Patient Care | May 2018 Hearing Review
Reflections on a trip to Denmark’s hearing care facilities and the “Camelot Period” of AR
A trip back to Denmark in the late 1970s shows the extent to which adult aural rehabilitation was considered essential in the care of those with severe to profound hearing loss.
In 1976, I was working at the National Acoustic Laboratories’ (NAL) Central Office in Sydney, Australia. My position there as “teacher of the deaf” was extremely flexible. Truth be told, no one really knew what I was expected to do, and I had a great deal of freedom choosing the areas in which I worked. I decided that I wanted to work with adults with acquired hearing loss, and spent the previous year running groups and seeing clients at one of NAL’s Hearing Centers.
This was a fascinating and enjoyable experience, but I realized I needed to know much more. There were few resources available for people who wanted to work in adult aural rehabilitation at that time, but I had been fortunate to receive a great deal of help and advice from Pat Pengilley at the HEAR Service in Melbourne. In retrospect, I realize how lucky I was, because Pat was a visionary who did so much—directly and indirectly—to improve the services offered to adults with acquired hearing loss. She shared her materials generously, and was always available to talk and offer advice and encouragement. It was Pat who first told me about the aural rehabilitation (AR) services provided in the Scandinavian countries. She believed that they provided a model that the rest of the world should try to emulate.
Pat was a great influence, but perhaps the most important event in my working life at NAL occurred in early 1976. Laurie Upfold, the head of the department in which I worked, came into my office, threw a set of papers onto my desk, and said, “You should apply for this,” then promptly walked out. The papers described how the World Health Organization (WHO) was awarding a fellowship to visit healthcare facilities in other countries.
I dutifully filled out an application to visit AR facilities in Denmark and Sweden. I didn’t expect to be awarded a fellowship; I was sure that it would be awarded to a medical doctor, but felt I just had to apply—not least because Laurie had told me that I should!
Fast forward to late February 1977, and my wife Kerryn and I were sitting on a plane bound for Denmark. I had been awarded the fellowship, and we would be spending six weeks in Denmark and six weeks in Sweden.
The trip didn’t start well. The first thing I did the day after we arrived was visit the WHO office in Copenhagen, and they were extremely surprised to see me! I had been expected in Aarhus in Jutland in the west of Denmark the previous day, and they were wondering what had happened to me.
Arrangements were hurriedly made, and we flew to Aarhus the next day, where we were to be for the following three weeks. The day after our arrival, I met Dr Ole Bentzen at Aarhus Hospital, who was responsible for my stay in Denmark. Dr Bentzen made sure I was going to get a comprehensive understanding of AR. One of the first things he did upon meeting me was to hold up two hearing aids and announce, “This is a hearing aid.” He went on to explain that we had two ears, so it was imperative that both should be aided. Around 80% of hearing aid fittings at the Aarhus Hospital were binaural, and Dr Bentzen was a passionate advocate of binaural fittings at a time when there was still considerable controversy about the topic. He has been proven right, and it is hard to believe that there are now any professionals who would push for monaural fittings in any but the most exceptional of cases.
Once the hearing aids were fit, clients received one-on-one follow-up with a hearing and speech therapist at a separate facility near the center of the city. At the first session, the new hearing aid (HA) user received a basic hearing aid orientation in which s/he was provided with information on her/his aids, provided with a simple explanation of his/her audiogram and its meaning, and counseled on the use of Hearing Tactics.
Hearing Tactics was the name given to the strategies that people could use to overcome some of the problems created by their hearing loss. The emphasis was on practical suggestions about how the hearing aid user could manipulate their environment and conversational partners to make speech comprehension easier.
A second session, also one-on-one, was provided a month later, and this concentrated on any problems the HA user had experienced in the preceding month. People having extreme difficulties would be offered additional training, but attendance at these was not obligatory and only about 5% of clients required these further services.
I had the opportunity to sit in on some of these sessions provided by Edith Holm, a senior therapist at the center. One of the clients was a woman who had worn only one hearing aid in her right ear for around 20 years. She had been fit binaurally, and was having difficulties adapting to amplification in her left ear. The exercises provided training using the left ear only, binaurally, and included some practice in a noisy background. At the end of the session, she told me that the sessions had been of great value, and she now preferred the binaural fit, even though she had found it extremely difficult at first.
