Reflections on Aural Rehabilitation: Interview With Mark Ross This paper contains an edited transcript of Kathy Cienkowski's interview with Mark Ross. The interview can be viewed at . We recommend you view the edited (not automatic) captioning for best results. Well I'm Mark Ross. I'm here at the University of Connecticut to talk about the early ... Article
Article  |   December 14, 2017
Reflections on Aural Rehabilitation: Interview With Mark Ross
Author Affiliations & Notes
  • Kathy Cienkowski
    Department of Speech, Language, and Hearing Sciences, University of Connecticut, Storrs, CT
  • Mark Ross
    Department of Speech, Language, and Hearing Sciences, University of Connecticut, Storrs, CT
  • Disclosures
    Disclosures ×
  • Financial: Kathy Cienkowski and Mark Ross have no relevant financial interests to disclose.
    Financial: Kathy Cienkowski and Mark Ross have no relevant financial interests to disclose.×
  • Nonfinancial: Kathy Cienkowski and Mark Ross have no relevant nonfinancial interests to disclose.
    Nonfinancial: Kathy Cienkowski and Mark Ross have no relevant nonfinancial interests to disclose.×
Article Information
Hearing Disorders / Hearing Aids, Cochlear Implants & Assistive Technology / Audiologic / Aural Rehabilitation / School-Based Settings / Part 2
Article   |   December 14, 2017
Reflections on Aural Rehabilitation: Interview With Mark Ross
Perspectives of the ASHA Special Interest Groups, December 2017, Vol. 2, 48-55. doi:10.1044/persp2.SIG7.48
History: Received July 31, 2017 , Revised October 9, 2017 , Accepted October 10, 2017
Perspectives of the ASHA Special Interest Groups, December 2017, Vol. 2, 48-55. doi:10.1044/persp2.SIG7.48
History: Received July 31, 2017; Revised October 9, 2017; Accepted October 10, 2017
This paper contains an edited transcript of Kathy Cienkowski's interview with Mark Ross. The interview can be viewed at . We recommend you view the edited (not automatic) captioning for best results.
Well I'm Mark Ross. I'm here at the University of Connecticut to talk about the early days of audiology with my colleague and friend Kathy Cienkowski. Yeah, I thought to recount the early history of the field and maybe my own personal experiences with it. My own personal experiences as a patient of course dates back in 1951 when I entered the aural rehabilitation program at Walter Reed Hospital. Remember, the field itself is thought to have started—and did start in modern embodiment—during World War II, when the Army service people were suddenly faced with people with hearing loss they didn't know what to do with. So, it developed an AR program specifically for people with hearing loss, soldiers with hearing loss. That was in 1944, 1943. I got into it 1951 as a patient from the Air Force and then I got my PhD in 1962. So, I didn't go to college until after I was a patient at Walter Reed, after I finished my stint in the Air Force.
Anyway, it's nice to go back and reminisce about the old time sometimes because we did some things right then that I wish we could do now, but we can't do. The program that was developed at that time was 8 weeks long, full time, at Walter Reed Forest Glen section of Silver Spring, Maryland. We went to class every day, all male soldiers at this time, all of us living together in the dorms, all of us interacting together after classes were over, with and all of us helping each other to adjust to the fact that suddenly young men [are] having to wear hearing aids. You go out into the world with body aids on. Now, it's a difficult concept for us to grasp. At that time, we just took it for granted. We're in the Army. The Army said, “Go to Walter Reed.” You went to Walter Reed. “You have to wear hearing aids.” You wore hearing aids. You had no options. You were ordered to wear it.
Actually, we were told we were very lucky, and I've always felt that way in some ways. In 1951, I was told “you are having a very miniature hearing aid. All you have to do is put it in your pocket. It's the size of a pack of cigarettes with a little wire up to your ear and that's it.” Early generations had to carry battery packs on one thigh, amplifier on the other thigh, have your cords going up to earphones. So, we were very lucky. And we were told that—I felt it was true then I felt it's true now. So, from the days of hearing aids—body aids to cochlear implants, you rehearse the history of audiology in my own experiences.
