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A brief treatise on the service of aural rehabilitation

Hull, Raymond H. PhD

doi: 10.1097/01.HJ.0000396583.74988.c2

Raymond H. Hull, PhD, is Professor of Communication Sciences and Disorders and Audiology/Neurosciences Coordinator of the Doctor of Audiology Program in the School of Health Sciences at Wichita State University. Readers may contact Dr. Hull at



Aural rehabilitation (AR), in a traditional sense, comprises a rather vague set of principles that collectively encompass a wide range of restorative services that are provided on behalf of persons whose ability to communicate has been compromised as a result of impaired hearing.

The term principles is used in this discussion since principles, per se, are generally characterized by sets of assumptions that emerge out of an entity or process for which they were designed. As one observes aural rehabilitation in a historic sense, the above is correct, since it seems that there are about as many theories as to what aural rehabilitation is as to what it is not, and as many models as there are persons who provide the service. Interestingly enough, as a result of a survey my colleague and I conducted two years ago, audiologists have not even reached consensus on what the process of aural rehabilitation should be called.

On the other hand, no single element, or several elements together in a single system of services, can capture the full essence of what aural rehabilitation involves. Since every patient seen for aural rehabilitation services is different, with various communicative/interactive/hearing needs, in order for the services to be effective, they must also differ accordingly in order to address patients' specific needs.

It has struck me with interest over the years that although the above is generally accepted to be true, some audiologists who provide aural rehabilitative services still tend to include the same services for all of their patients. Perhaps it is a result of a lack of time, or perhaps a lack of interest.

I've also observed that services provided in that manner are often only reluctantly accepted by patients, and may not be viewed by them as constructive. The reason? They are not designed to address their specific hearing/communicative needs. Rather, the services are designed to address the needs of persons with a hearing impairment in general. Others may provide hearing aid orientation in the name of aural rehabilitation, but little beyond that.

My purpose here is to stress that audiologists must move beyond what we have traditionally used in the name of “aural rehabilitation,” to view the process as an individualized personal/professional system of restorative services that address the specific needs of each patient. It can involve a single, rather brief one-on-one session on resolving a particularly difficult listening situation that the patient finds him or herself in fairly frequently, or it may involve a series of regularly scheduled sessions that center on counseling regarding the uses of hearing aids and an understanding of the nature of hearing loss and its impact on communication.

Clinical psychologists, physicians, occupational therapists, dentists, rehabilitation counselors, and other health and human services professionals address the specific complaints or needs of their patients by requesting information from them that, in turn, guide the goals and the procedures of their services. Their patients are, therefore, served as individuals who come to them with very specific needs.

Viewing patients who possess impaired hearing as simply patients who possess impaired hearing does not make sense. They are patients who come to the audiologist with specific hearing/communicative difficulties within their individual communicative environments, with specific persons with whom they desire to communicate, or in specific situations in which they desire to communicate, or in which communication is required.

The patient interview that guides these services does not necessarily mean using the numerous scales and questionnaires that are available, that sometimes take more time to administer than we have available to us. It does mean, however, that it is critical to ask our patients a single important question, “What can I do for you?” Once the patient has answered that question, then the audiologist can request specifics regarding the difficulties the patient is experiencing and move on from there to the services that will be provided. It is the same simple question my physician and dentist asks me when I go to see them.

The following are eight proposed principles that can guide the planning and execution of aural rehabilitation programs for our adult patients. Some are not new; others are important features that have guided me and other practicing audiologists over the years in our delivery of aural rehabilitation services. They are:

1. Aural rehabilitation treatment must always address the specific needs of the patient. In observing more traditional approaches to aural rehabilitation services over the years, this principle has gained even greater importance. What it means is that if a patient is having difficulty communicating in a specific environment or with a specific person, then it is critical that the audiologist work with him or her to develop strategies that are specific to that situation. In working to resolve that difficulty, the strategies developed will tend to generalize to other situations as the patient develops the resolve, self-confidence, and plan of action originally sought.

