This article first appeared in the IFHOH Journal (1995)
All of us have had the experience of suggesting to a friend or relative that he or she get a hearing aid, only to be told that it was not necessary since he/she could “hear all right”–this comment being made during the course of a conversation in which shouting was the only way to communicate. It is a frustrating experience for all concerned, much more so for the person with the hearing loss. Why, then, do people react this way so frequently? Why is it that only about twenty percent of potential adult hearing aid candidates actually use one? How can the clear evidence of a hearing loss be so continually and, sometimes, so argumentatively denied by affected persons?
In my opinion, denying or minimizing the existence of a hearing loss is the most significant aural rehabilitation challenge currently faced by hearing care professionals. There is no way to help those who disclaim the severity or presence of a hearing loss; to them recent developments in hearing technology and public law are irrelevant. These people will not accept a hearing aid, other types of hearing assistance devices, or any kind of aural rehabilitation program if they deny the existence of a hearing problem. Everybody, lay person and professional alike, has explanations for this problem. And all are probably correct to some degree for some people. Probably there is no single reason, but rather a different combination of possible ones for every hard of hearing adult who rejects auditory assistance. In this article, I would like to explore a few of the reasons I think are most pertinent.
Association with Age
As people get older, they begin to lose some of their sensory and physical capabilities. The sense of hearing is among those which show a gradual deterioration with age. Indeed, one of the stereotypes of older people portrays them as having difficulty hearing, perhaps with their hands behind their ears, saying “Eh?” in a high-pitched, querulous voice. A hearing loss doesn’t happen because we have been “bad” people or guilty of abusing our bodies in any way (though this can cause an additional hearing loss). It is a natural occurrence; on the positive side, it means we have lived long enough for it to happen. Many years ago presbycusis happened less often, simply because fewer people lived long enough for the process to begin.
Our culture is obsessed with youth and the youthful image. To be young is to be beautiful, mentally alert, vigorous, sexy, and able to participate fully in the pleasures of life. Aging, on the other hand, is associated with the converse of these faculties. In our society, it implies that one is mentally and physically desiccated, confused, fearful and dependent, and that the end of the road is imminent. No wonder we spend fortunes on cosmetics, plastic surgery, etc., trying to deny and camouflage the natural concomitants of age, the goal being to look as if we were recently dipped in a fountain of youth. I know of people well into their 70s and 80s who reject a hearing aid because they say it would make them look too old! What they really mean is that the hearing aid may force them to acknowledge the reality of the aging process. Other cultures value age and the wisdom of experience; we disparage and mock it, viewing it as a weakness, a personal misfortune. Trying to remain vigorous and attractive is one thing; denying reality is something else again. For many people, therefore, a hearing aid is an unwelcome reminder of the aging process, one that they simply cannot accept. They will go to almost any length, and sometimes they do, to deny a hearing loss, to themselves and to other people. These are the people for whom the most blatant cosmetic appeal (“The aid is so small that no one can see it”) falls on “deaf” ears; it is not the size of the hearing aid, but the acknowledgment of a hearing loss that is unacceptable.
The pity of this attitude, of course, is that while they can refuse to wear a hearing aid or use any other acoustic prosthesis (such as an infrared listening device in the theater), they cannot disguise the communicative consequences of a hearing loss. They still miss and misunderstand much everyday conversation; their social and cultural activities gradually diminish; and their lives become more and more constricted. Their attitude is self-defeating: In trying to deny the reality of a hearing loss, because of its association with aging, their conversational partners may ascribe their confused communicative behavior to senility–a condition most certainly associated with aging. Hearing aids, or
other assistive listening devices, will not restore youth or normal hearing, but they do signify that the existence of a hearing problem has been acknowledged, that the person is determined to do what is necessary to help himself or herself. This simple acknowledgment is the crucial first step in successfully coping with a hearing loss.
