We Must Return to Our Rehabilitative Roots: Part II

Today’s post concludes last week’s discussion by Dr. Maurice H. Miller:

Uniting the Profession 

Audiology has unfortunately faltered since Alpiner and McCarthy{{1}}[[1]]Alpiner, J.G. & McCarthy, P.A. (2000). Rehabilitative Audiology: Children and Adults. Lippincott, Williams & Wilkins. [[1]] concluded, in 1973, that there was one common thread that should hold audiologists together: “Their practice and engagement in the aural rehabilitation process.”  Whatever else we do, “rehabilitation of individuals with hearing loss was and must be ‘the uniting goal of the profession.’”

The founders of the profession would have been amazed and disturbed if they had lived today to see how far we have strayed from our rehabilitation roots.

The decline of the initial emphasis on rehabilitation was also influenced by the lack of insurance coverage for such services when performed by audiologists, a situation that exists today under lack of medical reimbursement.

The Importance of Group Experience

Individual audiologic rehabilitation is essential, but it needs reinforcement and supplementation with group experience. The group experience is central since communication is a group activity involving interaction with another or, quite often, several others. But initial therapy must be performed on a one-to-one basis; the audiologic rehabilitationist must determine when the patient is ready for group interaction.

Civilian vs. Military audiology
Military Audiologists benefit from having a “captive audience.”

The audiologic rehabilitation clinics established by the military recognized this and led to development of “listening clinics” created to “place these people back into effective communication with their fellows and their environment.” The curriculum included 1) daily individual and group lip reading instruction, 2) counseling including personal, economic or domestic problems, and 3) maintenance of contacts with the patient’s family. In addition it bridged the gap between veterans’ facilities and those civilian agencies that would continue to provide any additional rehabilitation measures that might be needed.  The intensity and necessity of ongoing rehabilitative measures beyond the eight-week course is evidence of the degree to which rehabilitation measures were recognized and considered essential to the recovery process, even in the much younger population than we serve today.  That was in the 1940s, but as Alpiner and McCarthy (2000) stated six decades later: “Even a few hours of post-hearing aid fitting rehabilitation is rare.”

It must be noted that the above approach needs modification for a primarily aging population, but much of the 1940s approach is applicable. Lack of insurance coverage for rehabilitation was not the problem then that it is now, and much of the rehabilitative approach needs radical modification since the Veterans Administration population hardly lacked the motivation of the elderly population that challenges us today.

Motivating the elderly presents special challenges that require the most imaginative, dedicated and insightful audiologic practitioners in the profession.

The military and Veterans Administration clients were a “controlled population” whose schedule could be determined and managed by those in charge. True audiologic rehabilitation precedes, as well as accompanies and follows all aspects of the hearing aid fitting process. It must not be a casual recommendation (e.g., “Come by if you have a problem with your hearing aid or your hearing”), but rather an organized, scheduled set of visits usually over a period of months, especially with the elderly segments of our population.


Audiologists must rehabilitate or our future is uncertain and cast with enormous doubt. Long-term individual involvement with the hearing-impaired patient in a rehabilitative structure to which the audiologist is dedicated is essential. Without it, our future is uncertain. With it, there is enormous hope for our profession.

Maurice H. Miller
PhD (Columbia, 1956), is Professor Emeritus of Audiology, New York University Steinhardt School of Culture, Education and Human Development. Throughout his career, he has directed programs in Communication Disorders at some of the nation’s leading medical and academic institutions and spent over 40 years as the Chief Audiological Consultant to the New York City Department of Health. He is the author of five books, over 120 articles in peer-reviewed journals and numerous monographs and chapters in widely used audiology textbooks. Dr. Miller  was the second person to receive the Lifetime Career Award from the American Academy of Audiology.

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  1. Many persons with hearing loss who wear hearing aids report a loss of the quality and appreciation of the music they “hear”. It is an important element in the life of many of these individuals. We have much to learn about how music is appreciated, and research in this area of auditory processing is on-going. The first step in auditory rehabilitation must focus on heard language. This is essential in the case of the “cognitive healthy” elderly person with hearing loss. Attaining and integrating good “speech reading” and listening skills at this stage will be invaluable to them as they begin to experience cognitive decline which includes reduced attention span and memory.

    Dr. Miller’s papers serve as the opening salvo in the effort to re-awaken the audiologist to recognize that they have a responsibility not only to amplify the signal but to treat whole person whose quality of life has been disrupted by hearing loss. It is time to reach back to the basics of the profession, Auditory Rehabilitation plus amplification. Auditory rehabilitation must be viewed in the broad sense of how impaired audition impacts the total quality of life of the persons with hearing loss. Now more than ever Audiologists must fulfill their role as essential professionals in the study and treatment of communication disorders.


    Ronald S. Tikofsky,PhD,
    Adjunct Professor of Speech Pathology
    Teachers College, Columbia University

    Visiting Professor
    Brain Function Laboratory
    Department of Psychiatry
    Yale University School of Medicine

    Senior Lecturer
    Department of Radiology
    Columbia University Medical Center

  2. Dr. Murray Miller’s papers address a serious set of issues in the field of Communication Disorders and Audiology in particular. I believe that Dr. Miller is absolutely correct in his statements about the misplaced focus on “fitting” in current Audiology practice. Although I am not an Audiologist, but a Speech-Language Pathologist and neuroscientist, it is clear that auditory function is an integral part of the total communicative process. There is no doubt that the correct selection and fitting of a hearing aid or cochlear implant is a necessary step in the treatment of hearing loss, particularly in the aging population. However, it is only the first step and needs to be followed by “Auditory Rehabilitation”. Treating the hearing impaired is not simply the proper adjustment of intensity at the appropriate frequencies and programming the hearing aid or implant. Audition is a complex cognitive process, and the intensity of the speech signal is but a small part of the process. Audition is a complex cognitive process, and the intensity of the speech signal is but a small part of the process.

    Dr. Miller, and I have often discussed these issues. It is clear to us that persons with hearing impairments suffer from a loss of the appreciation of the quality of spoken speech and music. Such “secondary” or “collateral” impairments have a negative effect on the individuals’ quality of life. Even with good amplification and sophisticated programming, many elderly and not so elderly persons still miss parts of the auditory signal in the absence of having acquired or be taught good listening and speech reading skills.

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