Conceptualizing and Conducting Preoperative Psychological Assessments of Cochlear Implant Candidates Robert Q_Pollard, Jr. University of Rochester School of Medicine

A review of literature pertaining to psychosociaJ research on cochlear implantation is embedded in this formulation of how preoperative psychological assessments should be conceptualized and conducted. This article considers various purposes of such assessments, including those relevant to candidate selection, exclusion, and readiness. Particular attention is directed to the conceptualization and operational investigation of candidate readiness, which includes aspects of motivation and informed consent. A number of related ethical issues are discussed. Assessment in this context is framed as both a data collection and an intervention procedure. The article describes specific methodologies useful in preoperative psychological assessment, including questionnaires, interviews, and psychological tests.

Little has been written from a conceptual perspective on presurgical psychological evaluation of cochlear implant candidates. The available literature offers similarly limited guidance on evaluation methodologies, especially for implant candidates presenting in clinical practice versus experimental settings, despite the prevailing opinion that psychological variables are important in candidate selection (Aplin, 1993a, 1993b; Clark, O'Loughlin, Rickards, Tong, & Williams, 1977; Cochlear Corporation, 1993, 1994a; DeFoa & Loeb, 1991; Evans, 1989; Gantz, 1989; Haas, 1990; Hellman, I gratefully acknowledge the assistance of Tovah W u , who conducted portions of the literature review used in this article. Correspondence should be sent to Robert Pollard, Department of Psychiatry, University of Rochester Medical Center, 300 Crittenden Boulevard, Rochester, NY, 14642 (e-mail: [email protected]>U). Copyright © 1996 Oxford University Press. CCC 1081-4159

Chute, Kretschmer, Nevins, Pansier, & Thurston, 1991; Knutson, 1995; National Institutes of Health [NIH], 1995; Quittner, Steck, & Rouiller, 1991; Spitzer, 1988). This article first addresses conceptual issues regarding purposes of the preoperative psychological assessment and the nature of candidate readiness (including motivation and informed consent) and then describes methodological considerations arising from these conceptualizations. Throughout, research findings from the professional literature are integrated with my clinical experience and pedagogical views regarding psychosocial issues in cochlear implantation.

Conceptualizations of Purpose The format and foci of the preoperative psychological assessment will be shaped by the examiner's conceptualization of its purpose. Most studies employing psychosocial variables have focused on postoperative responses to the implant rather than on the utility of psychosocial variables in making preoperative candidacy decisions. The deviation of experimental candidacy protocols from those pertaining to everyday clinical practice further limits the value of such research. Haas (1990) and Knutson, Hinrichs, Tyler, Gantz, Schartz, and Woodworth (1991) specifically caution that their research protocol's psychological evaluation criteria should not be interpreted as recommendations for clinical practice. Of those who have addressed preoperative evaluation from a clinical per-

Psychological Assessments in Cochlcar Implantation spective, Aplin (1993a, 1993b), citing d a r k et al. (1977), suggests focusing on the candidate's ability to cope with the procedure and potential for becoming a nonuser of the device. Hellman et al. (1991) list six psychosocial topic areas judged useful in making candidacy decisions regarding children. Evans (1989), also discussing children, stresses the need to evaluate cognitive, linguistic, and emotional functioning and recommends procedures ranging from psychological testing to dream interpretation and play therapy. Yet such topical and methodological recommendations are premature without adequate consideration of the rationale for conducting the preoperative psychological evaluation. The rationale should dictate the topical foci of the assessment and, consequently, the methods employed. Whether considering adult or child candidates, functions of the preoperative psychological assessment could include (a) identifying psychopathology that may exclude individuals from implant candidacy; (b) collecting cognitive skills data relevant to predicting postoperative outcomes; (c) collecting psychological data relevant to formulating judgments of candidates' readiness for implant surgery, including motivational and informed consent information; and (d) providing assistance, as needed, when problems are identified in these areas. The first of these purposes deals with the potential for psychological assessment findings to hold immediate, negative implications for implant candidacy. Gantz (1989) states that negative findings on the psychological assessment are one of the primary reasons for candidate rejection, more common than rejection due to medical and surgical limitations. Conversely, Spitzer (1988) found that psychological assessment results were not predictive of implant teams' ultimate decisions regarding surgery. A potential explanation lies in the breadth of what is considered psychological; severe mental illness, mental retardation, and more routine issues such as the candidate's postoperative expectations all may fall within the purview of a psychological assessment. Such breadth, coupled with the lack of guidance in the literature, makes it difficult to determine which psychological characteristics are more or less important to implant candidacy. Exclusion from consideration for implantation on the basis of psychopathology has not been adequately

