THE PSYCHOLOGY OF DEAFNESS - PART TWO

My last audiogram after stapedectomy on the right ear, superimposed for comparison.

The four levels of deafness:

Mild deafness or mild hearing impairment - the person can only detect sounds from between 25 to 29 decibels (dB). They may find it hard to understand everything other people are saying, especially if there is a lot of background noise.

Moderate deafness or moderate hearing impairment - the person can only detect sounds from between 40dB and 69dB. Following a conversation just from hearing is very difficult without using a hearing aid.

Severe deafness - the person only hears sounds above 70db to 89dB. A severely deaf person must either lip-read or use sign language in order to communicate, even if they have a hearing aid.

Profound deafness - anybody who cannot hear a sound below 90dB is profoundly deaf; some profoundly deaf people cannot hear anything at all, at any level of decibels. Communication is done with sign language and/or lip-reading.

Ramsdell’s Psychological Levels of Hearing.

• The primitive level - the background sounds of daily living. The wind, the creaking of our houses, the traffic outside and people moving around. Our social nature requires connection and interaction with the world around us. We just want to know it’s there. It may be quiet not soundless. These subconscious sounds connect us to life, ourselves and everything around us.
• The warning level - alerts and signals that protect us from potential danger. Sounds like thunder or rain and water in fast flowing rivers are instinctive. Some are learnt from life or parents such as the sound of traffic, car horns, sirens and fire alarms. Also alerts, such as alarm clocks, doorbells and telephones.
• The symbolic level – this is communication which informs and educates us. As when understanding speech, conversation, discussion and information broadcasts that allow us to take part in life. It enables us to understand others and respond to them.
• The aesthetic level - this gives pleasure by appreciating music, performances and company.

The psychological impact of sudden, profound hearing loss.

The deaf person will go through several stages before accepting their hearing loss. The acquired deafness affects every aspect of a person’s life, from relationships to feelings of insecurity when alone. All parts of life will be changed to some degree. The progression through these stages are like those of bereavement. Elisabeth Kübler-Ross (July 8, 1926 – August 24, 2004) was a Swiss-American psychiatrist, a pioneer in near-death studies and the author of the groundbreaking book On Death and Dying (1969), where she first discussed her theory.

The five stages of grief.

Denial and isolation.
Anger.
Bargaining.
Depression.
Acceptance.

Deafened Adjustment.

Identity confusion.

At first the deafness might be ignored or externalised such as suggesting that others are mumbling. This may be because they do not want to think about the impact it will have on their lives. This can be influenced by their own negative attitudes or past experiences of deafness.
Identity Comparison.
Does this make me an invalid? Why me? There must be a cure?
Identity Concession.
I am technically deaf but what is my place in the world? Where do I belong? I want to go back to where I was.
Identity Recognition.
An acceptance of being deaf and trying to join up the two different worlds that they are now in.
Identity Activism.
I am deaf but not dead! They start to explore the world of deafness.
Depression.
I can’t change anything! They grieve for what they have lost and despair at how others see them.
Identity synthesis.
The final coming to terms and acceptance of what has happened.

My thanks to my Lip Reading Tutor, Gill Houghton, for providing the guidelines and the insight into this subject and helping me with the recognition of what has happened to me and where I fit in this process.

THE PSYCHOLOGY OF DEAFNESS - PART ONE

“the world has gone dead”  

Dr Donald Ramsdell (1904–1965) is my hero. He was introduced to me by my lip reading tutor who has studied him (as have all hearing loss professionals).

He acquired his Ph.D. from the Department of Psychology at Harvard University, USA, in 1938. He became the Associate Professor in the then new Department of Psychology within the Department of Arts & Sciences at the University of Alabama. By 1942 he was a Full Proffessor having reorganised courses and established new ones.
In 1946 he worked at the Deshon General Hospital, Army Rehabilitation Centre in Butler, Pennsylvania, which was a Veteran’s Administration Hospital.
Later, he became Chief of the Clinical Psychology Section at the Veterans Administration psychology service, Boston.