One particularly impressive service provided in Aarhus was the use of hearing welfare assistants to assist older people who, because of age or ill health, found it difficult to attend the sessions provided in the city. There were around 40 hearing welfare assistants in Aarhus, and their work included accompanying clients to the hospital for testing, and making follow-up visits to check on the client’s progress and assist, wherever possible, if any problems had arisen.
The hearing welfare assistants were almost all middle-aged women reentering the work force after their children had left home. They had no formal qualifications, but were provided with a basic training course by the hearing and speech therapists. I accompanied one of the assistants on her visits one day, and was impressed by the quality of the service provided. The HA users obviously felt more comfortable in their own homes, and enjoyed the opportunity to be able to discuss any difficulties in detail.
One thing that especially impressed me was the assistant’s appreciation of what she did not know. On a couple of occasions, clients asked questions which the assistant was unable to answer. Rather than try to bluff her way through, she made notes about the problem, and assured the client that she would be seeking answers and any possible remedies from the hearing and speech therapists.
After almost three weeks in Aarhus, we took the train to Fredericia to spend a week at the State Hearing Institute. This was probably the most impressive of all the facilities I visited during the fellowship, and it’s sometimes hard to believe that such a service once existed. Mark Ross, PhD, often talks about the training he received at Walter Reed Hospital in the early 1950s as a “Camelot Period,” 1 and this is certainly a good descriptor for the experience at Fredericia. The State Hearing Institute was a residential facility, funded by the Danish federal government, and it provided services for adult clients with acquired severe or profound hearing loss who were experiencing special difficulties. All of the services—including accommodation and meals—were provided without charge, and most people attended for around one month. Rail travel to and from the facility was provided on weekends, and clients were placed on “sick leave” for the duration of the program, with their salary being paid by the government. Many of the clients were accompanied by their spouse, again, with all costs met by the government.
Kerryn and I were both quite young at the time and, at least at first, found it quite intimidating to be in a facility where all of the clients were much older than us. Looking back, however, I now realize that almost all of them were considerably younger than I am now! Our feelings of trepidation were increased at 7:00 AM the following day, when a wake-up alarm was rung in our room. You’ve doubtless heard the expression “loud enough to wake the dead;” this was loud enough to wake the deaf! Towards the end of our visit, when we were more comfortable with the situation, and the clients were more comfortable speaking English with us, we had a very enjoyable evening talking with a large group about their reaction to the courses provided. They were overwhelmingly positive, and I think that many of them would have also seen Fredericia as a “Camelot” for people with hearing loss.
The program ran from 9:00 AM-3:00 PM, Monday-Friday, and classes were provided in small groups (usually around six people in each). The day started with the whole group meeting together and singing a song from a popular collection of Danish tunes. I found this quite moving, and it was one of those musical experiences where I felt the hairs on the back of my neck stand up. It wasn’t the quality of the singing that elicited this emotion. The singing was fairly ragged with not everyone singing exactly in tune. Rather, it was the feeling of group cohesion and “togetherness” that was so apparent for almost everyone there. Participants gained an enormous amount from meeting and talking to others who were in the “same boat,” and I think that this was one of the major benefits of the program. The group song was indicative of this shared feeling of support, as well as a daily icebreaker.
As was common at that time, classes were provided in lip reading, and this was seen as one of the Institute’s key programs. Although pre- and post-training testing showed no significant changes in performance, those providing the training seemed unfazed by this outcome. They believed that they were improving the client’s confidence and this led to a reduction in the client’s perception of handicap. The tutors felt that a better measure would be a Social Hearing Index that showed the client’s conception of individual handicap before and after training.