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addressed in the literature. When described, such exclusion criteria have typically been employed by researchers to make a study's subject pool more homogeneous, not for clinical reasons (e.g., Gantz, Woodworth, Knutson, Abbas, & Tyler, 1993; Haas, 1990; Knutson, Hinrichs, Tyler, Gantz, Schartz, & Woodworth, 1991; and Knutson, Schartz, Gantz, Tyler, Hinrichs, & Woodworth, 1991). Clark et al. (1977) consider low intelligence and psychosis grounds for exclusion. Spitzer (1988) merely notes that a normal psychological examination is required. The recent NIH consensus statement on cochlear implantation (NIH, 1995) recommends that exclusion on the grounds of psychopathology be rare for both adults and children: "Severe mental retardation, severe psychiatric disorders, and organic brain syndromes (p. 10)" are the only such exclusionary criteria cited. "Severe psychiatric disorders" is a term open to some debate. The NIH statement does not specify par-* ticular illnesses or severity levels. In clinical practice, this is a judgment call. Severe depression or psychotic illness would likely lead to exclusion or at least delay of candidacy until effective psychiatric treatment could be rendered. Yet what about candidates who have histories rather than current manifestations of such illnesses? Since electroconvulsive therapy (ECT) and magnetic resonance imaging (MRI) cannot be provided to persons who have an implant (Cochlear Corpora-', tion, 1993; NIH, 1995), should persons with histories of ECT treatment, previous MRI scans, major depressive disorder, or other neurological or psychiatric conditions be excluded from implant candidacy? Debate also exists regarding mental retardation. While the NIH statement excludes those with severe forms from implant candidacy, Gantz (1989) argues that the device may be helpful to deaf persons with milder degrees, a finding already reported with one individual who had an IQ^ of 63 (Fritze & Eisenwort, 1989). At present, most research studies exclude persons with any degree of mental retardation, even some with higher, "borderline" I Q levels. Although this restriction of range makes it difficult to know how intellectual limitations may impact postoperative outcomes, several studies have demonstrated that IQ_ does not predict postoperative audiological and communication outcomes for persons with average intelligence or

18 Journal of Deaf Studies and Deaf Education 1:1 Winter 1996 above (Fritze & Eisenwort, 1989; Gantz, 1989; Gantz, Tyler, Knutson, Woodworth, Abbas, McCabe, Hinrichs, Tye-Murray, Lansing, Kuk, & Brown, 1988; Knutson, Hinrichs, Tyler, Gantz, Schartz, & Woodworth, 1991). Though broad intellectual ability measures have not shown promise in predicting postoperative audiological outcomes, some measures of specific cognitive skills have shown such promise, at least with postlingually deafened adult implant recipients. Collecting such data for predicting postoperative outcomes might be considered a second purpose of the psychological assessment, particularly if future research replicates and expands upon the current findings. Gantz et al. (1993), Knutson (1995), and Knutson, Hinrichs, Tyler, Gantz, Schartz, and Woodworth (1991) have found that certain tests of sequential visual monitoring and processing accuracy and speed predict as much as 19% of the variance of audiological outcome at 9 months post-connection, 30% at 18 months, and 25% at 42 months, depending on the specific outcome measure employed. When such scores are combined with scores from the Nonverbal Communication Strategies subscale of the Communication Profile for the Hearing Impaired (CPHI) (Demorest & Erdman, 1986) and the Health Opinion Survey (Krantz, Baum, & Wideman, 1980), up to 37% of the variability of certain audiological/communication outcomes is being predicted at 9 months post-connection (Gantz et. al., 1993). In summary, psychological characteristics can play an important role in considerations of implant candidacy. There are a few generally agreed-upon circumstances where certain types and severities of psychopathology should result in exclusion or delay of candidacy. Identifying such circumstances constitutes the first recommended purpose of the preoperative psychological assessment. When the candidacy decision is not so clear-cut, the team must consider carefully any psychopathology evidence in light of broader psychiatric versus audiological priorities and issues. Psychopathology can exacerbate long-term risk factors associated with implant use (e.g., the ECT and MRI issue) and certainly can impede candidate readiness. Though inadequately studied, data regarding specific cognitive skills, a second potential focus of the psychological assessment, may allow better prediction of