Psychological problems for the deaf person.

‘Hearing and Deafness’ is a summary of the status of USA audiology principles in 1978. Chapter 19 of my copy has Donald Ramsdell’s original 1946 psychological analysis of deafened soldiers returned from WW2.

Hearing and Deafness Edited by Hallowell and Silverman Fourth Ed.1978
Pub. Holt, Reinhart andWinston (1947).

Ramsdell responded to the frequently repeated phrase used by deafened soldiers that “the world has gone dead.” His observations and interpretations still remain the basis of the subject today, having remained unchallenged since his first work on the subject.

He established four levels of hearing by exploring how they connect us to life and interact with each other to give us a sense of well being.

1. Understanding speech is the - symbolic level which Informs, educates and entertains.
2. Appreciating sounds that please us is the – aesthetic level which gives pleasure.
3. Recognising sounds that alert us is the – warning level which alerts and prepares us for action.
4. Recognising the changing background sounds of the world around us is the – primitive level which is the auditory background sounds of daily living.  

The 1987 edition of the book includes a discussion on the application of his views to the subject of cochlear implants at that time. Thanks to him, it is now established that a hearing impairment will produce some mental adjustment in the deaf individual. These psychological difficulties from hearing loss are likely to be a greater problem than the loss of speech communication. Psychological difficulties do not always present in a proportional way to the severity of the loss, but they are usually related to the time at which the hearing impairment occurred. Those who are born with impaired hearing or who lose their hearing early in life do not seem to have such a severe problem as those who suffer hearing loss after having had normal hearing in adult life. It appears to be psychologically more difficult to lose hearing after having experienced several years of normal hearing than it is to be without hearing for a lifetime. The congenitally deaf person does not realise what he is missing, and so it is easier for him to adjust to his situation.

The effects of early cochlear implants

The cochlear implant principle has been around for fifty years. It was being inserted frequently in the USA in the early 1970s. Those early operations had only one electrode therefore there was no comparison pitch to detect (Ohm’s acoustical Law) leaving the deaf person frustrated by ‘nearly’ intelligible speech limited to only sensing intervals of acoustic pressure (periodicity pitch). Normal hearing, by concentration and attention, can separate the many different sound components by filtering the otherwise random noises that are heard.

The basic principal of the implant is to restore hearing by electrical stimulation of the auditory nerve. More electrodes were needed to advance the hearing ability and it was thought four or five would be best. By sub dividing the sound spectrum into different frequency bands it was hoped intelligible speech could be detected when the corresponding nerve fibre sensory units were stimulated. By the mid 1970s the technical difficulties were still formidable but the surgery for single electrodes was progressing successfully.

These implants restore detection of sound but could not differentiate words. There was no worldwide consensus or standardisation between the developing teams. The direct, hard-wired system did not work well. Electrodes broke and the wires through the skin were sometimes biologically rejected. The alternative subcutaneous coil with inductive coupling became the more reliable connection though there was a problem with accurate positioning of the external component. To achieve more electrodes inserted into the cochlear, multiple holes were attempted by a French team.  This needed more lengthy and complicated surgery. The engineering technicalities to go with it proved too difficult. Optimism for the future of multiple electrodes kept research moving forwards and the single electrode did have benefits for the deaf person. It provided a sensory awareness of the environment.

Suitable candidates were chosen from young or middle aged adults who had already learnt speech and language before becoming profoundly or totally deafened. Children or adults deaf from early childhood were not considered suitable. Those implanted, experienced a true sensation of hearing and awareness which was demonstrated in those who could previously get no benefits from hearing-aids now becoming psychologically happier. They no longer thought of the world as ‘dead’ and could feel part of it again. By receiving environmental sound signals their own speech became better too. Unfortunately the single channel, having first been helpful, subsequently became frustrating as the inability to learn and improve the recognition of words meant the recipient could make no further progress. The recognition of speech was impossible other than the brain’s ability to interpret a very restricted vocabulary based on visual clues and syllables. Even just two electrodes, suitably located, could help with a month or two of relearning to discriminate between sounds. What was developing well was the compression of the wide dynamic range of everyday sounds into an effective and tolerable electrical stimulation but ambient noise was troublesome in higher frequency sounds.