The program itself was a kind of dream program we can't afford nowadays, and I'm not even sure if it was really necessary. We had over-killed. Nothing was too good for the boys in those days. We had some speech reading lessons, auditory training lessons, academic lessons. We had hearing aids that we checked every week. Now the way we check hearing aids I'll talk about maybe a little bit because it was very interesting.
We did use the Carhart approach. I don't know if people know about the Carhart approach now. We actually compared four or five or six different hearing aids under the same conditions: aided SRT, aided discrimination. Noise testing was part of the procedure but was never done, at that time. It should have been done. We tested the aid.
You always knew we were trying to control the input. Have a black box, look at the output and somehow judge which one of these black boxes was best for that person. We didn't know what electroacoustic dimensions underlie speech intelligibility factors, and the hearing aids were very primitive. You could make only two adjustments on most aids, maybe three: Treble, bass, and flat. Maybe you could control output by using a different receiver. That was the way you controlled the output. But then you could have so many weaknesses with that. We had problems of input. People used live voice testing when they weren't controlling the input and had trouble with output. They take…live voice responses and they don't test the hearing while doing it.
I had no idea what dimension in the hearing aid was really responsible for the scores a person received. Was it [because] they had [the] best aided response? Was it less distortion? Was it frequency bandwidth? Was it the frequency response? Not until many years later did we start looking at things like that—because we had the tools to look at things like that.
Those were the days, too, when we didn't dispense hearing aids. It was considered to be unethical for us to dispense hearing aids. So, what we did in audiology was to recommend the specific hearing aid, go to a certain dealer or any one or two or three or four we'd recommend. You couldn't recommend just one because you thought you'd be colluding from getting some kind of kickback. It was a very suspicious era. And of course, the aid that they tried on you, while it may be the same make and model that we recommended, it could have performed very differently electroacoustically. It probably did. They did not do very good quality control when they manufactured the thing. So, there's a real range of performance among the different hearing aids.
Anyway, back to Walter Reed Hospital. Of all the experiences I've had in audiology as a patient, that was probably the most meaningful. But it wasn't only that. I was with a bunch of people who kind of supported me and I supported them, taking it for granted [if] you had a hearing aid and you needed help, you got help. It was the fact that 3 years later, me personally, when I was ready to be discharged from the Air Force, I asked for a booster shot. They sent me back to Walter Reed Hospital, for again 8 more weeks and that was 1955. And then from there, I started college and began to do this professionally after years as a patient.
One of the factors that always bugged me a little bit is the stigma supposed to be attached to wear hearing aids. You're not supposed to show them. You're not supposed to admit you have a hearing loss. Well we were never told that. When I first got my hearing aids, we were never told there was a stigma to wear hearing aids. There was a benefit to you. It was a blessing. And I kind of took that attitude with me over the years.
[I was] one of the first people in Africa to wear hearing aids, for example. I was stationed in North Africa, and I wore the thing. I never really made a big deal about it and nobody else made a big deal about it, as long as I didn't. Every once in a while, a little kid would point to it and say, “Mommy what's that up there?” I'd say, I talked to the kid and say, “It's a hearing aid. Helps me to hear better like your mother's eyeglasses help her see better.” “Oh” and that was it. So, I find all this sensitivity towards or belief that something's shameful involved in wearing a hearing aid, really kind of disturbs me somewhat.
A Developing Field
We were developing the field, looking to see what would work best. The diagnostic aspects of the field came as a result of the rehab aspect. In order to do good rehab, you had to have a measure of how much hearing loss the persons had and what kind of diagnosis they had. Was it a conductive loss? A sensorineural loss? And so on, the symptoms of hearing loss. So, it's like the diagnostic “scientific” aspects of the field were separated early on I think from the rehab aspects. This going back to Walter Reed Hospital. The early fathers of audiology were all quite scientifically bent, and since there was no real good evidence from—should have been from Walter Reed—that all the programs we underwent actually resulted in increase in speech perception ability or lipreading ability. We all felt it did, and that was good enough for us.
