audiometry

History taking


Suggested Learning Resources


You might like to look at the following books and videos but you do not have to buy any to complete this module.

Mackay, Hugh (1994) Why don’t people listen
Pan Australia

Elder, Bruce (1994) Communication Skills.
Macmillan Education Australia

Bolton, Robert (1986) People Skills
Simon and Schuster (Australia)

Cole, Kris (1993) Crystal Clear Communication: Skills for Understanding and Being Understood
Prentice Hall New York.

Sadler and Tucker (1993) Common Ground- A Course in Communication
Macmillan, Australia

Ellis, Richard and Mcclintock, Ann (1994)
If You Take My Meaning - Theory into Practice in Human Communication
Edward Arnold, Hodder Headline. London

Eunson, Baden (1994) Communicating With Customers
John Wiley and Sons, Brisbane.

Eunson, Baden (1994) Communicating With Customers: Instructors Manual
John Wiley and Sons, Brisbane.

McHugh, Shirley and Pollard, Jeannie (1991)
Pitman Business Communication
Pitman. Melbourne.

Shipley, K.G. (1997) Interviewing and Counselling in Communicative Disorders: Principles and Procedures (2nd Edition)
Allyn and Bacon

Katz, J. (ed) (1994) Clinical Handbook of Audiology (4th Edition)
Williams and Wilkins, Baltimore

Martin, F.N. (1996) Introduction to Audiology (6th Edition)
Allyn & Bacon, USA

AUDIO VISUAL RESOURCES


The following videos may be interesting to watch.

Everybody’s in Customer Service
Video Communicators Pty. Ltd. S.A. 1995

Telephone Techniques
Videotrain. Melbourne. 1990

Cleese, John
Awkward Customers
Video Arts, London. 1973

Cleese, John
More Awkward Customers
Video Arts, London. 1973

Colgan, Church and Becky
Customer Service: Dealing with Difficult Customers
McGraw-Hill USA



Common Communication Difficulties Experienced By Hearing Impaired Clients

When a hearing impaired client decides to come to see you it will be because they and/or someone close to them feels there is a problem.

The type of problems they will discuss with you have nothing to do with the state of their cochlea or hair cells or eardrums. Their major concerns will be based on the problems they are having with communication. They, or that significant other person, will tell you that the TV is too loud or that they are misunderstanding what is said to them, or they don’t enjoy the movies any more.

If we know the communication problems a client is experiencing then we are more likely to tailor the rehabilitation process more efficiently and effectively. Hopefully, we will have a happy client who will tell all his or her friends what a great service we provide.

Each hearing impaired client you see will have different needs and they will have different expectations of what the rehabilitation process will involve. Each client will have different abilities and different lifestyles. They will come from different backgrounds and will have different levels of support. With all these differences how can we talk about the problems hearing impaired clients experience? There are many similarities between the types of problems that clients will present with that are directly related to the impact of the hearing loss on the communication process. However, the way you deal with each client will depend on their specific needs and abilities.

Often, the solution sought for a communication difficulty is a hearing aid. It is expected that you will be studying this particular module in the early stages of your course. Therefore, this module will not relate the use of hearing aids and other devices used to communicate with the hearing impaired. Rather, it is concerned with the application of communication skills. To apply communication skills you will need to understand the reasons for communication breakdown relative to hearing loss.

The information in this module is relevant to the adult who has a post-lingually acquired (or adventitious) hearing impairment. That is, the hearing loss was not present at birth and is not related to hereditary factors. Post-lingual means the hearing loss was acquired after the person learnt to communicate verbally.


What is the purpose of communication?

There are so many answers to this question. You may have written that the purpose of verbal communication is to tell people what you are thinking or how you feel. Perhaps you wrote the purpose of communication is to give information, to instruct others to perform a task or to tell someone how to use a new piece of equipment.

Verbal communication also allows us to think. The language we use allows us to analyse situations or new information, to make decisions about what we will do and how we will feel.


How do we communicate?

Did you say we communicate by speaking?

Speech is only one mode of communication but is often used synonymously with communication. Speech is the verbal mode of communication. Other modes may involve writing, drawing, gesture or signs. This module concentrates on verbal communication, not because the other modes of communication are less important, but because, your major client group as an audiometrist will be the adventitiously, post lingually hearing impaired. That is, people who have an acquired hearing loss that started after speech and language was acquired.

Hearing keeps us in contact with our environment and with our fellow human beings. We are aware of the siren even when we can’t see the fire engine, the baby crying in another room or the knock at the door. However, the primary purpose of the hearing mechanism is to access spoken communication and keep in contact with our fellow human beings.


Do you experience communication difficulties?

Think about the situations in which you experience communication difficulties. Do you always hear every word someone is saying? What about when you’re listening to a person with a heavy accent, when you’re at a party or club or when you have other things on your mind?

Write down three situations in which you have experienced communication difficulties.


Over the next week make a note of situations in which you experience some communication difficulty. What happened? What sort of mistakes did you make? How did you feel?


Start observing other people. For example, while you are waiting in a queue at the bank or post office. Did you notice someone having communication difficulties? What circumstances caused that communication problem? What do you think could have made the situation easier?

Communication difficulties occur every day to hundreds of thousands of people. Some of these people also have a hearing impairment.

If the message being sent out is not the same as the message being received then there is a communication breakdown. Many things happen between the sending and the receiving of a message and we can’t always predict what will happen. However, when we know a hearing impairment exists we can be sure that it will impact on the communication process. Some things about the effects of hearing impairment on the communication process are predictable and that is what this module is all about. Remember though, not everyone will experience all the difficulties at the same time or to the same degree.

In short, this module is about the types of communication problems we might expect to be present and some ways to assist your adult clients, with post-lingually acquired hearing impairment, to overcome them.

What sort of problems might we expect a hearing-impaired person to experience....


Hearing impaired clients will often say things like;

• I can’t hear soft voices
• Don’t yell I’m not deaf
• If only people didn’t mumble
• Some words sound the same
• I can’t understand women’s voices as well as men’s
• Voices blur together in a crowd
• I can hear but I can’t understand
• I can’t hear at the club

If a client has a hearing impairment then they cannot hear sound as well as they did when their hearing was ‘normal’.

“I can’t hear soft voices”

The effect of a hearing loss may simply be that the client does not hear sound as loudly as they could before. If sound can be made loud enough they are still able to hear clearly. Clients like this are quite rare. Most clients you see will not hear sound as loudly as they could but also not as clearly as they could.