Now, in 2015, the technology is far beyond what those pioneers could have imagined. Both the surgical technique and micro-electronics needed for the 20 plus electrode devices now available would have been comic book fantasy. My implant processor will have more computing power than any part of the 1969 mission that put a man on the moon.

Hearing and Deafness Edited by Hallowell and Silverman Fourth Ed.1978

 Pub. Holt, Reinhart andWinston (1947).

This will be my hearing system.      Information from the Cochlear UK website.

Nucleus^® Implant portfolio

AUDITORY HALLUCINATIONS

“Hearing voices no one else can hear isn't a good sign, even in the wizarding world.” 

~  J. K. Rowling  ~

Auditory hallucinations are something I have been getting increasingly more frequently this last year. There is no need to worry, it is only when I think they are talking 'about me', rather than 'to me' or I think it is all a government conspiracy that I might have schizophrenia,   dementia, or   bipolar disorder!

 

These hearing equivalents of visions are very real at the time. Mostly what I get is a form of tinnitus (from the Latin tinnīre which means "to ring") that mimics the rhythm, tone and flow of spoken sentences. Conventional Tinnitus can be heard as ringing or sounds like clicking, hissing, or roaring. Mine is in the form of whistling but done quietly and easily ignored. There are a number of potential underlying causes including ear infections, disease of the heart or blood vessels, Meniere's disease, brain tumours, exposure to certain medications, a previous head injury, and earwax.

For me, these strange extras are sometimes like listening to a conversation through a wall into the next room. You know it sounds like a conversation but you can’t make out the words. Because my hearing is so poor there are many sounds that don’t become clearly defined and so it is just like normal listening to me. This is why I am so easily fooled by them. It is not volume I always lack, but definition of the spoken word. Water running, waves crashing and wind blowing is noise that does not require definition to know what it is. This means the uncertain sounds I falsely ‘hear’ are more convincing and distracting as they are like my every-day listening to real things. The most common one is to hear my name called. This is the primary method of getting my attention before speaking to me. The result is for me to look for who is calling.

Last month I heard my wife speaking to me from the kitchen. Not unusual you might think? In this case the kitchen is way beyond my distance range for hearing and I knew she had gone out a few minutes before. I thought she had come back and I didn’t hear her coming in the door so I got up and went to look for her.

Ray is a single syllable word that has registered in my brain since childhood. I do not associate it with a meaning. It is not only a proper noun, it is also 'me'. I believe the trigger for this interpretation of the sound is not a similar sounding noise-confusion. More likely it is my brain’s attempt to find a word that it is familiar with and most likely to be used in the uncertainty of the occasion. As with visual trickery by magicians ears can be fooled into believing they hear what is not really there. My brain fills in the gaps for me with pseudo words, hence sometimes I answer a question I was not asked. It is all in the mental interpretation of the stimuli.  This is often gleaned from the context in which it is being heard, or, I hear what I want to hear! The down side is that after a while I resist the reaction to the call and so miss the real thing when it does happen.

I haven’t yet been put in danger by obeying a command that I thought was a warning and so reacted instinctively in the wrong way by stepping into rather than away from the problem. These are the normal quick interpretations of sounds without first waiting to rationalise them that we all do by reflex actions. I am aware that I have slowed down my reactions, perhaps because of the distrust I have for what I hear. My increased concentration and lack of directional awareness around me means I wouldn’t move out of the way until I was knocked over. Then I would believe it.

Paracusia is the term for hallucinations that involve perceiving sounds without auditory stimuli. Auditory hallucinations are usually associated with psychosis but it is possible for someone to hear voices without suffering from any diagnosable mental illness. It is, therefore, necessary to distinguished between the following conditions:

Endaural phenomena (in the ear) are sounds that are heard without any external hearing stimulation.  Phenomena include transient ringing in the ears and white noise-like sounds.

