The experience of hearing loss is different for everyone. Speech-language pathologists and audiologists need to have a good grasp of both the physical—and psychological—realities of hearing loss. Hearing loss makes communication with the outside world difficult, and an individual’s personality affects adaptation of hearing loss. A psychologist and psychiatrist, both hard-of-hearing themselves, bring an inside view to some of the potential psychological effects of hearing loss and the ways that clinicians can address them.
No two people have the same reaction to life circumstances. Hearing loss can induce observable psychological effects at various points in development. The potential psychological effects of hearing loss are different for children and adults, and an individual’s personality affects adaptation to hearing loss and cochlear implants. In general, hearing loss makes interaction with the outside world difficult. Having a hearing loss has been described as an invisible handicap, especially in the social realm. In fact, Helen Keller once said that deafness cuts one off from people, whereas blindness cuts one off from things.
Hearing Loss in Children
Hearing loss is challenging at any age, but it poses unique issues for the young child. Having a hearing loss does not mean a child will develop psychological problems, just as a child from a family of divorce may or may not have emotional difficulties. The stressor (hearing loss, divorce) is superimposed on pre-morbid personality (coping skills) as well as biological predispositions. It is a combination of psychological, biological, and social factors that make a child more at risk than the general population. Some of the more commonly noted secondary aspects of hearing loss include communication and behavioral problems, self-esteem and image problems, and depression and introversion.
Undiagnosed or misdiagnosed hearing loss can result in problems as the child may know something is not quite right but is not getting the proper professional attention. When a hearing loss—even a mild one—is correctly diagnosed, the child knows the truth about what is wrong, as opposed to thinking she is "crazy" or "stupid." Though less common today, children may be misdiagnosed as attention- or emotionally disordered, which can lead to many secondary self-esteem issues. When misdiagnosis occurs, the problem becomes twofold—the child receives an inaccurate and usually negative label, and their actual problem goes untreated for a long period of time.
To some extent, communication issues are universal among people with hearing loss. When a child has difficulty interacting in a spontaneous way, a whole host of secondary problems can arise, and any or all of these issues can develop into more serious problems. These include learning difficulties, social isolation, and depression. Normal interactions require tremendous attention for the child with hearing loss. Listening becomes a multi-sensory task, involving a much greater level of visual and general attention than it does for those with normal hearing. While the child may communicate effectively, it requires a great deal of energy to do so. One of the most typical symptoms that motivates individuals with hearing loss to begin psychotherapy is fatigue, which can exacerbate depression.
Increased incidences of behavioral problems are often cited in the literature on children who are deaf or hard-of-hearing. Behavioral problems in children such as hyperactivity or aggression can be the outward expression of internal difficulties—such as depression, anxiety, and learning disorders— and should be investigated. Behavioral problems are often best dealt with by school or mental health professionals with experience in these areas. When treating children with behavioral problems, clinicians must set limits, speak simply and clearly, avoid overly stimulating or distracting environments, and involve parents more than usual. Scheduling appointments at optimum times of day (based on parental knowledge of when their child is usually at their best) is also useful.
In addition, children rarely perceive being different as a virtue. Children with any unique qualities may develop a negative self-image as a result. This is often evident in children with a variety of traits that come to characterize them, such as being overweight and wearing glasses.
One personality trait often associated with hearing loss is introversion—the terms shy, quiet, and sensitive often refer to this. The general theory is that the child with hearing loss is more inner-focused as a result of reduced stimulation from the outside world. They may withdraw from peer interactions due to this inner focus, the extra effort demanded in communicating, or simply due to the alienating feeling of " being different." As a result, parents must apply extra effort to helping their child with hearing loss participate with peers and in social groups.
Self-expression is difficult for all children, and this is greatly compounded by hearing loss. Parents and professionals must be extra-sensitive to children with hearing loss, as they are not always able to articulate their needs and feelings. They must be aware of potential problems and assist the child with hearing loss in becoming more comfortable with self-expression. Children with hearing loss need to be in an environment that welcomes questions and feelings, and while parents may not always have the answers, they should be at ease and curious about the questions. Clinicians can ask children who have hearing loss questions in the course of their work ("How do you feel about your new hearing aid" or "What do you think about your new hearing aid?") in an unobtrusive and casual manner and watch the child’s response. Be careful about leading questions. "How do you like your new hearing aid" may indicate to the child that he is supposed to like it, which does not promote honesty if the child actually does not like it.
All children should be taught that they have strengths and weaknesses and be encouraged to explore who they are and pursue the things they like and do well. It is the difficult chore of the parents of children with hearing loss to continually explore and question whether behaviors observed are a normal manifestation of the child’s personality or a response to some form of distress caused by the hearing loss. Parents must find the delicate balance between overanalyzing every behavior and not paying enough attention to their child’s actions. Finally, parents need to develop their own support systems to help them deal with their feelings.
Hearing Loss in Adults
Hearing loss in adulthood is a somewhat different psychological picture. A distinction can be made between psychological symptoms of early- and late-onset hearing loss in adults, although individuals in both groups commonly report anger, denial, isolation, social withdrawal, fatigue, and depression.