But to develop a field without any real solid evidence that what you're doing is effective, I think was probably responsible for the fact that it never got followed up, because we couldn't point to some science. I said this…speech reading program, this psychological rehab program, really does help people adjust to hearing loss and function better. We did not have much of that evidence. We just had “How do you feel?” “Oh, I feel great. It's wonderful.” And we've been working, trying to get evidence for years. We know in our guts when we work with somebody who comes to us and it's 2, 6 weeks, months later when you see him again they're doing so much better, they feel so much better. “Well, prove it.” Well, I don't have to prove in it my life. “Prove it statistically.” Well, we don't have those. So, those of us who worked in rehab had a hard job to kind of convince the profession at large to continue to emphasize aural rehab as a major component in the field.
What took off was the diagnostic scientific aspects. We would develop tests for central nervous system, central auditory system diagnosis, retrocochlea, cochlea conductive. All these tests with all kinds of acronyms. We had more acronyms than the world had. Well it serves, like many vocabulary do serve, to separate ourselves from the masses out there. We had our own vocabulary with our own acronyms and nobody else could be part of the field unless you knew the acronyms.
Well, what I used to enjoy was making ear molds. Well I had my ear molds made. When I tell people about this, they find it hard to believe. The very first ear molds that I can recall were made with plaster of Paris. Kind of thing you used in cement, I guess it was. At Walter Reed, we laid down on a gurney to poke the cotton tab into the ear, but you didn't have prepared cotton tabs. You got to take a piece of cotton, wrap […] dental floss around, tie it off yourself, and then poke it in. Coat the ear with mineral oil, coat your hands in mineral oil, and then you got to mix it up and pour it into the ear. Then you don't move very much until 5 or 10 or 15 minutes. When your ear feels like it's burning, it's set. You take it out. And, I guess we made pretty good ear molds in those days. But soon after, thank goodness, they began to come out with other, silicon-based impressions that made life a lot easier.
You could not, as an audiologist, prescribe hearing aids. You could not say a certain frequency response is better because that was taking on a medical function. We could not be seen as diagnosticians or medical practitioners. It wasn't until we had real ear measures that we really knew what we were doing, what was going on in the ear. I wonder how often people nowadays exclude—how many audiologists do (this) as a routine part of their electroacoustic analysis of the hearing aid, actually look what the real ear output of the hearing aid is. Twenty, and 25 or 30 percent of audiologists only do include this as a routine part of the evaluation. I always felt that was an essential a part of our function. If we didn't know what was going on in the ear, how can we possibly predict which is the best hearing aid? Or which is an adequate hearing aid? I am not sure if there is […] a very best hearing aid.
But we looked at, in those days, looked at things that we don't look at anymore. For example, Békésy. How many people now know what a Békésy audiometer is? I had it done on me many times, of course. When I first tested my right ear, it was 1,000; 2,000; 3,000; and 4,000 octave, a half octave. But I was hearing much better than I thought I should be. I did a Békésy and I found I had a peak at 15–20 dB between 2,000 and 3,000. It never showed up in traditional audiometry. My cousin has a hearing loss [that] drops off at 1,000 cycles to two, and about a 45 to 50 dB difference, and he does very well. He's having a fight with his wife. He doesn't want a hearing aid. She said you need it. I believe her. But, it would make a very big difference if his hearing dropped off at 1,950 or dropped off at 1,050, both of which would look the same on octave-based testing. At 800 cycles of information, you can understand speech in that area of the spectrum. Anyway, real ear measures I think were something we've sorely missed and made possible a lot of progress in the field.