postsurgical audiological outcomes in the years ahead. Evaluating psychological aspects of candidate readiness, the third purpose of the preoperative psychological evaluation, is so important and complex an issue that it merits considerable explication in the next section. Conceptualizations of Readiness Readiness for implant surgery is herein conceptualized as a multidimensional psychological concept that embodies two broad factors. The first is motivation, in terms of both enthusiasm and incentives (motives) for seeking the implant. The second is informed consent, which subsumes knowledge of "reasonable expectations" about cochlear implantation but also includes much more. This conceptualization of readiness is consistent with NIH's (1995) recognition that "determining candidacy requires consideration of . . . the subjective needs and wishes of individual candidates (p. 10)" as well as with the more traditional, objective aspects of readiness commonly stressed in the implant literature. Motivational Components of Readines Enthusiasm. There is wide consensus in the literature that implant candidacy and postoperative outcomes depend on persons' motivation (enthusiasm) about undergoing the operation and active participation in the "mapping" and training periods that follow. Knutson and colleagues found that scores on the Health Opinion Survey yield significant positive correlations with audiological outcomes after implantation (Gantz et al., 1988, 1993; Knutson, Hinrichs, Tyler, Gantz, Schartz, & Woodworth, 1991). The survey's ability to predict "willingness to comply with the extensive rehabilitation process" (Gantz et al., 1988, p. 1105) appears to be the key. Enthusiasm plays a role apart from postsurgical audiological outcomes, however. Perhaps inappropriately, nonusers of the device are frequently grouped with persons for whom the device was not audiologically beneficial in studies that contrast better and poorer outcomes, even though nonuse may not relate to audiological factors. Knutson (1995) and Quittner and Steck (1991) report several nonaudiological variables associated with nonuse in children. It is well

Psychological Assessments in Cochlear Implantation known that usage rates are lowest among adolescent implant recipients, a fact thought to be related to teens' susceptibility to negative feelings about psychosocial and identity implications of using the device (Berliner & Eisenberg, 1985; Cunningham, 1990; Gantz, 1989). Concerns regarding body image and identity are neither rare nor insignificant and must be explored in the psychological assessment (Evans, 1989). Not only can these issues affect preoperative motivation and postoperative usage patterns, if not resolved presurgically, I have seen them lead to requests for surgical removal of the device and even recipients' becoming suicidal. Degive and Archinard (1992) further note that a candidate's desire for implantation is often ambiguous, where mourning regarding deafness, also a manifestation of identity concerns, can be salient. The psychological assessment must explore and report on these aspects of enthusiasm, not only to draw conclusions regarding their impact on the individual's candidacy, but to determine if psychological interventions are necessary apart from the issue of implantation. Incentives. The second aspect of motivation deals with the reasons one is seeking an implant. Infrequently discussed in the literature, incentives or motives are a different but equally important matter to investigate in preoperative psychological assessment. Knutson, Schartz, Gantz, Tyler, Hinrichs, and Woodworth (1991) point out that psychological distress in the face of hearing loss may be the primary motivating factor for some candidates. Notwithstanding the normalcy of a broad spectrum of reactions to hearing loss, acute adjustment reactions are not compatible with this conceptualization of candidate readiness, as discussed earlier. One young adult candidate I assessed stated his belief that the implant would allow him to obtain an "important job like a Dean Whitter stockbroker," though he had neither the education nor the experience for this. Some parents have described their motives for pursuing cochlear implantation for their child in ways that emphasized a belief that not doing so would reflect badly on them, that "we wouldn't be doing all we can" for the child. Pronouncements such as this should raise concerns that the implant is being pursued for psychological reasons pertaining to the parents, also incompatible with the present conceptualization of readiness.

