Richard S. Hallam

Acquired profound hearing loss: Mental health and other characteristics of a large sample

The study investigated the mental health and other characteristics of people with acquired profound hearing loss (APHL) and contrasted this group with acquired hearing loss (AHL) in general. A survey was completed over the internet by 95 adults and by 27 people who had attended a one-week course of rehabilitation. The latter group completed questionnaires of anxiety and depression, post-traumatic stress, and hearing handicap. The survey covered a wide range of factors associated with the history of hearing loss and evaluated previous contacts with professional services. The data from the two samples were very similar and were combined. The results indicated the existence of sudden and progressive onset groups, reliance on lip-reading, a severe effect of tinnitus, and some support for the conclusion that the psychosocial impact was greater in APHL than in AHL. A subgroup of APHL was severely distressed and handicapped. Respondents valued medical and audiological services but there was little evidence that previous counselling and support had been helpful. Recommendations for rehabilitation are briefly discussed.

Persons with acquired profound hearing loss (APHL): how do they and their families adapt to the challenge?

The study examined the impact of acquired profound hearing loss (APHL) on the relationship between the hearing impaired person and their normally hearing close family member, usually a partner, and identified the kinds of adjustment leading to maintenance or deterioration of the relationship. The participants were 25 people with APHL and 25 family members, interviewed separately in their own home. Analysis of the interview transcripts adopted a grounded theory methodology. The different levels of analysis were linked in terms of a core category based on the social construction of a committed relationship. The conceptual codes were grouped as: (a) aural impairments giving rise to the need for adjustment; (b) pragmatic adjustments to spoken communication and family activities; (c) managing the adjustments without negative consequences; (d) adjustments leading to negative interaction. The results suggest that APHL places considerable strain on relationships and increases their vulnerability to failure, consistent with previous research. They highlight the need for professional support and suggest that a systemic conceptual framework is needed that includes the public response to profound hearing impairment.

Conversation tactics in persons with normal hearing and hearing-impairment

Abstract Objectives: To investigate the tactics people use when aural communication fails owing to environmental circumstances or impaired hearing. Design: Persons with different degrees of self-reported hearing impairment completed an online questionnaire constructed from items taken from the literature on communication strategies but reworded to be understood by people with normal hearing. Tactics were examined for frequency of use in two severities of impairment and between genders. All the data were then factor analysed and factor scores related to variables of relevance to communication. Study sample: A large convenience sample (n = 188) with a range of self-assessed hearing impairment from normal to profound. Results: Descriptive data revealed some differences in frequency of use in relation to severity and gender. Factor analysis yielded six clearly interpretable factors, the largest relating to disengagement (avoidance). Self-assessed impairment was chiefly associated with a speech reading tactic, negatively with environmental optimization strategies, and to a small extent with disengagement and conversation repair. Conclusions: Only the tactic of speech reading was closely associated with impaired hearing, with some evidence that females were more inclined to use it. Otherwise, all tactics were commonly employed, regardless of hearing status.

Conceptual Frameworks for Case Formulation

There is public skepticism about psychotherapy that comes from a lack of transparency about its practices. A conceptual framework for case formulation has to recognize technical expertise, relationship skills, and understand therapy as both art and science. Evidence is lacking that therapeutic expertise relates to outcome, leading to the suggestion that more attention should be given to reasons for failure. Progress depends on the availability of a common language to describe problems. However, there are constraints on the adequacy of evidence that can be gathered for formulation. Formulation has to accommodate multiple perspectives on pragmatic issues. Low-level inferences (information about a client in literal, ordinary language) are distinguished from high-level inferences (i.e. interpretation and hypothesis about a client). A client’s self-interpretation is seen as part of problem description, whereas ICF (individual case formulation) is a therapist’s account. These two perspectives differ and therapists have to operate at a “double-level” of understanding. Goldfried’s “Case Analysis and Synthesis of Events” (CASE) system for problem description is discussed. Arguments are made for a functional (ethological) approach. Different models of case formulation are analyzed critically: integrative, cognitive, problem solving, functional, functional analytic, Acceptance and Commitment Therapy, and psychodynamic. Proposals for ICF are outlined.