Auditory training classes were conducted using the clients’ hearing aids. A wide range of training materials was presented through an induction loop system, which provided the group with the opportunity to become familiar with this form of coupling. Training exercises were also presented using the telephone. This provided clients with the chance to practice telephone use in a supportive and non-stressful environment. Additional auditory training was available after hours through a recorded program that was broadcast through speakers in each client’s room. Clients could choose their preferred level of difficulty, and record their responses on printed sheets that were later scored for accuracy. There was also a self-training room where clients could practice with telephone training facilities and tapes of environmental sounds. By today’s standards, these materials would probably appear to be quite simple, but before the advent of PCs and the Internet, they represented a large corpus of materials of varying levels.
The Institute closed sometime in the 1990s, and despite assurances that similar services would be provided at a local level, this does not appear to have happened. I presume it was the victim of a reluctance to commit government funding to support such long-term care, but it is a great pity that there does not appear to be any real successor to this extraordinary program.
I remember speaking to a group of Danish therapists in Odense in 2008, and mentioning the program provided at the State Hearing Institute. It was quite apparent that virtually none of them had any idea that such a facility ever existed, and I spent a little time telling them about the services provided. Their reaction was that it sounded almost too good to be true, and they assured me that nothing similar would ever be funded again.
Most of the clients that I saw in Fredericia would now be considered candidates for cochlear implants (CIs), and there are many who would argue that the development of this technology has made facilities such as the State Hearing Institute redundant. I regard such views as, at best, an oversimplification of the situation. CIs do provide adults with acquired deafness with unparalleled access to speech and other sounds in their environment, but they do not “solve” all of the problems created by hearing loss. My view is that the results obtained are extremely impressive, but I also believe that few CI users achieve their full potential. The lack of systematic and readily available training and support prevents most people from reaching their optimal level of performance, but there appears to be little enthusiasm for the provision of such programs.
The Fredericia facility was one of the last programs to provide such intensive support for adults with acquired hearing loss, and I greatly regret its demise.
Our final two weeks in Denmark were spent in Copenhagen, the country’s beautiful capital. Aarhus and Fredericia were attractive cities, but there is something magical about Copenhagen, even when the winter drags along into April.
It was in Copenhagen that Kerryn saw snow for the first time, and where we met at least one other visionary in the field of adult aural rehabilitation. My sponsor in Copenhagen was Lars von der Leith, who headed the Audio-Pedagogical Study Group at Copenhagen University. Lars later headed up a university-based training course to prepare hearing therapists to work with adults with acquired hearing loss. Lars’ group at that time had led a study that had resulted in the publication of Hearing Tactics,2 a small book which described the problems created by hearing loss, and attempted to detail ways to overcome or, at least, alleviate them. It was the result of a collaboration between teachers, psychologists, and people with hearing loss, and provided many useful insights and suggestions. I had heard Hearing Tactics discussed in both Aarhus and Fredericia, and now I knew where many of the ideas had originated.
There were a number of post-graduate students working in this department, and they would meet and eat lunch together around a round wooden table. I joined them for several meals and, fortunately, like almost all Scandinavians, they were able to switch to English so that I could be included in the discussions. At that time, the projects being undertaken included studies of auditory (A), visual (V), and auditory-visual (AV) speech perception, and an investigation of gesture and other non-verbal cues. This group had assisted in the development of the HELEN Test, a sentence test that included lists that were presented auditory-only, visual-only, and auditory-visually. I gained an enormous amount from these discussions, and they helped shape the direction of my work over more than 40 years.
James Jerger’s account 3 of his visit to Copenhagen in 1960 includes mention of the ideas for speech testing put forward by Dr H.W. Ewertsen of Bispebjerg Hospital. Ewertsen stressed the need to have a test that more closely replicated the realities of everyday, face-to-face communication for hard-of-hearing adults. The HELEN Test consisted of 8 lists of 25 sentences, which presented such simple questions as, “What day comes before Friday?;” “What is half of four?;”“What language is spoken in France?,” and “What color is milk?” The listener’s task was to answer the questions (although I think they were also allowed to repeat the question). A practice list was presented in quiet at the listener’s preferred listening level, and they had to score 100% correct to move to the next round of testing. Noise was introduced to reduce the listener’s auditory score to around 50% correct, and lists were then administered in the A, V, and AV conditions.
I was very impressed by this work, and with the help of a Danish/English dictionary and the receptionist at the Danish Consulate in Sydney, eventually translated them into English. I continue to use these lists in my work with clients whose auditory skills are limited or have little confidence in their ability to understand speech.