Adults with early-onset hearing loss may have grown up dealing with some of the above problems. Clinical psychological knowledge tells us that all children bring manifestations of their childhood difficulties into adulthood. Some of these difficulties will continue to be problematic, and some will not. For instance, the child with hearing loss who was isolated and had poor self-esteem may be an isolated adult who underachieves. Adults must be understood as the totality of their developmental experiences, and hearing loss and its consequences are a part of that whole. Clinicians need to be curious about how clients feel about their hearing loss, how it was managed and discussed in their family, and how they feel it affects their choices in adulthood. Adults who have early-onset hearing loss often report that, while there were negative aspects of their hearing loss, they have come to incorporate the hearing loss into their personalities—it is part of who they are and of their identity. As a result, they have developed ways to cope with and manage the hearing loss in their daily lives.
The situation is very different for late-deafened adults. These individuals have developed a personality that does not incorporate hearing loss. They have jobs, families, and personalities and relate to those aspects of their lives as fixed. When hearing loss occurs, it is a very disorienting experience. Rapid losses are more disorienting than gradual losses. Late-deafened adults often report that their hearing loss robs them of an understanding of their identity and often initiates an identity crisis. They may manifest a "reactive" depression and/or anxiety in response to a typically external situation.
Late-deafened adults will often mourn the loss of their hearing as they go through Kubler-Ross’ five stages of grief—denial and isolation, anger, bargaining, depression, and acceptance (see references). Professionals interacting with late-deafened adults should try to get a general sense of which stages the client is in.
Denial, isolation, and anger are readily observable by clinicians. A newly diagnosed adult may mourn the loss by becoming withdrawn and refusing amplification. Family members and audiologists are the greatest help in this early stage. Patients often need to be taught new ways to interact in the world to increase their involvement. Bargaining frequently takes the form of comparing ("I can’t really hear anymore, but at least my health is good") or devaluing ("Who cares if I cannot hear—I never really liked music"). Depression can manifest itself as tearfulness, slowed responses, or even changes in weight or sleeping patterns. If previously dapper men begin showing up for appointments unshaven or women come without makeup and with sloppy hair, they may be depressed. Professionals can note such things in an unobtrusive way ("How are you feeling this week?") and even talk with family members if they come with the client. It is believed that depression precedes acceptance because it represents a healthy beginning in truly taking in the negative aspects of one’ s disability. Finally, acceptance takes many forms for different people, but it usually indicates some integration of the loss into one’s life. In this circumstance, acceptance may mean having all the negative feelings about one’s hearing loss while not letting those feelings interfere with relationships and daily life. When going through the stages of mourning, functioning may be affected over the short term, but the person usually will move toward some degree of acceptance. If they do not, they may need emotional support from either a therapist or a support group.
The Psychology of Cochlear Implants
Personality and psychological factors can affect the surgical outcome in cochlear implantation. Professionals working with cochlear implants acknowledge a great deal of variation in satisfaction and performance with implants. Some of the factors that affect outcome—which is traditionally measured by speech-recognition ability—include length of deafness, IQ, speechreading ability, and hearing ability before implant. Research also notes certain psychological factors that can affect outcome, such as an individual’s point of view (pessimist/optimist), expectations (realistic/non-realistic), and type of support system.
There is a dearth of literature on the relationship between personality and cochlear implant surgery outcome. Personality can be thought of as the complex total of who we are, how we think, how we perceive information, and how we interact with the world. Cochlear implant surgery is a life event that will interact with and be shaped by our personality. The way an individual responds to stressful situations, illness, and physical stress in general will predict, to a certain extent, how that individual responds to an implant. Thus, a person who is rigid and pessimistic may look for, and comment on, all of the bad things about an implant, regardless of how it functions. While it may be healthier for an individual to observe the implant as part of a long process and to feel positive, it is very difficult to change the way people evaluate the world. Most people adapt in their own way over time. If they do not, they may benefit from talking with a therapist.
People with hearing loss also are affected by a society that values physical perfection and beauty. There is an often subtle and unconscious bias about people who wear hearing aids and cochlear implants. In general, these prejudices are not mean-spirited, but the expression of fear—a fear of facing some of the bad things that can happen to people in life. People tend to want to feel good all the time and do not welcome exposure to things like disability, illness, and death. People often want to avoid exposure to situations and individuals who remind them of these concepts. Try having a conversation about death and dying at your next family gathering and watch the room clear out. This is simply a psychological fact of life, and professionals need to be aware of it.
Speech-language pathologists and audiologists can benefit from a collegial relationship with a therapist that works with patients with hearing loss. We often present small group lectures at clinicians’ request to encourage clients to understand the emotional effects of hearing loss. One of the goals of good psychotherapy is to help individuals understand how their personality works so they can observe it in operation and see how it affects their point of view.
Finally, professionals working with clients with hearing loss must always pay attention to the many variables of hearing loss. The important ones include when the individual became hearing impaired, the cause and degree of the loss, and the progressive nature of the loss (gradual or sudden). The more severe the loss, and the earlier the age at which it was acquired, the greater the impact can be on psychological development. When working with individuals with hearing loss, it is imperative to establish a dialogue that invites information about the history and nature of the loss. The onset and degree of hearing loss make for a diverse group. This diversity can create an identity crisis for individuals who are neither "hearing" nor "Deaf" as they find where they fit in society. Professionals must have a go od grasp of both the physical realities of the individuals’ hearing loss (degree, cause, course) as well as where individuals feel they belong on the cultural continuum of hearing loss.
Many of these issues are common and can be present in individuals with hearing loss without necessarily being problematic. Whether or not they rise to the level of being a problem is determined by a complex combination of personality and environment. Clinicians can become more empathic listeners and more effective providers when they are educated about these generalities and the specifics of their clients’ hearing loss. This includes both physical and psychological information. In the end, the latter will often affect how the client uses the physical information and assistance offered to them.