Otoacoustic emissions (from the ear) are a different form, in which a person's ear emits the sounds. The person cannot hear those sounds made by their own ear but they can be heard by others.

These categories do not account for all types of auditory hallucinations.

Others include exploding head syndrome and musical ear syndrome. In the latter, people will hear music playing in their mind. Other causes can be: lesions on the brain stem (such as from a stroke), sleep disorders such as narcolepsy, tumours, encephalitis, or abscesses. There is also hearing loss and epileptic activity. (extracted from Wikipedia)

 

In the past such things were treated by trepanning or witch trials. In later times the victim would be chained up in the street or imprisoned in an insane asylum. By the late 18^th century the theory was that these hallucinations were the result of disease in the brain (mania) and treated in a Sanatorium. Attempts were made to treat it by dousing in cold water, starving, or spinning patients on a wheel. This gave way to brain specific treatments including Lobotomy, shock therapy and branding the skull with a hot iron!

Non-disease associated causes for auditory hallucinations have been shown to occur in cases of intense stress, sleep deprivation and drug use. High caffeine consumption has been linked to an increase in their likelihood. A study has revealed that as few as five cups of coffee a day could trigger the phenomenon. The primary means of treating the conditions is medications which affect dopamine metabolism.

There is on-going research into those auditory hallucinations which have a lack of other conventional psychotic symptoms (such as delusions, or paranoia). These studies indicate a remarkably high percentage of children (up to 14%) experiencing sounds or voices without any external cause, though it should also be noted that "sounds" are not considered by psychiatrists to be examples of auditory hallucinations. Differentiating hallucinations from "sounds" is important since the latter phenomena are not indicative of mental illness.

The causes of auditory hallucinations are unclear. Dr. Charles Fernyhough,  of the University of Durham poses a theory that gives evidence of involvement of 'the inner voice'. (Extracted from Wikipedia)

For those of us that are deaf the voices are clearer than normal because they are from the brain instead of the dysfunctional ear. A distinction that hearing people cannot make as their normal hearing is perceived in the same way.

Seeing Things? Hearing Things? Many of Us Do  ~ OLIVER SACKSNOV ~ March 2012

HALLUCINATIONS are very startling and frightening: you suddenly see, or hear or smell something — something that is not there. Your immediate, bewildered feeling is, what is going on? Where is this coming from? The hallucination is convincingly real, produced by the same neural pathways as actual perception, and yet no one else seems to see it. And then you are forced to the conclusion that something — something unprecedented — is happening in your own brain or mind?    Read more here:

Also see the Hearing Voices Network, the Mental Health Foundation's fact sheet on hearing voices and the NHS Choices Information pages.

EMERGENCIES UK

"Be Prepared... the meaning of the motto is that a scout must prepare himself by previous thinking out and practicing how to act on any accident or emergency so that he is never taken by surprise."

~   Robert Baden-Powell  ~

“What if you trip over in the dark coming back from the supermarket across the park or fall into a ditch, how would they know or find you in time?”

This was said to me half in jest and half in earnest but it raises a very good question.

What if I had?

The scenario relates to all UK emergencies in out-of-the way places.

 

The park in question is seldom used in the evenings or in bad weather. The supermarket opening times are late. Someone might stumble across my body in the morning. The ditch is unseen in the dark and so would I be if I was in it! It was, in fact, a bunch of keys we were looking for at the time not a body! We did eventually find the keys because of their distinctive tag which was more easily seen in the long grass.

Then, one evening, I took a constitutional walk to the supermarket and, of course, it was dark. But then, I am a grown man with many years experience, so what!

