts or consequences that result from applying the solution as well as identifying factors that facilitated or constituted an obstacle to implementing the solutions retained. In the case example, it is likely that the use of assertive strategies would constitute a good solution for attaining the desired goal, but a possible obstacle to implementing this strategy was Mrs. Smith's disclosure of her hearing loss to her granddaughter. The self-stigma associated with hearing loss (see Gagné, Jennings, & Southall, 2009) may have constituted an obstacle to implementing this solution.
Using a goal-setting approach based on the ICF as a conceptual framework for AR, combined with a problem-solving approach to AR, requires the active participation of the client. However, the client is uniquely qualified to identify and describe activity limitations and participation restrictions; decide whether to accept, try, and adopt a possible solution; determine whether or not the goal was attained; identify impacts and obstacles; and determine any factors that impeded or facilitated the application of the solution. Actively involving clients in their rehabilitation programs will result in setting goals that are important to the client and increase the likelihood that the client will apply the identified strategies. These attitudes and behaviors are satisfying and they lead to empowerment and personal growth (Pope & Stika, 2009).
Benefits of the Biopsychosocial Model
Medical (curative) models of health (biomedical approaches) that focus on restoring one's health to normalcy do not apply to people with chronic impairments. People with a permanent hearing loss have an impairment before they consult hearing health care professionals. Moreover, regardless of the quality of the services provided, the hearing loss will remain after the intervention program is completed. The goal of rehabilitation services is to help people minimize the effects of their impairment at the personal, psychological, and social level—that is, to minimize or eliminate important activity limitations and participation restrictions that are due to the hearing loss. Services also should seek to allow the client to (re)establish a state of psychological well-being and a positive social image, including self-esteem and self-efficacy.
Biopsychosocial models of health, such as the ICF, provide a rehabilitation framework for people who seek to overcome the effects of their impairments. A problem-solving and goal-setting approach to rehabilitation has been applied successfully to overcome the activity limitations and participation restrictions reported by individuals with hearing loss (Jennings, 2009; Hickson, Worrall, & Scarinci, 2007; Trychin, 1997). In other disciplines, client-centered intervention programs have been successfully incorporated into treatment programs based on biopsychosocial models of health for more than 60 years (Rogers, 1951). Client-centeredness enables the client to play an active role in every component of the treatment program. Studies have shown that individualized client-centered approaches are efficacious in overcoming the activity limitations and participation restrictions reported by clients with hearing loss (Laplante-Levesque et al., 2010b). Moreover, studies have shown that when a client-centered approach is used to engage clients in their own rehabilitation program, they report improvements in their psychological and psychosocial well-being as well as satisfaction with the services received (see Erdman, 2009).
For many hearing health care professionals, this three-pronged treatment approach will require a major shift in the type of services they provide to their clients. Moreover, it is likely that this approach to rehabilitation calls upon professional associations and graduate training programs to offer course work and clinical placements that will train future audiologists to provide AR services based on these principles.