There were some striking differences between the HA programs in Aarhus and Copenhagen. For example, only 30% of adults in Copenhagen received binaural aids, compared to 80% in Aarhus. Another major difference between the two programs was that post-fit interventions carried out at the State Hearing Institute in central Copenhagen were conducted in small groups (4-6 people), whereas all post-fit care in Aarhus was conducted one-on-one. I had been told tongue-in-cheek that Jutlanders from Aarhus were rugged individualists and needed one-on-one care, while those in the east of the country were afflicted with a “herd mentality,” and didn’t really think for themselves! An alternative reason was offered to me in Copenhagen and this involved the high intelligence of those who lived in the capital compared to the country bumpkins in the west! It was all meant in good fun, however, and I still wonder why such different models developed in such a small country.
The group sessions in Copenhagen were conducted weekly, and clients attended four 2-hour sessions. The course provided information on hearing aid use and provided practice in various listening situations. This included information and training in the use of induction loop systems, which were already provided in many theaters and churches in Denmark.
At the completion of the four-week program, around 25% of adult cases received further training. This was again provided in groups, and one of the exercises involved conversational training with class members working in pairs using a prepared script, with one asking questions and the other giving answers. Having three pairs working in the same room also created the kind of background noise that many people with hearing loss find extremely difficult.
Instruction was also provided in the Mouth-Hand-System (MHS), a series of hand cues which were used to differentiate between consonants with similar lip shapes. This system, which was developed at a school for deaf children in Fredericia, preceded Cued Speech by about 60 years and was used extensively by Danish adults with acquired deafness. The Institute also served as a venue for weekly meetings of a social club for MHS users. These provided clients with the opportunity to practice using the system and to meet and socialize with others with similar problems and concerns.
In looking back at this visit, I am more than a little saddened that many of the services and programs outlined in this article no longer exist. In part, this was due to shrinking budgets, but other factors were also involved in the demise of the Danish approach to aural rehabilitation which flourished between about 1950 and the 1980s. The move to decentralize services was probably also a major factor in the closing of the Fredericia facility. In theory, this was a sensible move. Providing services closer to a client’s home has great appeal, but the unfortunate consequence was a loss not only of an excellent program, but also of the collective knowledge of the therapists who worked in Fredericia during that “Camelot Period.”
The need to develop better tests of an individual client’s ability to understand speech in various sensory conditions and environments remains an ongoing concern, and looking back at the work done in Denmark in the 1970s might provide some clues as to how best to proceed.
Finally, the lack of adequate outcome measures makes it more difficult to show the benefits of such an approach to AR. Until systematic research is conducted to show how AR programs can help adults with acquired hearing loss, the difficulties in finding support for such work will remain.
A recent book by Michael Booth about the Nordic countries called The Almost Nearly Perfect People reminded me of my time overseas. I don’t claim that the system I saw in Denmark in 1977 was perfect, but it was probably “almost nearly perfect.” If the aftercare system that existed in Denmark during that period could be added to the technology of today—HAs, CIs, PCs, and tablets—we would be moving much closer to achieving the best outcomes for our adult clients.
I hope that this account of the first part of my fellowship has provided the reader with some idea of the programs that existed in Denmark some 40 years ago. In a future article, I will describe the programs I saw in Sweden.
Correspondence can be addressed to HR or Geoff Plant at:[email protected]
Original citation for this article: Plant G. ‘Almost nearly perfect’ adult aural rehabilitation: A tour of Denmark in 1977. Hearing Review. 2018;25(5):18-21.
Ross M. Aural rehabilitation: Some personal and professional reflections. Hearing Review. 2001;8(8):62-67. Available at: https://hearingreview.com/2001/09/aural-rehabilitation-some-personal-amp-professional-reflections/
von der Lieth L. Hearing tactics. Scand Audiol. 1972;1(4):155-160.
Jerger J. An audiological journey in a smaller world. Hearing Review.2015;22(11):20-22. Available at: https://hearingreview.com/2015/10/audiological-journey-smaller-world