On my way back across the open playing field that's so wonderful in warm summer sunlight, a place to dawdle and dream ... (but not that day, it was perishing!) I noticed a long shadow approaching from behind. It kept pace with me whenever I slowed or quickened. In my deaf world there were no other signs of life, just darkness ahead and a bright light from behind. I stopped and turned, I don't know why, I had both arms occupied carrying bags, so could not defend myself. The figure saw my hesitation and rushed forward. I caught a glimpse of something long and solid in his hand as he lifted it from his side. I stepped back instinctively to lessen the blow but he missed me by a small fraction, to my great relief. The man fled onwards down the path into the blackness. All there was to show for my experience was the lingering smell of newly baked bread from his French stick! He probably wanted to get it home in one piece but I was now secretly wishing he had hit me with it so I could have the broken end with my cut-price ham and cheese from the deli!

I have worked in conjunction with emergencies for many years. I needed no reminding of the consequences but, even if I had a mobile phone, how would I communicate my distress to an emergency operator whose questions and instructions I could not hear?

I have, for several years, used the I.C.E. notification on my phone address book which the police would find (along with my body!) and know who to contact and give the unfortunate news. At the time of its introduction it was a novel idea and well meant because this is such an easy and quick way to save time and trouble on everyone’s behalf.

I was also well aware of what questions the emergency operator would ask. I had memorised this when I was working in the hospital as well. Although I could not hear on the telephone, I knew the routine for emergency contacts which summon the different in-house specialist teams. If I found anyone in distress, I could at least do my part. The service required no return questions just specific location and type of emergency needed to save time. The switchboard would pass on the details through the call system without delay and without having to stop and ask for information (unless it was not done correctly).

I could probably do something similar with the 999 emergency operators as well but first I would have to explain that the conversation was going be one way only and I would repeat my requests to be sure that they understood me. My problem would be to anticipate what they might say or what answers they might request from me. Such as; who I was, what service I wanted, where I was, what the problem was, any special complications etc.? Trying to relay this in a precise coherent manner whilst in a cold wet ditch on a dark and freezing winter’s evening might be difficult. I had a flashing torch in my pocket to signal to passersby or searchers to show where I could be found, just in case. A coloured flashing light is more easily seen and investigated from a distance.

It was, therefore, very welcome when firstly the local Sussex Police started using a text service for contacting them by prefixing the 999 service with 65.

The ‘Typetalk’ Emergency Line, for deaf and speech impaired people is not widely used by hard-of-hearing people and requires specific additional equipment at home. It is now called Text Relay which uses an intermediary speaker to help with questions and answers. This service is being developed much more widely now to help in many other circumstances for deaf people using their mobile phone microphones to hear for them. The voice to text service can now be used in meetings, lectures and open places.

Now this whole country is connected to an SMS messaging service for emergencies by texting to the 999 number and getting a reply from the police, ambulance, fire rescue, or coastguard.

The service also helps those who cannot speak as well. This is of particular interest when the caller is unable to speak because of injury, disability or a need for secrecy (as in domestic violence or crimes in progress).

You will need to register your mobile phone before using this emergency service.

More information:    Questions and answers:    The emergency SMS service:

This is, of course, a UK emergency service and must only be used in an emergency when:
Life is at risk and;

• Crime/trouble is happening now;
• Someone is injured or threatened;
• Person committing crime is near;
• There is a fire or people trapped;
• You need an ambulance urgently;
• Someone is in trouble, or missing, at sea,
• Someone is in trouble on the cliffs or on the shoreline

The SignVideo service which does communication in sign language (BSL) is unable to relay emergency 999 messages of any kind. This is due to the current telecom restrictions on video relay and interpreting services.

Now I can go out and about in the full knowledge that I can get help if I need it by myself. I will not have to wait for another passerby to use their phone for me if I am trying to help someone else, unless I have my hands full. It also works in noisy roadside situations as well.

For more on Hearing loss and safety visit:

Emergency text (SMS) – Deaf Message Service (DMS) – In Case of Emergency (ICE)

http://www.deaflink.org.uk/important-services/emergency-services
http://www.signhealth.org.uk/health-information/emergencies/