July/August 2010 Issue

Hearing Loss in Older Adults — Its Effect on Mental Health
By Claudia Dewane, DEd, LCSW
Social Work Today
Vol. 10 No. 4 P. 18

If there were no need to communicate every day, older adults with hearing loss would have no problem. Helen Keller is credited with noting that blindness cuts us off from things, but deafness cuts us off from people. The significant impact of hearing loss on communication and interaction with others sometimes goes unrecognized by healthcare practitioners.

Coping with hearing loss is different from other disabilities in that it is an invisible handicap. The reactions or behaviors associated with hearing loss may not be apparent, and even the sight of a hearing aid doesn’t guarantee recognition of a disability.

A day in the life of a hearing-impaired older adult may include struggles with the following:

• hearing alarms or telephones;

• understanding someone while talking on the phone;

• understanding when several people are talking;

• understanding when a speaker’s face is unseen;

• hearing in a car, wind, or traffic;

• understanding speech on TV;

• understanding whispering;

• understanding people in a large room;

• understanding unclear or accented speech;

• being unaware someone is talking;

• understanding in public places;

• ordering food;

• understanding cashiers or sales clerks; or

• enjoying “sweet nothings” in a romantic situation.

Individuals with normal hearing often assume that simply saying something louder or turning up the volume will enable a hard-of-hearing elder to hear. Volume is not necessarily the issue; difficulties with sound and word discrimination may be involved. The need to repeat or experiencing non sequitur responses adds to negative perceptions of older adults with hearing loss as being slow. Internalizing these stereotypes and the resultant negative self-perception certainly contributes to emotional sequelae of hearing loss.

Hearing loss plays a role in how older adults experience and react to environmental stressors. For example, losing a job is difficult for anyone. Is it harder for a hard-of-hearing individual? Knowing that certain jobs may be more difficult to pursue, accommodations need to be requested and limitations may need to be acknowledged. Such adaptations influence perception of a crisis in a way that’s different from an individual with normal hearing.

Adults who have early-onset hearing loss report that while there are negative aspects of hearing loss, they’ve incorporated them into their personalities. They develop ways to cope with and manage hearing loss in their daily lives. It may be somewhat different for older adults who experience hearing loss at a later stage. These individuals have already developed a personality that does not incorporate hearing loss. They are accustomed to life as hearing individuals. Hearing loss may trigger an identity crisis, and reactive depression may occur.

There is a cultural continuum of hearing loss. A sense of belonging is important to mental health, yet individuals who are hard of hearing don’t belong entirely in the hearing world or in the deaf culture. A significant cultural difference exists between older adults who are somewhat deaf and those who are Deaf, that is, totally without hearing. (The distinction is noted by lowercase and uppercase of the letter D.) Varying degrees of dependence on assistive listening devices extend along the continuum.

Hearing loss can create a psychological solitary confinement. Yet many older adults with hearing loss deny the disability or the impact it exerts on their quality of life. The average delay in seeking help following a diagnosis of hearing loss is five to seven years. Thus, a practitioner working with older adults experiencing hearing loss may need to ascertain the individual’s stage of acceptance, as well as the location along the cultural continuum. Family members who attribute hearing loss to normal aging and physician descriptors of hearing loss as mild or moderate inadvertently bolster individuals’ denial.

Older adults who are hard of hearing often report that when their hearing loss causes communication problems, it can result in difficulty thinking or concentrating. This results in inattentiveness, distraction, and boredom. The most serious consequence is withdrawal or abandoning participation. The resultant self-talk is predictable: “I can’t participate, so I might as well pack it in. I can’t contribute, so what good am I?”

Older adults with hearing loss face many of the same fears that anyone with a disability encounters. They worry about loss of significant relationships or jobs or about being perceived as incompetent. Communication breakdown problems may show up in physical symptoms such as tension, exhaustion, and psychological symptoms.

Psychological Implications
Sometimes hearing loss exerts a direct impact on mental health. Depression and adjustment disorder can occur as a natural response to hearing loss and its subsequent impact on the quality of life. On the other hand, some people have pre-morbid mental health issues and hearing loss simply compounds the problem.