2. Among older patients with presbycusis, both peripheral and central auditory involvement should be addressed as those symptoms manifest themselves.

This principle goes beyond considerations that involve the selection and fitting of hearing aids and other preliminary aspects of the aural rehabilitation service. This aspect involves not only the development of listening strategies that accommodate the peripheral and central nervous system aspects of auditory decline in advancing age, but also includes strategies of environmental design and the speech habits of those with whom the patient frequently communicates, all enhancing speech understanding in spite of the complexities of the aging auditory system.

Services that involve enhancement of cognitive function that can otherwise impair auditory/linguistic processing in communication can also be incorporated, including strategies for improved analysis and synthesis of auditory/linguistic information, increasing speed and efficiency of auditory processing, increased auditory vigilance, and accuracy of attending behaviors, and auditory sorting behaviors, among others.

These strategies are similar to those provided on behalf of returning veterans who have sustained concussions or other close head injuries with accompanying central nervous system auditory dysfunction, but are modified to accommodate older adults with aging auditory systems.

3. Both individual and group therapy programs should be available to patients.

The one-on-one patient-therapist model is only one approach and should not be the only one considered. If formal aural rehabilitation services are offered, a group therapy setting that provides opportunities for group discussion of hearing difficulties is important for consideration. They can be powerful sessions. Group services permit the patient to discuss with peers their hearing and communication problems which also may be common to others in the group. However, group services are not suitable for everyone. Each patient must be evaluated as to his or her potential for successful entry into a group environment.

Some patients should begin treatment on an individual basis before joining group sessions either because the difficulties they are experiencing in communication may contraindicate the ability to interact in a group environment, or the specific communicative situations in which they are experiencing difficulty are not conducive to group discussion.

On the other hand, group therapy can be a very powerful tool for the development of a more positive attitude regarding hearing impairment since members of the group can truthfully say, “Yes—I have also experienced that situation,” and offer suggestions on what worked for them.

4. Counseling is essential to the effectiveness of the therapy relationship.

Counseling is one of the most important activities involved in aural rehabilitation. Audiologists are becoming more aware of this, and more audiology preparatory programs are including formal courses and practicum in counseling as part of their curriculum.

It is critical that major attention and effort be directed toward developing counseling skills in both future professionals and practicing audiologists so that they can become effective listeners, providers of constructive support, facilitators in problem-solving, instillers of confidence, and a catalyst in the development of constructive strategies to resolve difficult listening/communicative environments. If an audiologist is not a good counselor, he or she may want to consider questioning their reason for entering the field.

5. Environmental design is an important component of AR services.

Coaching the patient to stage-manage communication events and environments to maximize the probability of successful participation can be a tangible and rewarding aspect of aural rehabilitation.

Teaching the patient to increase his or her listening advantage by rearranging furniture, reducing echoes, reducing background noise levels, decreasing the distance from the talker, optimizing lighting for enhanced listening, requesting that the talker speak with greater clarity and/or to use the microphone as it has been designed to be used, and even manipulating the actual design of an environment to one's communicative advantage is an important part of aural rehabilitation. Those presented are only a few examples of areas in which the patient can become a positive catalyst in improving otherwise difficult communicative environments.

6. Patients should be encouraged to establish and maintain a balance between assertiveness and submissiveness when working to change environments and speakers to their listening advantage.

In other words, it is important to encourage patients to be realistic regarding their expectations as to the changes they can make both in regard to the listening environment and those to whom they are listening.

On the other hand, encouraging patients to become assertive in making changes without being overly aggressive can be an important therapy objective, and should be a goal in patient counseling. But acceptance of realistic expectations relative to communicative environments and those with whom communication is to take place should also be addressed. Not every communicative environment, nor can all speakers be changed to the listener's listening advantage. Likewise, not all speakers can be taught how to effectively communicate.

Few of us, even those with normal hearing, can claim successful communication with all persons with whom we come in contact, nor in all places. Patients may be assuming too much personal responsibility for specific communication failures and can be helped to become realistic about their possibilities for change. As I tell my patients, we live in a world filled with poor speakers and places that are not designed for communication. Sometimes we must accept that fact.