Formulation—the Main Issues

The skills of case formulation are held in high regard but have been little researched. In this book, the analysis of these skills is conceptualized within a problem-solving, not a diagnostic, framework. Formulation is viewed as a collaborative process that provides a rationale for the process of therapy for both client and therapist. The importance of formulation is put in question by the finding of equivalent outcomes with different forms of psychotherapy. However, skill in formulation may help to explain individual differences in therapists’ effectiveness. In any case, there is need for a model of reflective practice. The framework of problem solving is discussed in relation to psychiatric classification, etiological models, the evidence base, and models of practice. It is argued that the present divide between researchers and practitioners is perpetuated by a narrow conception of evidence-based practice. Nomothetic knowledge, in the form of principles and general processes, should be applied ideographically.

The Process of Reasoning in Individual Case Formulation

The kind of reasoning that enters into ICF is explored. Earlier critiques of practitioners’ reasoning skills are rebutted. Retrospective and prospective reasoning styles about cases are differentiated. The role of hypothesis testing and base rates is explained. Common errors in processing information under conditions of uncertainty are illustrated. The roles of deductive, inductive, and abductive reasoning are explained and illustrated.

Formulation Skills and the Therapeutic Relationship

The difficulty of disentangling the therapist’s relationship with a client from their ability to formulate a problem is discussed. It is noted that self-help and therapy delivered by computer can be effective. The concept of the therapist as healer or shaman downplays the role of formulation and this model is criticized as implausible. Correlational research concerning the quality of the relationship and its relation to outcome is reviewed and various interpretations offered. Research on differences in therapists’ effectiveness and the role of feedback on progress is examined for its possible relevance to the theme of the chapter.

A Functional/Systemic Framework for Case Formulation

Kanfer and Saslow’s early conceptualization of a functional formulation is described. Haynes and O’Brien’s more recent “Functional Analytic Clinical Case Model” (FACCM) is discussed. Topographical and functional analyses are distinguished, and the need to define “acts in context” is stressed. The description of behavior has to be separated from an account of causal mechanisms. Event dependencies and learning contingencies are distinguished. The concept of a behavioral repertoire and a constructional approach is explained. The role of language and “meaning” in the functional approach are considered. Moderating and mediating mechanisms are explained. The idea of functional relationships needs to be made compatible with a variety of higher level systemic analyses. The value and use of formulation diagrams in therapy are discussed. A simplified system of symbolic conventions for an ICF diagram is proposed. This encompasses the representation of causality, types of relationship, causal mechanisms, client awareness, reciprocal relationships, and vicious and virtuous circles. The problem of representing the causal effects of past events, private experience, and beliefs is examined and solutions offered. The concept of systemic analysis, and the person as a subsystem, is introduced.

Future Prospects for Individual Case Formulation

It is observed that professional esteem for case formulation skills is not mirrored in some contemporary evidence-based practices (EBP). There is little evidence of systematic training in case formulation in the psychotherapy literature. The focus on symptoms in EBP limits the scope and importance of formulation. By contrast, prevention programs focus on psycho-educational skills and problem solving. The cost-effectiveness of manualized EBP carried out by relatively unskilled therapists is questioned. Doubt is expressed that effectiveness studies are aiming high enough in terms of expected outcomes. The following problems when evaluating outcome are discussed: results influenced by a subsample of early responders; therapy of inadequate length; difficulty of assessing therapist competence. Training issues are discussed in relation to CBT (cognitive behavioral therapy) skills. The dissemination of EBP with briefly trained therapists is critically discussed. The future of case formulation and psychotherapy are considered.

Theory and Evidence in Individual Case Formulation

In the “common factors” approach to psychotherapy, formulating according to a theoretical model is seen as one aspect of a specific model of practice. Consequently, within research into common factors, there are few attempts to develop an evidence base for a generic process of assessment and formulation. Some psychotherapists deny the relevance of science to practice. For those who apply an evidence base, there is no consensus on how this should be done when formulating on an idiographic basis. The origins and development of the single-case experimental model are described, as well as its influence on ICF. The meaning of the application of science to practice is still a contested area. Arguments and evidence for ICF are put forward.