Inability to hear and discern message and meaning can result in feelings of shame, humiliation, and inadequacy. It can be highly embarrassing to be unable to behave according to applicable social rules. The feeling of shame linked to hearing loss stems from older adults inadvertently reacting in inappropriate and socially unacceptable ways, such as responding to a misunderstood question in an inaccurate fashion. Older adults may think “How stupid I must look!” “How embarrassing!” or “What will others think?”

Feeling inadequate, stupid, awkward, embarrassed, different, or abnormal are some of the negative emotions that plague older adults with hearing loss when the condition manifests itself in an unpleasant way. The desire to hide hearing aids often arises from feelings of shame. Hearing aids render visible the fact that an older adult differs socially from others. Society’s value on physical perfection and beauty affects everyone, including older adults. Many elders who are hard of hearing report subtle and sometimes overt prejudice toward those with hearing aids or implants. The ancient terminology of “deaf and dumb” carries a new meaning.

Hearing-impaired older adults may feel shame related directly to difficulties in understanding what is being said. Inability to understand verbal communication results in feelings of isolation when elders are left out of group conversations. To avoid shame, elders with hearing loss sometimes choose isolation. Either situation is unfortunate.

Contemporary psychiatrist William Glasser, MD, proposes that all individuals have five basic needs. How might hearing loss affect these needs?

• Survival: Is the sense of security threatened when an elder is concerned about hearing a fire alarm or a car horn?

• Love and belonging: Where do elders who are hard of hearing belong in the larger society? How does hearing loss affect a relationship or the ability to have a relationship?

• Power and recognition: Does hearing loss affect job performance or others’ perceptions of the abilities of the individual who is hard of hearing?

• Freedom: How is autonomy or self-sufficiency affected?

• Fun: Does the loss impair elders’ abilities to hear jokes, banter, or music or to have fun in any number of ways?

The stress of living with hearing loss can put people at risk for many reactions, including distrust, chronic sadness or depression, nervousness, anger or irritability, isolation, poor self-image, feelings of incompetence or inadequacy, or feeling marginalized.

 A sense of guilt frequently accompanies hearing impairment in older adults. Many elders with hearing loss assume responsibility for unsuccessful communication and blame themselves for misunderstandings caused by the hearing loss. Many feel apologetic about repeatedly asking for others’ help to understand what is being said or when they’re unable to participate in social events.

Some elders who are hard of hearing feel isolated or lonely within their own families. They miss the side conversations or easy banter during family outings or conversations. Family members may feel just as lonely, as though they’ve lost a comfortable relationship because of the hearing loss. Hearing loss affects everyone in the family—not just those who are unable to hear. With this invisible disability, others tend to forget hearing difficulties and minimize the extent to which hearing impairment may result in misunderstandings.

A Significant Loss
Depression is a common emotional reaction to any loss, and hearing impairment can involve a number of losses. The primary one is the reduced ability to hear and communicate successfully or on equal terms, resulting in interpersonal difficulties. Second, status and career possibilities may suffer from the perception that elders’ skills are affected by the loss.

Depressed, hard-of-hearing elders may experience fear, anger with themselves, self-reproach, self-loathing, guilt, incompetence, unworthiness, and sadness. They may see the future as negative and hopeless, with decreased initiative or energy to live an active life. At worst, thoughts of suicide can occur. The prejudices that are unfortunately often associated with hearing loss can exacerbate low self-esteem. Older adults with hearing loss carry a social stigma as troublesome, slow witted, and tiresome. If a person who is hard of hearing internalizes such prejudices, self-esteem suffers a severe blow.

The negative emotional strain caused by the hearing loss can provoke a depressive exhaustion, especially if it is difficult to implement a solution to functioning in everyday life and validate an elder’s perception as being an equal member of the community. Personal life is affected because it becomes gradually more difficult to understand conversations, increasing isolation and feelings of being a nuisance.

Working With People Who Are Hard of Hearing
When working with elders, it’s not unusual to encounter individuals with hearing loss. If an individual has not been diagnosed with a hearing loss but it is obvious that there’s a hearing deficit, referral to a qualified audiologist may be in order. It’s helpful to know the capabilities and differences between a hearing aid dealer or dispenser and an audiologist.