We say that the client’s discrimination has been affected. Therefore, no matter how loud speech is, it will still not be clear.

Therefore, the majority of hearing impaired people will have a hearing impairment that affects the volume as well as the clarity of speech.

The ability to discriminate speech is also affected by the client’s age. One effect of aging on communication is that discrimination becomes increasingly difficult. For example, two clients have the same hearing loss, one reports a great deal of difficulty and the other very little difficulty understanding speech. The first client is seventy five years of age and the second client is thirty five years of age. Do not automatically presume that a client will have greater discrimination problems because they are elderly but you do need to be aware that this is a possibility.

“Don’t yell, I’m not deaf”

Even though hearing impaired people do not hear as loudly as people with normal hearing, many cannot tolerate increases in volume as easily. This phenomenon is called recruitment. It is described as an abnormal growth in loudness function. In other words, a small increase in loudness may appear as a big increase to the hearing impaired client.

Family and friends of a hearing impaired client may try to help ease the communication difficulty by raising their voice level. The may well receive a frustrated response, “Don’t yell, I’m not deaf”.

“Some words sound the same”

The most common type of hearing loss in adults is a high frequency hearing loss. That is, the low frequencies are heard better than the high frequencies.

In speech the low frequencies are important as they provide the following;
• the intonation patterns, eg, you know an utterance is a statement or a question because the intonation rises when a question is spoken
• the main energy for the production of vowels is in the low frequencies
• vowels tend to have more energy than consonants so they provide a lot of the volume for speech. It is common to hear your clients say they can hear that someone is talking but they can’t understand what is said.

The energy for consonant sounds is predominantly in the high frequencies. The consonants (apart from the nasals) tend to have very little volume. For example, the vowel sound in the word ‘hard’ is around 35dBSPL louder than the soft ‘th’ sound as in ‘thing’.

Therefore, words like ‘thing’, ’sing’, ‘king’ and ‘ping’ sound similar when a client has a high frequency hearing loss.

Even though these sounds are similar they often look different.



Activity : Ask someone to say the following words silently (that is, mouth the words) but without exaggeration while you look at them or do it yourself while looking in a mirror.

mother brother son one
blue glue thing sing
king ping shoe sue
that bat cat sat
fish wish fool pool


As you can see, each pair of words looks quite different. To a hearing impaired client these pairs will sound similar.

“I can’t understand women’s voices as well as men’s”

Can you tell if it is a man, woman or child speaking without seeing them?

Usually you can. Do you know why? This ability is related to fundamental frequency.

Men’s, women’s and children’s voices are different essentially because of the size of the larynx. Men normally have a larger larynx than women, and children have the smallest. We perceive men’s voices as being deeper than women’s and children’s voices. Men have a lower fundamental frequency. The vocal folds determine the fundamental frequency and therefore our perception of the pitch of the voice.

It is often said that men’s voices are easier to hear. This is probably because of the harmonics generated. Harmonics are integral multiples of the fundamental frequency. For example, if the fundamental frequency is 70Hz, harmonics will occur at 140Hz, 210Hz, 280Hz, 350Hz, etc. This means that if the fundamental frequency is lower then more harmonics will be in our audible range of hearing, making it easier to understand what has been said.

“Voices blur together in a crowd”

Hearing impaired clients find it difficult to hear well when they are with a group of people. It becomes increasingly difficult, as hearing becomes worse, to isolate the voice that you want to listen to and ‘shut out’ the other voices.

Most people with normal hearing are able to listen selectively. That is they can concentrate on what they want to hear.

Most people with a hearing loss have difficulty in doing this. This is one of the most common problems mentioned by hearing impaired people.


It is even more difficult when the hearing is asymmetrical. That is, a person’s hearing in one ear is worse than the other.

This is because we rely on the time and intensity differences between our ears to establish the location of a sound. This allows us to ascertain who is speaking and we can then focus on the speaker.

It is also difficult for hearing impaired clients to understand what is being said when the speaker is talking quickly. The words seem to blur together.

“I can’t hear at the club”

Hearing impaired people often complain that they cannot hear when the level of background noise is high. Different clients will express this in different ways. They may simply say: “I can’t hear when it’s noisy” or they may say: “I don’t bother going to family parties any more”.


Hearing in noise


Hearing in noise is a difficulty experienced by everyone. Hearing impaired people have even more problems because of the effects of the noise on speech.

What is noise? It is defined as unwanted sound. Consider what happens when you’re trying to watch your favourite show and your friend talks to you. Your friend’s talking is noise. Compare this situation to when there is an ad on the TV and your friend is telling you about a job vacancy that pays twice the money you now earn and for which you have the necessary qualifications and experience. The TV is not noise in the first instance but is noise in the second instance.

In English, it is essentially the high frequencies that give us the clarity for speech and the low frequencies give us the volume of the speech and the intonation patterns. That is, the consonants are mainly high frequency sounds and the vowels are mainly low to mid
frequency sounds.

Most hearing impaired people can hear the low frequencies better than the high frequencies. Therefore, hearing impaired clients will complain that they are unable to hear clearly.

In background noise this situation is made worse and it relates to a phenomenon called the upward spread of masking.

This is a phenomenon where low frequencies mask higher ones but the reverse does not happen. That is, low frequency sounds interfere with speech understanding more than high frequencies.

The upward spread of masking is often what happens in a crowd or at a party. Most people have trouble hearing in this type of situation. Hearing impaired people have more trouble in background noise partly because the upward spread of masking has a greater effect in a damaged cochlea.

Noise can also effect people in a way that does not directly affect the sound of speech. For example, noise can be annoying. Therefore, if a hearing impaired person is already experiencing difficulties hearing in background noise it is likely they will start to experience added stress because of the effect of the noise on how they feel. They may find the noise is causing psychological distress or it may increase their heart rate and blood pressure. This will, therefore, affect their ability to concentrate on communication and cause fatigue.

Why does Bob deny he has a hearing problem? Perhaps it is because he feels that to admit he has a hearing problem means that he has admitted to being an old man and he still feels like he did at fifty. Perhaps he feels that his competence is threatened. That is, an old deaf man is an old stupid man who relies on others.

Some of the reactions that may be involved are; frustration, anxiety, discomfort, impatience, anger, a loss of confidence, loss of control or a threat to competence.