But back to Walter Reed, again. Let me just make the point that, really, I think it was the interaction that we had with others, that mutually supportive [interaction], that enabled all of us, that I can remember, just pretty reasonably adjust well to a hearing aid. Do you know who else is a graduate of Walter Reed? We overlapped, but you probably know his name: Sam Trychin. Sam Trychin was another graduate. He was in the Air Force and he was in Walter Reed just in between the times I was. We became good friends later, but he also, I think, reflects some of the same advantages that I reflect in the experiences that we both had. He's the big proponent of [Auditory Rehabilitation] AR groups. In coping with hearing loss, he's done more good as a psychologist with AR than audiologists have done, I think. We have a lot of audiologists that are really interested and work well in this area: The Academy of Rehab Audiology, which began 40 years ago now.
Anyway, I've seen the field grow and [been] very fortunate having a hearing aid that would work with me from the time of BTE hearing aids, binaural hearing aids. I have no hearing now left in my right ear, practically none of my left. I can function with an implant pretty well. What my life would be like if I didn't have this, I don't know. It would not be the same. It would not be the same for anybody who was a long-term wearer of hearing aids, [they] would have just had to adjust their life quite differently.
Going back to what I was saying before, the practice at the time not to dispense hearing aids was a big issue for audiology. On the one hand, people say you can't not benefit from recommending a hearing aid because you'll have a vested interest in the sale of hearing aids. And that's true. It's also true for a surgeon who has to do an appendectomy or of dentists who do a filling. They have a vested interest in recommending some service or product. We have to have enough faith in our professional colleagues that they would recommend aids that would benefit the person and not take personal profits from it, except for the cost of doing an actual job. So, we had finally after many years, we had approved where the audiologist could dispense hearing aids. And that probably has changed the field of audiology somewhat because now, 80%, I hear, of the graduates of AuD programs are going into private practice.
A Turning Point
You know another turning point in the field was the rubella epidemic of ′64-′65-′66. That's early enough in the field—audiologists at that time, and there weren't that many of us, maybe 500 or 1000 audiologists in the whole country, because we didn't have that many. Well, it was a new field and we didn't have much need for our services. Everybody could buy a hearing aid through a dealer. And we weren't allowed to dispense hearing aids at that time. But suddenly, all these children come up to our clinics with hearing loss, like the Zika epidemic now.
They had perceptual problems, they had hearing loss, they were blind, they were sheltered away. Our clinics were full of them, were full of these children. And we had to train more people very quickly, and with a focus on pediatrics. I did a lot of consulting in those days with preschool programs that [were] developed as a result of the epidemic, including those we developed here, in this building. Also, we had the schools locally. We had a program for Deaf children staffed by teachers of the Deaf that we consulted and helped develop.
I'd go to these places, and I found very often that I could not understand the teacher standing next to me because of the noise in the background. We were trying to develop an auditory approach, but the kids had no clear signal coming through to them. And how could we ever possibly have these children develop language through hearing if they couldn't understand the signal going in? That got me personally interested in classroom acoustics. That underlay the first chapter I did with Jack Katz's book on speech reception and classroom acoustics.
But what I found—it was such an obvious factor now, but not then—was that if you had better signal-to-noise ratio you could hear better. It sounds like such a revolutionary statement now, doesn't it? But we looked at hearing perception as a function of distance from the source, as a function of noise in the room. Clearly, noise, room acoustics had an effect upon speech perception. And so that moved us into that area.
But then we found, I found, part of the development of the field, that aids had very poor quality control of the hearing aids, very poor. There's an article by John Gaeth and E[Evan] Lounsbury that was a trailblazer that looked at maybe 100 hearing aids, the performance, actually worn by children in classrooms. Overall distortion of 10% was considered acceptable. Frequency responses ended at 2,000–3,000. Peak responses at 1,500 or something like that would be 15–20 dB higher than the next highest peak. They were terrible responses.
And then we had the idea that the kids were performing with monaural aids—when they were working—monaural aids when they could have functioned better with binaural aids. This started the whole controversy of monaural verses binaural. Right now, I think we resolved the controversy, generally. There are people, older people in particular, some of whom do better with one than two.
But they came back to help propel the profession of audiology forward, when we had really literally thousands of kids in our clinics. We had programs in church centers and church basements, schools. St. Joseph here had one. We had one here, we had one in town—all over, preschool programs for Deaf children. And most of them turn out to be manual programs. We were trying to function here, focus here on residual hearing. That's been my particular focus over the years.