Association with a New Challenge
For many other older people, the reluctance to use a hearing aid does not really signify a denial of the aging process. They recognize what their face in the mirror is telling them. What prevents them from wearing a hearing aid is that it represents change. It means learning and adapting to something different–in this case, how to use and insert a miniature but sophisticated electronic device. Change is the key word. As we get older, we do get more set in our ways; learning new material does require that extra motivation, that extra push; it is more comfortable to stay in the rut, with tomorrow being much like today. Audiologists often hear comments reflecting this attitude from clients (usually, though not always, the older ones): “I can’t be bothered,” “It’s so complicated,” “I’m an old lady (man) now,” and so on.
It is difficult and we should not underestimate the effort and re-orientation that takes place when an older person decides to wear a hearing aid. It means that he or she is determined to rejoin the larger society to some extent. It implies a modification of a restrictive and unsatisfying, but adaptive, life-style that has evolved over the years. It means, in effect, the affirmation of life, instead of passively waiting for the inevitable end. It means new learning and exercising one’s brain cells, perhaps the most difficult chore there is (and not just for the older person!).
There is no magic formula that I know of to convince someone who is older to accept the challenge inherent in wearing a hearing aid. Perhaps by conveying the belief that he or she is valued and is of value, we can provide the motivation for the initial effort. Follow-up procedures are important for any one during the critical initial adjustment period, but particularly so for the first-time hearing aid user who is older. They need to know that someone will be there, to help them over the rough spots, and to answer their questions patiently and with sensitivity. Yes, it is difficult for an many older people to accept use of a hearing aid, but this fact does not relieve us of the responsibility to make the attempt.
Association with Disability
We know from psychological research that people with disabilities have traditionally carried an aversive and negative image in most societies. A hearing impairment is a disability, one that is often associated with an entire cluster of unfavorable characteristics, such as dementia, strangeness, feebleminded, “dumbness” and so on. Hard of hearing people who were born with normal hearing are likely to reflect society’s prevalent attitude toward disability. If they do, denial of their own hearing loss is understandable; they simply cannot reconcile the prejudices and attitudes they grew up with and their own current status. How can they now perceive themselves as part of a group they used to disparage, that they thought were strange? How can they now think of themselves as one of the “others,” the outsiders of society? It is easier to deny the hearing loss than confront themselves.
Of course, as mentioned above, this denial eventually becomes an exercise in futility. The effects of the hearing loss cannot be hidden and the attempts to do so soon become counterproductive and essentially irrational. The irony of the situation is that by not helping themselves, the “deniers” become even more disabled in their functioning and reputation, thus exacerbating the very situation they were trying to avoid.
The Cosmetic Focus
It is clear, then, that without a change in public attitudes toward hearing impairment, our success in convincing people to acknowledge their hearing loss is always going to be limited. People with hearing losses are part of the larger public, with attitudes toward disability in general, and hearing-impairment in particular, that basically reflect the values of their society. What we need are more public educational programs regarding hearing loss and what can be done to alter its communicative and psychosocial consequences. In an era when sophisticated advertising in our media can “sell” anything from products to politicians, it should not be too difficult to minimize the denial phenomenon and the
stigma associated with hearing aid usage. Unfortunately, it seems that much of the efforts of the hearing aid industry in this regard are basically counterproductive and schizophrenic.
For at least forty years that I know of, we have been getting mixed messages from the hearing aid industry. On the one hand, much of its advertising emphasizes the advantages of hearing aid usage in improving communication capabilities. On the other hand, different advertisements stress the miniature size of their hearing aids, or the fact that “no one need know you are wearing one.” (Forty years ago, hearing aid companies advertised that they would send an inquirer information about their products in a plain brown envelope!). The more the industry focuses on cosmetics, on the fact that a hearing aid can be hidden, the more powerful the subliminal message that a hearing loss is a condition that should be hidden. I am convinced that for every person who succumbs to the cosmetic appeal and who purchases and wears an “invisible” hearing aid, there are several others whose feelings of shame and reluctance to acknowledge a hearing loss are being reinforced. At the least, the industry is perpetuating stereotypes it has an interest in changing, which is why I call many of its efforts counter-productive and schizophrenic. The professional community bears its share of responsibility for this situation. I know audiologists who would never think of recommending a large hearing aid, even if it embodies some desirable features (such as a telecoil). They assume that their clients share the public perception that a smaller, less visible hearing aid, is more likely to be worn ( or purchased, an important consideration in a dispensing practice). Of course people have a right to select any size hearing aid they want, but they also have a right to be informed about different alternatives and the relative advantages and disadvantages of each. Some consumers will select function as their primary criterion in a hearing aid.