The person who suffers from a hearing problem may feel frustrated because they don’t understand what is being said to them. They may feel anxious that they will not be able to understand or feel embarrassment that they may appear incompetent. They may feel impatience because they believe that other people mumble and try to talk to them from another room. They may feel anger that others do not make more effort to help them understand or they may direct the anger at themselves for being unable to understand. Sometimes hearing impaired people lose confidence in themselves and react badly to being told they have a hearing problem because it is a representation of the aging process. They may feel that if their competency is threatened they will have their status reduced.

The communication partner may feel frustrated that they can’t make themselves understood, anxious because they don’t know what to do, discomfort because they feel awkward about pointing out that they have been misunderstood or impatient and angry that the hearing impaired person can’t understand them. They may also lose confidence, as they do not know how to handle the situation.

It is possible that your hearing impaired client is experiencing grief as a result of their hearing loss. The grief process may be related to the loss of hearing or what the loss of hearing represents. That is, the client may be grieving because the loss of hearing represents that they are elderly. The stages of grief are;
• shock or disbelief
• anger
• guilt
• denial
• fear
• acceptance

You may, occasionally, be the object of their anger. This may in fact have nothing to do with you personally and more to do with the grieving process. Clients who voluntarily seek assistance for a hearing problem or readily admit they have a hearing problem may be at the level of acceptance. However, the grieving process is not a step-by-step progression. Even clients that seem to have accepted their hearing loss may experience all the stages of grief again if a new development occurs. For example, a sudden and unexplained increase in hearing loss may result in shock and disbelief. The client may go through the stages of grief more quickly than previously but it still may be a necessary part of their rehabilitation.

Hearing loss has been referred to as the ‘hidden handicap’. It has been called this because you can’t tell by looking at someone that they have a hearing problem. Sometimes this means that they are judged by others as rude or senile. A hearing impaired person may not respond and therefore be thought of as rude or they may answer inappropriately and thought of as being senile.

How might a hearing impaired person try to deal with communication problems?

Sometimes hearing impaired people try to control social situations so that they do not have to feel frustrated that they can’t understand what others are saying. They may dominate a conversation and not allow anyone else to “get a word in edgewise”. That is, they start talking, choosing the topic of conversation, and do not pause at all during the conversation. They may also use a loud voice.

Many hearing impaired people have trouble regulating the level of their voice. Often hearing impaired people shout in an effort to hear their own voice or they whisper for fear of shouting and causing embarrassment to themselves and their friends.

Some hearing impaired people react to a hearing problem by withdrawing from social situations.

A hearing impaired client is not just ‘a pair of ears’. A hearing impairment is more than a loss of hearing. Hearing impaired clients may experience many emotions directly related to the effects of their hearing loss. These emotions will affect the communication process. They will also affect the rehabilitation process. A client may be more or less willing to participate with you in a rehabilitation program depending on their emotional response to hearing impairment.




Communication Strategies



Why should you be concerned with using effective communication strategies to overcome difficulties experienced by hearing impaired clients?

Do you want the client to understand you? Do you want to do your job quickly and efficiently?

Using effective communication strategies means that your client will have the best possible chance to understand you. It will also mean that you will be able to complete what is required of you in a more efficient manner.

Being able to communicate well with your clients will help to make them feel better and your behaviour, as a good communication partner, will provide a role model to any observer. By using effective communication practices you will appear more convincing to your clients and any observers and therefore, they are more likely to take your advice more willingly


How do you communicate effectively with a hearing impaired client?



There are some basic rules to observe when speaking with hearing impaired people. These will be addressed below however you will remember from your Client Interaction module the importance of first impressions and non-verbal communication.

Implementing effective communication strategies to ensure optimal interaction with hearing impaired clients

There are certain ways of talking to hearing impaired clients that will optimise the communication process.

Look directly at the client
If you look directly at the client they will be able to make use of visual cues. Speech reading is the use of visual cues to help understand what is being said. Many people use the term lip reading to mean the same as speech reading. Lip reading is one aspect of speech reading. Other aspects include looking at facial expressions and gestures.

The main cue is lip reading. That is, hearing impaired clients will be able to understand better if they can see the shape of your mouth. Remember in Activity 1.5 that words that sound similar often look quite different.


Activity : Ask someone to say the following words silently (that is, mouth the words) but without exaggeration while you look at them or do it yourself while looking in a mirror.

words.pngcasehistory1.png


What happened?

Did these words look different or the same?

Each groups of words look very similar.

Speech-reading will help in understanding speech but this help will be limited. About 30% of sounds can be understood by speech-reading alone. However, when combined with some auditory information speech-reading becomes more useful.

Therefore, you should look directly at your client when you speak to them and not move around too much. This will allow the client can focus on you. You should not cover your face. If you speak to your clients while chewing on a pencil or putting your hand over your mouth they will not be able to use visual cues.

Clients should be encouraged to wear their glasses (spectacles) to get the most out of visual cues.

When you are talking to the client you should be careful not to yell. The speech-reading pattern is distorted by yelling.

Looking directly at your client is also referred to as talking face to face.

Don’t shout
As just mentioned, if you shout, the speech-reading pattern will be distorted. Another reason for
not shouting when you are talking to your client is that some hearing impaired people cannot tolerate louder sounds. This is related to some clients’ loudness growth patterns. Clients with abnormal loudness growth perceive a small increase of the loudness of a sound to be a big increase in the level of the sound and may result in them experiencing physical discomfort.

So, even though hearing impaired clients can’t always hear well some cannot tolerate a loud voice. You can raise your voice slightly but it is better to talk a little slower and speak clearly rather than talk loudly. You may also utilise an assistive listening device if it is available in the workplace.

It is best to sit fairly close to the client so that you do not have to talk as loudly.

Speak a little slower
In speaking more slowly you must take care not to exaggerate your lip movements. It is beneficial to say each word clearly but not to speak so slowly that your sentences sound jerky. That is, you should articulate each word clearly but not leave big gaps of silence between syllables and words.

Rephrase
If a client has difficulty understanding what is said it is rarely helpful to repeat the words in exactly the same way. It may be that the words are difficult to hear or the combination of words is difficult to understand. Therefore, it is better to rephrase what you have said. That is, say the same thing in a different way.

Use contextual cues
It is much easier to understand what is said when you know the topic of the conversation. This is called the context. So when you use contextual cues you could tell the client the topic of conversation or give them a visual cue. For example, if you are talking about Tahiti, you could show them a postcard with the word Tahiti written on it clearly. Or you could say: “I want to talk about my holiday to the island of Tahiti”.