Well Richard (Seewald) and I were sitting around some convention and I was telling him we have to look—that's where the real ear age come[s] in—we have to look what actually is being perceived by the person. What are the outputs of the signal relative to the person's threshold? How much actual aided hearing is the person getting? And how important is that in terms of speech acoustics? And how do we do that at various inputs?
So, I sketched a concept out. Richard just put the napkin in his pocket went off to get his PhD, went off to Canada and sent me a gift of the napkin. That was later framed. So, I had the napkin that we worked on with framed to my wall. Later he when he developed the DSL [Desired Sensation Level] test, which is a very advanced diagnostic and prescription test for hearing aids. I sent it back to him.
For me, I guess it is relevant to development of the profession. But at the same time, I was very sensitive to classroom acoustics, we were getting that information from the psycholinguists on the biological basis for language, that children being exposed to an auditory signal, an auditory language, in a communication setting would naturally evolve language. They had the biological basis for it, had the structure to take in acoustic signals in an experiential atmosphere and develop meaningful language, conversation. So, in other words, their brains could do what we couldn't do overtly. That's led to the concept we had to provide these children the best possible signal or signal-to-noise ratio that we could.
So, we had classroom acoustics, we had binaural hearing aids, we had biological basis for language. And then we also had programs where we would send therapists from this department to homes saying the home is the best schools for children. They were being visited by therapists Toni Maxon, Diane Brackett, Marion Philips and other people like that from here, went out on a grant that we had, to try to use the material at home and interact with the parents—[they] would be the best teachers for the children. Teach them how to talk to the kids. Teach them how to communicate with the children, how to utilize everyday activities that provide meaningful linguistic input.
Which reminds me of a story of Robert West, who was one the founders the American Speech and Hearing Association [now the American Speech-Language-Hearing Association [ASHA]], the first president, my professor at Brooklyn College. After he left Wisconsin, [he] came to Brooklyn and I guess I was undergraduate and a graduate student at Brooklyn. He used to say that scientific developments could be viewed as a circle. A small circle is what represents all we know, in the middle of the circle. The periphery of the circle represents what we don't know—what we're pushing out. The more we learn, the bigger the circle. The more we know and the more we don't know. So, both the periphery and central aspects are both increased at the same time. So, you ask one question, you solve one question, and it brings up another half a dozen questions you want to ask. But that's the nature of this field. I think in any scientific progress, that's the nature.
Family-Centered Care
Well for children it's also a part of what was permitted by law. You could not fund programs. We didn't have early identification and management programs. You went to a program at age 3, was the earliest. So, if we pick up a kid at 6 months or a year, what do you do with the child? Bring the child into the clinic once a week? Which we did. And first thing they had to do was separate the child from the parents. And it was tears, it's crying and screaming, and the parents out there biting their fingernails. It's much better to work through the parent to the child.
Dave Luterman, a very good friend of mine, has really focused on this area for many years, working with the parents. We differ a little bit in the sense that I always think you've got to make sure that signal going into the child's head is perfect—the best you can do, as well as make sure the parent provides the most support for the child. Because that parent is the first teacher. And that home is the first school. In those days too, we should remember, we felt very pleased that we can pick up a child with a hearing loss at age 1, 1 and a half. Age 1 and a half was considered early detection. And we would not put a hearing [aid] on a child until we measured the child's hearing. So, we'd bring the kids back week after week to get thresholds before we fit a hearing aid. And a child could be 2 or 3. If a child was fit by age 2, it was early management. You think of that now, you're appalled by it.
You know what also gets to me? When I think about it. I look at some of the people with implants, children who weren't implanted from an early age. The performance of deaf children with implants and with aids—and just dramatically different. A deaf child cannot wear a hearing aid unless they have some residual hearing. Assuming that they have none, or very little, residual hearing, they've got to be visual. And we were forcing them to be oral when they couldn't make it orally.