Coping with hearing loss involves an adjustment process. It isn’t just an ancillary factor helping someone achieve optimal functioning in later life. It may, in fact, be the most important factor. It’s critical for an older adult to come to terms with the impact of hearing loss on his or her identity.

Many professionals are accustomed to working with marginalized populations, and hard-of-hearing elders are such a population. Many describe feeling marginalized in their own families. One of the most hurtful (albeit unintentional) responses to a hard-of-hearing person’s request to repeat something is: “Never mind, it’s not important.” The implication is that the elder isn’t important enough to include.

Help hard-of-hearing elders find ways to avoid embarrassing and awkward situations. Involve significant others and emphasize that the burden of communication is not the sole responsibility of the older adult. Good communication requires the efforts of at least two people, even when one of them has a hearing loss.

Helping an older adult grieve and find meaning in the loss of hearing is therapeutically crucial. Rarely are hearing-impaired elders given permission to express the felt, perceived, and feared losses they associate with this physical limitation. Physicians or audiologists who address that level of emotional identification and support are uncommon. In fact, it is rare that ear, nose, and throat specialists or audiologists talk to patients about the psychological results of hearing loss. The anger felt by elders with hearing loss is frequently displaced onto the physician and/or the mechanical assistive devices prescribed to help them. It may be one reason why so many hearing aids end up in drawers.

It’s important to speak openly and naturally to older adults with hearing loss. Take all feelings seriously and show respect. Don’t speak on behalf of an older adult with hearing loss, and if you address the elder in the presence of another family member, avoid using that person as an interpreter if the hard-of-hearing elder doesn’t hear the question. Instead, repeat the question clearly or rephrase in another way and allow the individual to answer for himself or herself.

Mental Health Practitioners
Initially, practitioners should assess a hearing impaired individual’s level of acceptance of the disability. To borrow from acceptance and commitment therapy, the ultimate goal is to accept the situation and commit to action, to achieve a sense of moving from being a victim of hearing loss to a survivor. What would accepting the disability mean to the sense of self? Helping older adults explore how handicapping the disability is constitutes the next step in the helping process.

A mental health professional without training in hearing loss may inadvertently underestimate or misattribute the level of frustration an older adult with hearing loss may experience. Elders may hear noise but be unable to discern what it is. This is particularly true of speech. Different types of hearing loss (conductive, neural, or mixed) all result in different types of communication impediments.

Educating yourself on the complexities of living with hearing loss is essential. A particularly thorough, self-directed certification program can be found online at the American Academy of Hearing Loss Support Specialists (www.hearingloss.org/academy/index.asp).

Practitioners can assist patients and clients by linking them with appropriate resources. There are self-directed learning modules on speech reading and living with hearing loss. The Hearing Loss Association of America provides education, support, and advocacy for people who are hard of hearing (www.hearingloss.org). Participation in self-help groups has been shown to have the most healing effect. Support your patients or clients in self-advocacy. Empower them to advocate for themselves in the workplace or home. Familiarize yourself with the Americans With Disabilities Act and assistive listening devices.

Educate elders with hearing loss about fight, flight, and freeze responses to stress. Normalize their behavior. Discuss the difference between guilt and shame and work on eliminating shame-based reactions to hearing loss. Rational emotive behavior therapy techniques may be quite useful in this quest.

Work on self-efficacy and self-respect. Using a strengths-seeking approach helps hearing-impaired clients to recognize all the abilities they possess despite the hearing loss. Values clarification and helping clients to define themselves as more than their hearing loss will mollify depressive feelings.

Behavioral techniques such as relaxation training, rehearsal, visualization, and even hypnosis can assist with developing coping skills. The concept of resilience is cited most often in the psychological literature as one of the most important aspects for maintaining mental health. Older adults with hearing loss are often among the most resilient and resourceful. It’s often beneficial to have elders tell their stories of living with hearing loss. Feel free to incorporate humor as appropriate. Many elders who are hard of hearing will share funny stories resulting from their hearing loss. Many will even recount the occasional positive side of being unable to hear.

— Claudia Dewane, DEd, LCSW, a clinical social worker for 30 years with a specialty in trauma work, is an associate professor of social work at Temple University. She has a profound bilateral hearing loss and is a hearing loss support specialist certified through the Hearing Loss Association of America.