If all else fails
There are times when the best communication practices fail. If all else fails write it down. That is, write down a key word or even a few words. Occasionally it can help to point to what you are talking about, if that is possible.


Arranging the environment to ensure optimal interaction

What does arranging the environment mean?

It can mean changing the position of your desk, the use of soft furnishings or changing the seating arrangements. You might have to think about using blinds or curtains for your windows.

Why do you think this is an issue?

As you now know there are certain ways of talking to a hearing impaired client to optimise the communication process. To assist in the communication process there are ways of arranging your office to ensure that your behaviour is assisted by the physical environment.

The way you speak and your body language are the most important factors in optimising communication with your clients however, making the physical environment more pleasant can only help.

Temperature
If your office is too hot or too cold it may be difficult for clients to feel comfortable, not to mention the clinician. You may be asking the client for information that creates an emotional response in them or that is asking them to disclose personal information after having only known them for a short period of time. If you are not feeling comfortable or if your client is not feeling comfortable then it is likely you will both be distracted and unable to discuss such issues. The weather is not something you can control but you may know, eg, that your office becomes hot in the afternoon because it gets a lot of sun. You could use blinds or curtain to block out some of the heat.

Maintaining eye contact
Clients will feel that you are interested in them if you maintain eye contact. This does not mean staring at them for long periods of time but it does mean that while you are talking to them they like you to appear interested by looking at them and perhaps nodding and smiling at appropriate times.

If the arrangement of your office furniture makes this difficult, you need to consider how to rearrange the furniture and/or seating arrangements to improve the situation. Modern office furniture sometimes comes in modular form that makes it difficult to rearrange, therefore, if you are thinking of buying new furniture you may have to think carefully about its flexibility.

Lighting
One of the most important cues that hearing impaired clients rely on is speech reading. That is, a hearing impaired client needs to be able to see you, particularly your face, to optimise the communication process. Therefore, your face should never be in shadow. If you sit with your back to a window without blinds or curtains and it is a bright day the light behind you may cause your face to be in shadow. The client will not be able to use speech reading cues and they may not be able to maintain eye contact because they will be looking directly into the brighter light. How do you think the client may feel?

You will not want your client to feel intimidated. Therefore, you could have your windows tinted, use curtains or blinds, re-arrange the room or the seating arrangements.

Distance
It is best not to place too great a distance between yourself and the client as your conversation is about confidential issues. A discrete distance will help the client feel secure in the environment. Remember, the further the distance the harder it will be for the client to hear you.


Reduce any source of background noise

As has been discussed earlier, hearing impaired people generally have a great deal of difficulty hearing in background noise. If there is a constant noise in your office it is best to try and eliminate it. If you cannot eliminate background noise you can try and reduce its intrusiveness. You could try to absorb the sound using acoustic tiling on the ceiling or acoustic barriers. Soft furnishings may also help absorb some of the background noise.

Hard surfaces in your office might create a reverberant room. That is, it is possible that your office has an echo effect. Soft furnishings will help reduce this effect.

Access issues

Some of your clients may have other disabilities in addition to the hearing loss. For example, many people find mobility becomes more difficult as they become older. Narrow doors, passageways, steps into and out of rooms will make it difficult for these clients. Some of your clients may be in wheelchairs or in strollers. Can these clients even get into your office without a great deal of difficulty?

Final Comment

Sometimes you will have control over the way your office is organised and sometimes you have to work with whatever you have been given. Perhaps you will be able to improve a less than desirable situation with the budget you have available (which may be $0). You and your clients will benefit.


Activity: Make a list of the things you need to consider in creating a comfortable and functional consultation room in which to perform clinical hearing assessment.



Hearing Tactics


Evaluating communication abilities

Why would you want to evaluate communication abilities?

The reason is that each client is different. Even if clients have the same degree and type of hearing loss they have different abilities. When do you evaluate communication abilities?

For many clients that you see it is inappropriate to evaluate communication abilities. You will be asked to see clients for a variety of reasons. Some will only be seeing you for a hearing assessment or as part of a hearing conservation programme. Whatever the reason, if you feel the client should be assessed for communication difficulties you can include a comment in the report. For example, “It is recommended that he/she be seen for an evaluation of his/her communication needs and abilities”.

If you already work in a hearing clinic you may be able to use what is available. Perhaps one of your colleagues has devised a simple questionnaire. It may include questions like;

Do you have difficulty hearing people speak when it is quiet?
(a) all the time
(b) some of the time
(c) never

Do you have difficulty hearing people speak when in a noisy room?
(a) all the time
(b) some of the time
(c) never

Do you miss hearing the doorbell ring ?
(a) all the time
(b) some of the time
(c) never

Do you have difficulty hearing the telephone ring?
(a) all the time
(b) some of the time
(c) never

You can evaluate an individual’s hearing ability informally while you talk to them. As you ask the client questions during the case history, you will start to ‘get a feel’ for the kinds of abilities they have by how they deal with your questions. You can ask specific questions during the case history, about the kinds of communication difficulties they have. For example, “What causes you to think you have a hearing problem?”, “Do you have difficulty hearing your family speaking ?”, etc.


Establishing communication needs

The simplest way to establish communication needs is to ask the client. Asking the client is the most direct way but will be limited by the client’s perception of their needs.

Consider the following:
1. the client knows they can hear well in a quiet room when talking to one other person
2. the client knows they can’t hear speech well in a noisy room
3. the client doesn’t know they can hear well at the cinema
4. the client doesn’t know they can’t hear well in a meeting

In this example, the client is not aware they can’t hear well in a meeting. It could be the client never attends meetings and therefore, never has a need to hear well in that situation. On the other hand, it could be that the client enjoys going to meetings on a fortnightly basis but is unaware that they sometimes mis-hear what is being said.

Is it your responsibility to establish this is as a communication need of the client?

You can ask the client about the things they like to do and how they cope with the communication involved. Care needs to be taken that when you are establishing communication needs, they are the client’s needs and not what you think the client needs. One of the most important aspects of using communication therapy is its relevance to the client. If the client perceives that what you are doing is irrelevant to themselves then they are less likely to receive much benefit from it. If this circumstance arose you may be better off to say something like; “When you next go to a meeting, see if you have any difficulty in understanding the speaker/s. You might check with a friend after the meeting as to whether you heard everything properly. Let me know the outcome at our next appointment.”