As an Audiologist
Because I was probably the first audiologist to go through a training program with hearing aids or a hearing loss, I've often been told, or it's been suggested, that the reason I've been kind of effective is because I could model for them—audiologists and other people—what you can do with the hearing loss. And I've always resisted that notion. I've always made a big point of saying you don't have to have a hearing loss to be a sensitive clinician. You don't have to be stupid in order to be a good therapist.
So, my first emphasis has always been, you're working with the person their needs come first—not your needs—their needs come first. But you know, I can't argue with the fact that, for many parents, when I used to come into the program with two aids on, (they) would see me and they would feel that maybe their kids could perform, set the goals a little higher.
One of the things we used to have is—goals were very low for deaf children. They would come out of high school, this high school program of Deaf schools, reading at the 4th grade level and that was appalling. Not because they were not intelligent, but because the language education was based auditorily. Which they didn't have access to.
Now over the years, many student audiologists have been in touch with me over the years, asking me what my major problem was as an audiologist with a hearing loss. There's some things I couldn't do. Let's face it. There's some things it would be difficult for me to do. But it's compensated for many other things I can do, depending on my own personal skill and interest and so on.
When I first went into the field, working at the San Francisco Hearing & Speech Center as one of my clinical settings, I had to take talkback responses from patients in the presence of two or three of the supervisors to see that I was able to take talkback responses accurately, which is very possible. You can locate the microphone and the angle of the face, I can watch them and listen to them, and I had no problem. But in the VA, what we did was have write (down). And that was always another challenge for people who were illiterate. But most people could write the monosyllabic words, the W-22 lists, had no trouble.
Well right now I'm retired. I'm 90 years old now. I retired 4 years ago, the way I view it, because after I retired from the University of Connecticut and worked for the League for the Hard of Hearing in New York for 5 years, commuting in, I started to write articles for Hearing Loss journal every issue, trying to translate scientific articles into consumer language, which it gets to be a real challenge not using all the acronyms or using all the jargon that we would get involved with. And for 18 years I did that after I retired. And it was one of the most rewarding periods of my life. I really enjoyed it. Even now I'm a member of the HLAA, and we meet here, right next door at the University of Connecticut once a month.
Well it's okay. I feel that I'm living this long. I feel fine. But I do we think about it once in a while. That here I am starting in the field as a patient, because we really had so much academic training as patients, information about hearing loss was part of the training program, anatomy and physiology. Well you know, right now I think people who sell hearing aids, provide direct services, provide any interaction between a therapist and a person wearing hearing aids, it could be potentially be AR. You explain the hearing aids usage to the person, you answer the questions, you're engaging in a therapeutic interaction with them, so we should remember that.
But there should be some explicit focus on AR. We used to have it here. We have it a lot of places where, after the hearing aid is recommended to use, you get together one evening a week for an hour and a half, 2 hours, (it) would go over an 8-week program or a 4-week program. Does it help? I think it does. Do we have evidence that it helps? Mixed.
It's your students who come to the AR program, to the HLAA program, (who) are getting a kind of training that it's hard to put down on the books. They listen to the people talk about the hearing loss. They relate to them not [as] professors or therapists as objects, patients but as colleagues, as equals. And you look and listen to them as people, not as patients. And they learn, they learn a lot.
The Future
Well the other example Robert West used to give besides the circle getting broader learning more the more we learn, the more we know—the more we don't know. Progress is a spiral. Now that's not a circle. You come back to the same spot, but you're one level above. You've tried something and you know what failed, as well as why it had succeeded. And you keep going and maybe the third time around you still seem to be doing the same thing. But you're not, because […] if you're smart you profited from the other times you've been in that position before. So, I think […] progress being a circle and a spiral is [what] I always took with me.
We would like to thank Rebecca Kelly-Campbell for her assistance with the transcription of this video, and Charisa Lansing and two anonymous reviewers for their thoughtful critiques of this work.
We've Changed Our Publication Model...
The 19 individual SIG Perspectives publications have been relaunched as the new, all-in-one Perspectives of the ASHA Special Interest Groups.