7. Improving the speech habits of significant others in the life of the patient can be a positive element in aural rehabilitation treatment.

It seems that clinicians too often concentrate exclusively upon the patient, with little or no attention given to significant others who are important aspects of the patient's communicative environment, other than helping them to understand the nature of their family member's hearing impairment.

General improvement and refinement in speech production and vocal expressiveness of those individuals, including a decrease in the speed of their speech utterances and clearer enunciation that accompanies reduced speed of speech without “over-enunciation” can reduce the patient's difficulties as much as, if not more than, some activities that are directed only to the patient.

This can be an extremely powerful part of therapy. However, diplomacy is a critical factor here. Providing instruction on speech production to a patient's spouse, children, and other significant others in a sensitive manner can be an extremely positive addition to aural rehabilitation treatment.

Occasionally, I am asked to work with local news broadcasters, ministers, and public speakers to improve their manner of speech on behalf of persons with impaired hearing. Once I worked with a network television news broadcaster whose speech was timed at well over 200 words per minute (WPM) during his news broadcasts, when the normal speed of speech using American English is around 145-150 WPM. That speed of articulation was prohibiting many viewers from understanding what he was saying, including of course those with impaired hearing since at that speed, only parts of words are being uttered and sentences take on the acoustic characteristics of a single long word.

To improve the understandability of his speech, I worked with him to reduce the speed of his speech utterances to a more normal rate, which in turn improved the clarity of his speech. As those services ensued, I asked my patients to watch the news broadcasts to determine if speech intelligibility was improving. The results were positive. In this way, both the viewers with impaired auditory function and the news broadcaster benefitted from the service.

8. Improved cardiovascular health may become a new avenue for aural rehabilitation.

Cardiovascular health in adults, including elderly adults, has been found to be a catalyst in enhancing both peripheral and central auditory function.

Numerous studies have been conducted over the past five decades that have demonstrated the synergism between even moderate forms of exercise and improvements in cardiovascular health and its positive impact on auditory function even in very elderly adults who had previously led sedentary lives. Just walking appears to positively impact not only peripheral and central function, but also cognition, including decision making, speed of auditory processing, and comprehension. I am not suggesting that audiologists also become trained as exercise physiologists, but to become aware of the relationship. Leading a sedentary life does not enhance central auditory function.

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If audiologists are going to reach a consensus as to what the process of aural rehabilitation involves, we must include in that consensus, addressing the specific auditory/communicative needs of individual patients. Effective treatment services by audiologists require strategies that address problems in hearing and communication that are specific to their patients' own important communicative environments and those with whom they communicate.

Above all, whatever the assessed needs of our patients, audiologists must be insightful and flexible in offering services that are meaningful to the patient in order for our services to be beneficial and an avenue toward rehabilitation as a restorative service.

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1. Bode DL, Tweedie D: Improving communication through aural rehabilitation. In Hull, RH, ed., Rehabilitative Audiology. New York: Grune and Stratton, 1982.
    2. Hull RH: Improving communication for aging adults who are hearing impaired. In Hull, RH, ed., Hearing in Aging. San Diego: Singular Publishing Group, 1997.
      3. Hull RH: Introduction to aural rehabilitation for adults: History, theory and application. In Hull, RH, ed., Aural Rehabilitation: Serving Children and Adults. New York: Delmar/Thomson Learning, 2001.
        4. Hull RH: Fourteen principles for providing effective aural rehabilitation. Hear J 2005;58(2): 28-30.
        5. Hull RH: Techniques of aural rehabilitation for older adults with impaired hearing. In Hull, R.H. (Ed.) Introduction to aural rehabilitation. San Diego: Plural Publishing, 2009.
          6. Hull RH, Kerschen, SR: The influence of cardiovascular health on peripheral and central auditory function in adults: A research review. Am J Audiol 2010;19(1):9-16.
          7. Hull RH, Silveira K: Aural rehabilitation: What's in a name? Presentation at AudiologyNOW! April 2, 2009.
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