An alternative to asking an open question such as “In what situations do you have problems because of your hearing?” is to have a list of situations and ask the client if they experience difficulty hearing, for example,

Telephone ring Doorbell ring
Television dialogue Cinema dialogue
Face-to-face conversation Quiet, group conversation
Noisy group conversation Speakers at meetings


If the client indicates they do experience difficulties you can then ask more specific questions.

When you establish communication needs it is worthwhile to find out which are the most important to the client so that you can make your communication therapy as relevant as possible. For example, if the client has difficulty understanding the dialogue of television programmes – which programmes ? Be specific. If you choose a favourite programme and explain to the client that together you will use this programme as a measure of how much his or her hearing ability is improved by appropriate hearing device fitting then you have involved the client in their own rehabilitation and empowered them. Rehabilitation is always more successful with the patient’s ACTIVE participation.


Client History



Compiling a Case History to ascertain client needs


Compiling a case history may take a minute or it may take half an hour. When you see a client for the first time you will decide what sort of information you need to obtain from them. The purpose of the consultation will then determine the case history you take.

Case histories are generally taken at the beginning of the appointment but you can add to them at any stage. If you were achieving audiometric results that were not what you expected from the information gathered in the case history then you will need to ask the client more questions.

During the case history you will start to form ideas about your client’s hearing difficulties and how you can best help them. The case history is a very important part of the test procedure but should never be used as a tool on its own. However some things that the case history might assist in determining are;
• the need for an interpreter. That is, if the client is from a different language background and is having difficulties understanding the questions. Ideally this would have been determined prior to testing.
• the need for amplification to assist in conducting the case history interview. If the client is particularly hearing impaired and is finding it difficult to understand the questions due to their hearing loss then the interview may need to be conducted through the earphones attached to the audiometer or with some other amplification device. This would be a good indication of the client’s need for a hearing aid.
• the need for tinnitus counselling. If the client is particularly distressed by tinnitus, the testing may be difficult and counselling for their tinnitus condition may need to be taken care of in the initial stages of their hearing rehabilitation.
• the need for special testing. For example, if the client is having the test for compensation purposes, their motivation may be predominantly monetary gain not necessarily hearing rehabilitation. Careful testing procedures will need to be maintained. The client may have other special needs that should be taken into account when determining the test procedure/s to be used.
• the need for special consideration. For example, some clients will be claustrophobic and may seem distressed at the idea of being in a sound booth. Opening the door during testing is the best solution. The results may be slightly depressed, but this is preferable to no test result being achieved.
• the need for special care. For example, if the client reports a recent middle ear infection, otoscopic inspection may be painful so the clinician must remember this when looking in their ear canals.
• the need for referral to medical practitioners. If the case history indicates there are medical issues that have not been fully investigated, you will prepare a report for the client’s doctor.


Most importantly, the case history will help determine the communication needs of the client.
When you ask the client about the types of problems they are having you will be beginning the rehabilitation process. You will also find out how the client feels about the possibility of entering into the rehabilitation process.

Obtaining a comprehensive history gives you the chance to establish a good working relationship with your client.


Activity: Obtain two different types of client history sheets. You can use examples from a text book or you might obtain them from a hearing assessment clinic. Compare them and write down the differences.

Consider these questions:
• What category of client is the history used for?
• What questions are asked in one and not the other?
• Why are different questions used?
• How will the history affect your assessment procedure?
• How will the history affect your decisions about what will happen after the assessmen


Questioning techniques


There are different ways of asking questions. Some questions will only get a yes or no answer and some will get more information than you want.

How would you answer these questions?
What is your name?
What colour is snow?
Do you like dogs?

These questions are called closed questions. There are only one or two answers to each of these questions. These sort of questions are very efficient at obtaining information. You achieve the answers you want very quickly. Closed questions, however, are very inefficient at obtaining information about what is worrying your client or how they feel about their hearing impairment.

Have you ever played the game 20 questions? This is where you can only ask questions that can be answered with ‘yes’ or ‘no’ to guess what the other person is thinking. For example, I am thinking about ‘horses’. My partner could ask: “Are you thinking of an animal?”, “Is it a pet?”, “Do you have one”, “Does it live at the zoo?”. It takes a while to get to the information but you will eventually arrive at the answer you want.

It would have been easier to ask: “What are you thinking of?”. This is an open question. The answer is less predictable and sometimes more time consuming. These sort of questions are better at obtaining information about feelings and concerns. However, you do have to be careful that you keep control of the interview. It is easy to spend too much time on less important questions.

A good interview will incorporate both types of questions depending on the information you need to obtain.

Interviewing the client to complete a case history


As an audiometrist you will be interviewing clients for specific reasons. One purpose of the interview is to obtain the information you need to do your job. Another purpose of the interview is to establish a working relationship with the client.

One of the most important reasons to interview clients is to obtain a case history.

To interview the client to obtain a history you need to consider:
• who will be recording the client history
• the history form to use
• communicating with the client
• involving the client’s ‘significant other’
• interview technique
• the purpose of the history
• the age of the client

Who will take the history?


Usually the clinician who will be performing the assessment should take the case history. However, it is possible that you will work in a clinic where this does not happen. For example, if you work for a doctor, they will usually take the case history. Many clients do not like to be asked the same questions again so you may simply ask: “Have you been having some trouble with your hearing lately?” and “Have you ever had a hearing test before?”.

Sometimes the person accepting the initial referral will take some history information from the client. That is, the person who arranges the appointment at your clinic might ask the client who referred them and why. They may also obtain their personal details.

However, you as the clinician should take the essential components of the history. This enables you to get a ‘feel’ for the client’s case and more importantly, to build a rapport with the client. This ‘rapport-building’ cannot be underestimated, it is very important. If the client trusts you and feels comfortable talking with you, then you will achieve a better result and more pertinent information regarding the client’s aural history may be revealed.

Sometimes the client will provide a case history. They may be asked to fill out a self-evaluation questionnaire. These are usually completed before the appointment. You should always go through these questionnaires with the client to explain any misunderstanding or difficult questions.

It is important to remember that once the testing begins, it is not necessarily the end of the history taking. More questions may need to be asked along the way. The case history is a fluid and essential part of any test procedure.


Using various history forms


While getting your history forms you may have noticed a variety of forms available. History forms can take on a number of styles and be used for different types of interviewing. Below are three types of history sheets.