It is this group that can help change public attitudes toward hearing loss. Simply by selecting hearing aids based on function and not cosmetics, by using visible assistive devices (such as infra-red receivers in a theater), these people convey the message that a hearing loss is not a personal disgrace which must be camouflaged at all cost. Their lives demonstrate that they are not diminished in stature, in self-esteem or the esteem of their community, by virtue of their hearing loss. In the long run, it will be the example of those who publicly acknowledge their hearing loss when necessary, and not as an end in itself that will make the greatest difference in public acceptance.
Hearing aids are expensive. Two are almost twice as expensive as one. Unlike computers and other electronic gadgets, their absolute cost is increasing year by year. New hybrid, programmable hearing aids may cost $2,000 each. This is not a negligible consideration, no matter how much dispensers may minimize its effect to the prospective hearing aid user. The evidence from a number of surveys points to the expense of a hearing aid as a significant, though not necessarily a determining, factor in the purchase of a hearing aid. Cost will be a more significant factor in the acceptance of a binaural hearing aid fitting. Because of the additional expense, some people will opt for one hearing aid, although audiologically there may be a clear listening advantage for two.
There’s not much we can do about the cost of hearing aids. They are expensive and are likely to remain so for the foreseeable future. What has to be communicated to prospective users is the life-changing possibilities of improved hearing, so they can weigh that value against the financial expense. Ensuring the availability of a supervised trial program can help consumers make this kind of decision. Eventually, perhaps, public and private health insurance programs will cover the cost of hearing aids and thus reduce the total burden for individuals.
Everybody, it seems, has a friend or a relative who has had an unsuccessful experience with hearing aids, and is quite vocal about it. Many of these people, and there are too many of them, discourage potential hearing aid candidates from trying one, since they “know” that hearing aids are useless. Their attitude plays right into the usual reluctance to accept amplification. We should keep in mind, however, the fact that the “failures” would not have tried a hearing aid in the first place if they did not have an evident hearing problem (to their family and friends, if not to them). It is quite possible that they were ill-fit or poorly counseled, and this happens all too often, but it is also possible that they went into the hearing aid experience with high and unrealistic expectations. If one expects too much, one is sure to be disappointed. A hearing aid will not restore normal hearing. Sometimes it seems that a new user, after fighting the necessity of wearing a hearing aid for years, expects that his or her new aid will completely solve all previous listening problems. A hearing aid does not work that way. It is an aid, not an ear replacement. When listening difficulties still occur, when one’s own voice sounds strange and “stuffy,” when one is suddenly aware of a world of strange noises, when some loud sounds actually cause pain and discomfort, it is easy to get discouraged and discard the hearing aid. Many of these problems can be ameliorated with audiological assistance; some take time to get used to, but can be lived with; and other problems will remain. The point is that one must enter into the hearing aid experience with realistic expectations. Does the aid offer sufficient listening advantages in important communicative situation? Perhaps there are just one or two such situations, but if these are crucial then the hearing aid is necessary. Hearing aids are too expensive, and too potentially helpful, to be placed in dresser drawers rather than in people’s ears.
The statistics of hearing loss indicate that only twenty percent of adults who could be helped with a hearing aid actually wear one. This figure reveals our most significant aural rehabilitation challenge. If people do not acknowledge that they have a hearing loss, there is no way to help them. All the recent developments in assistive listening devices are useless if people will not wear them. Clinical programs in aural rehabilitation cannot be executed if people do not take advantage of them. People with hearing loss are part of the wider society. Public attitudes toward hearing loss must be made more accepting, if significant increases in hearing aid use are to occur in the future.
The preparation of this paper was supported in part by Grant #H133E80019 from The National Institute on Disability and Rehabilitation Research