Activity:Look at the three history sheets set out on the next pages. How are they similar or different from the ones that you have found? What type of testing would they be used for? (eg., diagnostic, screening, paediatric, communication difficulties, hearing aid fitting, tinnitus). How much time do you think it would take to complete the history?

casehistory1.png

casehistory2.png

casehistory3.png
As you can see, history questionnaires can take on a number of styles. They can be used to collect data regarding the client’s aural history or they can be filled out by the client themselves, allowing them to indicate problems in particular areas.

Selecting the appropriate history form is important. To choose the best history form consider these questions;
• What do you want to know about the client?
• Are you interested in actual happenings regarding their ears and hearing loss or do you want to know how they are feeling about their particular hearing situation?
• How old is the client?
• Why are you assessing this client?
• How much time do you have with the client?
• Will you see the client only once, or will you be seeing them for many appointments?
• Who else might be involved with the client?

Of these questions, the most important is “Why are you assessing this client?”.

If you are seeing the client as part of a screening programme, your history taking will cover only a few questions.

Screening programmes are designed to quickly find people who have some hearing loss and then send them for a full assessment. People with no hearing loss would not be followed up. The time allocation for each client in a screening program may be as little as ten minutes. In this case you do not want your history to take ten minutes. It would be more appropriate for your history to take only one minute. For example, you might take their personal details, obtain permission to tell the employer about the results and ask: “Have you ever had trouble with your ears?”, “Have you had a hearing test before?” and “Do you experience ringing in the ears or dizziness?”. This is one type of screening history. If the client has a hearing loss a full history and assessment will be recommended.

Alternatively, you might have been asked by a doctor who is an Ear, Nose and Throat Specialist to assess a client who has been experiencing severe communication difficulties with a view to hearing aid fitting. You have been allocated one hour for the assessment. In this case you require an understanding of the client’s communication needs, their feelings about their communication difficulties as well as the basic personal and medical background. In this case a history interview of fifteen to twenty minutes is appropriate. It allows you to get the information you need and to establish a rapport with the client. This is one type of diagnostic history.

Case History I is another type of diagnostic history. Which client group do you think this history is suitable for? Is it a self assessment questionnaire? How long do you think it would take to complete?

Let us look at the questions in more detail from Case History I. Why do we ask these particular questions in a diagnostic case history?

Pre Test Quiet If the client works in noise, it is important for them to have had a noise free time of sixteen hours prior to testing. Otherwise a temporary threshold shift, (TTS), may occur, giving a false reading for the test. That is, the hearing could seem worse than it is, temporarily, as the hearing may improve after a break from the noise.

URTI’S (upper respiratory tract infections) If the client is suffering from a cold or hay fever, this may affect the results of the hearing test in the lower frequencies. It also may be having some affect on the client’s comfort if they are particularly unwell and unable to concentrate.

Do you feel you have a hearing loss? It is always interesting to acknowledge how the client ‘feels’ about their particular condition and to see if it matches with the actual hearing test result. If the client’s feelings about their hearing are different from the audiogram, the discussion with the client regarding their hearing results will need to be handled with particular care.

How would you rate your hearing? Again this may provide a discussion point with the client after testing has been completed. If the client is experiencing severe difficulties with his hearing but audiometrically his thresholds show a mild hearing impairment, other factors may be involved. Is the client seeking monetary compensation for a hearing loss? Does the client have other problems which are affecting his communication?

Sometimes the results may indicate a severe hearing loss and the client feels they have no trouble hearing. When this happens, more questions regarding communication behaviours may need to be asked.

Have you had a hearing test before? If the client has had a previous hearing test, you may get some indication of what their hearing levels are. However it is not a good idea to look as these results, if they are available. Knowing the client’s previous hearing levels may prejudice your testing. Compare the results when you have finished the test.

If the client hasn’t been tested before, more information regarding the test procedure may be needed. The client may be nervous, or unsure what is required of them. Give them extra instructions if they feel uncomfortable.

Do you ever experience earache or pain? If the client has had recent ear infections or has a long history of middle ear problems this needs to be recorded. If the problem was recent, did they receive any treatment and/or are they still on treatment?

Have you ever had any discharge from your ear, other than wax? Again, if the client has had ear infections with discharge, the history of this needs to be recorded, for the same reasons as in the previous question.

Do you ever experience any ringing or buzzing noises in your ears? Any incidence of tinnitus or head noises needs to be recorded in terms of its severity, whether the noises appear occasionally or if they are constant, where in the head/ears the noises are heard (unilaterally, bilaterally or centrally)? If the problem is particularly distressing for the client, other forms of history taking or questionnaires may need to be used or you may need to consider referring them to another clinician.

Do you ever experience dizziness or balance problems? Noting balance problems may not be necessary for every client, but if any other asymmetrical symptoms are reported or these problems are recent, it is important to record them as they will help to complete a picture with certain types of hearing impairments/ conditions.

Have you ever had any medical treatment to your ears or ear operations? Ear operations need to be noted, asking clients for as much detail as possible. Some clients will not know the nature of the operation, but others may be able to give you the exact name of the procedure (eg., stapedectomy, tympanoplasty, mastoidectomy, etc.). This type of information will help in understanding the audiometric result.

What type of work do you do? If their work is in construction, manufacturing, mining, transport, printing or other noisy occupation, then a noise injury may be suspected. If they have a job that can be classed as ‘noisy’ then other questions such as “Do you wear hearing protection?” may also need to be asked.

Are you involved in any noisy activities away from work? (eg., shooting, motor sports, power tools, loud music)
Recreational noise can impact on some hearing impairments, but this is not as common as once thought. Unless they play in a band or mow lawns as a second income or are a professional shooter, then asking this question may be irrelevant.

Have you ever done any military service? (If yes, how many years?) If a period of military service is reported, this may be necessary to comment on if a noise injury is suspected (although some forms of military service don’t involve excessive noise exposure).

These questions can be modified as required by the clinician, depending on the type of clients you are most likely to be testing. Keep your questions relevant and short. We don’t wish to tire the client before the testing has begun!

Comments on activity

Remember the questions that were asked at the beginning of the discussion of Case History 1?
• Which client group do you think this history is suitable for?: This history form is appropriate for adult clients being tested for general purposes. It is particularly appropriate for clients who are being assessed as part of a pre-employment medical.
• Is it a self assessment questionnaire? This form can be used this way. Most of the questions are written in a way that most people would understand. If it is used as a self assessment questionnaire the clinician would still have to go through the answers with the client.
• How long do you think it would take? This history would take about five to ten minutes to complete.

Testing children will involve different sorts of questions. For example, questions about recent middle ear infections or upper respiratory tract infections are important. Other important questions are: “Does the child have behavioural problems?”, “Do they often raise their voice?”, “Do they need the TV volume louder than average?”, “Is there a family history of deafness?”.

The age and developmental level of the client will need to be considered when taking the case history. A child under three will not be able to give you any useful information regarding their hearing except for the presence of pain. Older children will be able to answer simple questions on where they have difficulty hearing but will not be able to give you information on family history or previous ear operations. From about the age of fourteen years, it is probably best to address most questions to the child. Most teenagers will be able to answer questions appropriately.



Reflection: If a client has come in for an assessment for a hearing aid , what important questions should be asked?


Did you say?
• Do you feel you have a hearing problem?
• Have you ever worn a hearing device before?
• In what situations do you experience difficulties because of your hearing loss?
• Was it your idea to have a hearing test or did someone else suggest it?
• What type of work do you do (paid &/or voluntary)?
• Has your social life been affected by your hearing problem?

These are a few general questions you can ask. As you get to know your client a little better, you can ask more specific questions. For example, Mrs Tanswell tells you the only difficulty she has is her inability to hear her grandchildren when they visit. Her daughter, Clare, comes to the appointment and mentions her mother does not always hear the doorbell or telephone. You can then ask Mrs Tanswell about the telephone and doorbell.

Self-evaluation questionnaires


Sometimes it may be necessary for the client to evaluate their hearing difficulties on a more personal level. Self evaluation questionnaires are often used when you want to know how the client is reacting to hearing loss and communication difficulties. For example you might want to know how the hearing problem is affecting the client’s communication, lifestyle, self-esteem, relationship with their partner, etc.

Self evaluation questionnaires are sometimes scored. These types of questionnaires are often used in rehabilitation programmes. They would then be used to compare how the client is feeling after a rehabilitation programme, which may include hearing aid fitting, compared to how they were feeling when you first starting seeing them.

Some particular conditions, such as tinnitus, may need more in-depth questions to be asked. Because these questions could take a long time to answer or because the client may need to think carefully about the responses to make, it may be wise to have the client fill out a self evaluation questionnaire before they attend for their appointment. It is important to go through the questionnaires with the clients and discuss the results with them. You may need to explain difficult questions or clear up any misunderstandings the client may have had. By going through the questionnaire with you the client has an opportunity to tell you more about something that is especially important to them or that is particularly bothering them.

The questionnaires’ uses may be varied but generally they are to ‘rate’ the client’s difficulties and to give an insight into the emotional side of the impairment. They are most commonly used before the client is seen for the first time and are usually used as a starting point for further questions. They may also be used to determine the type of program you may refer the client to.

However, as in everything there are advantages and disadvantages to using these types of questionnaires.


Advantages and disadvantages


Disadvantages
• The client may have reading or writing difficulties. They may be embarrassed and not attend their appointment.
• The client may not understand the words used and so may not answer the questions properly.
• The questions may not be relevant to the client.
• The client may not feel able to express what is really worrying them if there is no question covering this concern.

Advantages
• The client has time to think about their answers.
• The client can check details with other people.
• It may save time.
• Answers may highlight areas of difficulty that the client had not considered.



Activity: If you were designing a self evaluation questionnaire to find out about a client’s hearing difficulties, what type of questions would you ask?

There are a few examples available that you could use as models. One of these is ‘The Hearing Handicap Inventory for the Elderly’ by Ventry and Weinstein.

References:
Ventry I.M. and Weinstein B.E. (1982) ‘The Hearing Handicap Inventory for the Elderly’: A new tool Ear and Hear 3 (3) 128-134.


Comments

There are no right or wrong answers for this activity. Did you concentrate on the client’s feelings about hearing loss, include questions about the effect of the hearing loss on their social life and relationships with family and friends? Perhaps you asked clients to rate their answers on a scale of 1 to 10. Perhaps you asked clients to consider their reactions to certain situations, eg, “What do you do when you can’t hear your doctor?”.

Show your questionnaire to a clinician who works with hearing impaired clients and ask their opinion of it. You may like to try your questionnaire out when you start clinical practise. Check with your supervisor first.


Communicating with the client


Remember you are dealing with someone who possibly has a hearing loss. Therefore, the room should be well lit and at a comfortable temperature. You should be facing the client, enabling them to see your face clearly. Don’t cover your face during the interview and speak clearly at all times. If the client is nervous, take your time and try and make them feel relaxed. If they appear to be very hard of hearing and communication is particularly difficult, perhaps try interviewing them through the earphones on your audiometer. There are also some portable amplification devices that you can use.

One issue in interviewing a client is to have them hear you loudly enough so that they can answer your questions. However, in many of your interviews you will be asking clients personal questions after having just met you.

How would you respond to a clinician who sat in front of a window with the sun streaming in so that you were blinded by the light and could not see their face? Or if the room had client files open on the desk so that you could read the comments made by the clinician? Or if the chair you were sitting in had a broken arm? How would you feel if the clinician sat eating in front of you or people were using the office you are in as a passageway?

Would you feel like telling this person anything? Would you ever go back?

The most important aspect in interviewing clients is your behaviour but clients are unlikely to tell you much personal information unless they have some privacy. Clients also need to feel that you care about them, have the time to spend with them and that you are a competent professional.

Think about how you might seem to your clients. Put yourself in their place. Would you be comfortable enough to talk about personal issues?

Communicating with the client’s ‘significant other’

Many clients bring someone with them to their appointments. This ‘significant other’ person could be their partner, a neighbour or it could be a relative. The ‘significant other’ is usually someone who has a close emotional attachment to the client. Some clients will ask if they can bring this person in with them. It is usually best to say yes to such a request unless you have a strong objection. For example, if the room you are working in has very little space. You could say: “I’m sorry, there is only enough room for the two of us.”.

If the client has brought someone with them, you might like to include them in the history taking. This is often helpful especially if the client is unclear on some details. Often the other person can give more details on particular communication difficulties. Often the client is happy to have their ‘significant other’ with them. Many hearing impaired people have come to rely on their partner for communication and so you may find all the answers are coming from the other person and not the client themselves. If the ‘significant other’ does dominate the conversation, and you see this as a problem, you may need to ask questions more directly to your client.

It sometimes happens that the ‘significant other’ dominates the conversation about their problems with the hearing impaired client. This may provide important information to you but you must be aware that it may be making your client uncomfortable. In this case you could ask the ‘significant other’ to wait in another room. For example, you could say: “We’ll be doing the hearing test now, please wait here and we’ll be back in about twenty minutes.” This will provide an
opportunity for the client to express their feelings about certain issues that may have come up.

The issues brought up by the ‘significant other’ may need to be addressed at a later time. It could be that your client won’t talk about certain issues because they do not accept that they have a hearing loss. The ‘significant other’ may have some very important comments to make.

If the client is a child, obviously the parent will be the main source of information for the history taking. If the child is a pre-schooler or young child, it is a good idea to ask them some simple questions, “What is your name?”, “When is your birthday?”, “How do your ears feel today?”, to build a rapport with them. Most children feel more comfortable if their parent remains with them. Occasionally the parent will tell you that they believe the child will do the test better if they are not in the room.

Interviewing a client from a language background different to your own

When there is a language barrier, an interpreter may be necessary for a successful interview and hearing test to be completed. If an interpreter is used:
• if possible, before taking the client in, explain the purpose of the appointment to the interpreter and ask for any helpful cultural information
• introduce yourself and the interpreter to the client
• look directly at the client as much as possible
• talk to the client as if they did understand English (they may understand a little)
• use short sentences
• avoid jargon and difficult words
• sit next to the interpreter so that the client can see your face and the interpreter’s face with minimal effort
• acknowledge the interpreter’s assistance at the end of the session by thanking them

When asking questions, do not look at the interpreter if possible, unless further clarification is sought. It is important that the client feel they are the most important person in the room. Professional interpreters will translate the client’s comments as directly as possible, they will not offer their own opinions.

Many clients from a language background different to your own will attend appointments with a family member. Occasionally problems arise because you are not sure if the family member is translating everything that is said between you and the client. If you are concerned you may have to say something like: “Could you tell your grandmother everything I say please.”. Of course, you have to be very careful not to offend anyone. It may be that the client had instructed their grandchild to answer all questions for them.


If no interpreter is available and language is a problem, it may still be possible to ask some simple questions. However, it may be necessary to go straight into testing, leaving the history taking until a later time. Instructions for testing are possible when there is a language barrier. Sometimes gestures and practise attempts may be needed until the client understands what is required.

Other difficulties arising when interviewing clients from different language backgrounds may be related to cultural differences. We may not be aware of these differences but they may impact on the test results and the rehabilitation process. Some cultures have beliefs on the position of women and their ability to act as a clinician. Some cultures find it unacceptable for a male clinician to be alone with a woman. Some cultures react differently to the discovery of a hearing disability. Some may presume that because you are involved in the health area that you are a doctor. Any misconceptions the client may have about your professional status must be explained.

If you work in an area with many people from a different language and cultural background to your own, you should find out what you can about that culture.

The most important aspect of working with clients from backgrounds different to our own is to show respect and not to make assumptions based simply on ethnicity.


Creating a permanent record of the client history


When compiling a client history you will take notes.

One reason for taking notes is to remind yourself about the client and what happened when you interviewed the client. Another reason is that, should it become necessary, another clinician can become involved with the client without having to repeat what has already been done. Occasionally notes will be used for legal purposes. For example, if the client lodges a compensation claim against an employer you may be asked to provide information about your assessment.

Most clinics will use a standard file size that you will have to use. Many clinics have standard inserts to record various parts of the contact with the client. These may include a history form. It is easiest to use a history form but there is no reason why you can’t simply use a blank piece of paper. Most clinics will file client records by name and in alphabetical order.

Many clinics now have some computer based record keeping. Usually hard copies of client files are kept as well.

You will need to be familiar with your clinic’s requirements no matter how it is done, particularly when you start to do clinical practice


How should you write your notes?

You should write so that other people can read what you have written. It is best to write in pen, preferably black or blue. Also you should date every entry and sign your name in such a way that your colleagues know who has written the notes. Some clinics have a policy that corrections should not be covered over ,eg, with correction fluid.

Every contact with or about clients should be recorded. For example,

25.2.99 - Tel call from Dr Tamaneski, referring GP - wanted to know results of test. Told him moderate SN loss, report was posted yesterday. Asked for report to be faxed today. Done.
Jean
1.3.99 - Mr M rang. Cancelled follow-up appt. Has been very ill. New appt arranged 15.3.99
Alison

A very important point to remember when making notes about clients is that they may request to read their files. Your clinic may have some policy guidelines about this but it is always best to write notes that you won’t mind the client reading. Personal comments and opinions about clients should never be written in a file. Comments like “Has a funny accent”, “Is a horrible person”, “Has weird ideas” are totally unwarranted. You must never write these sorts of comments anywhere. If you wish to write information down it should be information reported by the client. For example, “Mr M reports that he is finding it difficult to accept that his hearing loss is causing communication difficulties”.

It is a good idea to write notes as you obtain the information from the client. It is difficult to remember everything a client has said to you if you wait to write it down. However, while you are taking notes you have to take care not to appear to be ignoring the client or uninterested in what they are saying.

Think about the contact you have had with different professional people. What is it about another person’s behaviour that makes you feel like they are interested in you? Remember your clients will feel happier if you seem to be interested in them. You won’t seem interested if you keep your head down and read out questions from a page.

If you decide to record an interview with a client you must tell them. Let them know what you want to use the recording for and obtain their permission.

All information in your client file is confidential. You must never give information about a client unless the client has given you permission, preferably in writing.

It is best to get that permission in writing.

For example, even though the assessment was requested and paid for by the client’s workplace you still need the client’s permission to send the results. You could have the client sign: “I consent to the disclosure of the results of this assessment to my employer.”


SUMMARY

Basic details to remember for all history taking are as follows:

• Record client’s name and contact details on all documents
• Date all documents and all subsequent entries
• If questionnaires are going to be repeated, number them in sequence
• Write all details clearly when recording history information
• All details you include may be available for the client to read, so always remember to be sensitive when recording information
• It is advisable to get client to sign a consent of information release, especially for medical reports or compensation assessments
• Do not leave client files within view of others who may use the room
• Observe strict confidentiality
• Sign all entries.