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An elderly man I evaluated was being pushed toward implant candidacy by his spouse and children, who were growing increasingly frustrated with the communication demands brought upon them by his progressive hearing loss. His own lack of motivation for the implant was exemplified by limited compliance with the paperwork and appointment requirements of the implant center. During the psychological assessment, he demonstrated extremely limited knowledge about implants, even after completing educational visits with the surgeon and audiologist. When asked in different ways or at different times whether he wanted the device, he expressed marked ambivalence. His spouse, who was included in the interview, revealed that she and the children had driven the process of the man's candidacy from the beginning, based on their own limited comprehension and inappropriate expectations about cochlear implants that they gleaned from the popular media. In assessing motives, the examiner should be satisfied that the reasons the candidate is seeking implantation, often revealed in discussions of the history and dynamics of the presenting request, are reasonably free from distortion and coercion. This discussion will lead to the candidate's conceptualizations regarding deafness, the device, and what life would be like with or without the implant, data that is relevant to evaluating the second aspect of readiness, informed consent.

Informed Consent Components of Readiness The conceptualization of informed consent deserves considerable attention because of its complexity and importance in this area of medical ethics (Caplan, 1995; DeFoa & Loeb, 1991; Evans, 1989; Pollard, 1992). The conceptualization presented here is intended to relate to adult and child candidates. A discussion of children's rights and abilities to provide informed consent for cochlear implantation is beyond the scope of this article (see Evans, 1989). A primary distinction is first made between informed consent at a technical level and informed consent at a phenomenological level. Informed consent at a technical level. This aspect of in-

formed consent primarily consists of the "reasonable

20 Journal of Deaf Studies and Deaf Education 1:1 Winter 1996 expectations" so commonly stressed in the professional and consumer literature (e.g., Cochlear Corporation, 1993, 1994a, 1994b) but rarely denned. At a minimum, knowledge of the device itself (its components, placement, and function), the surgery and recovery process, the mapping and training period, and die range and frequency of various audiological and communication outcomes constitute reasonable expectations. This implies that the examiner must have knowledge of the device and surgical procedure to be used and must remain up to date on die norms of postoperative outcomes (see NIH, 1995) and on research relevant to preoperative prediction of outcome (e.g., Fritze & Eisenwort, 1989; Gantz et al., 1993). Knowledge pertaining to surgical risks, the MRI prohibition, and alternatives to cochlear implantation is also necessary (NIH, 1995). The psychological assessment should verify that the candidate and relevant others have understood and retained die aforementioned information; mere documentation that diis information has been transmitted by the implant team is insufficient. The examiner should not regard reasonable expectations as simple or commonly held. DeFoa and Loeb (1991), in a survey of clinicians and researchers, found a high rate of unrealistic expectations among implant recipients. From a psychological perspective, there should be investigation, also, of the candidate's expectations regarding psychosocial outcomes of implant surgery, especially when motivations for the implant are predicated on them. Knutson (1995) has indicated how limited the present research base is regarding psychosocial outcomes, yet candidates' and families' hopes * regarding implantation frequendy reach beyond the audiological realm to desired changes in emotional, social, educational, or vocational realms (Brauer, 1993; Pollard, 1993a). Therefore, review of this matter is a critical aspect of evaluating informed consent. Although a thorough critique of the research in this area is needed, it is beyond die scope of diis article. A brief review follows. A significant limitation in die literature is that die vast majority of psychosocial outcome studies have been conducted with posdingually deafened adults, because this was the first group widely accepted for implant surgery in bodi experimental and clinical settings. Anodier limitation is die lack of rigor in psy-

chosocial experimental protocols, bodi in die measures employed and die lack of appropriate control groups. Survey and interview studies, die least rigorous type, provide evidence diat posdingually deafened adult implant recipients frequendy report pleasure in renewed auditory "contact" widi dieir environment and increases in social and personal confidence and feelings of safety (Cochlear Implant Club International, no date; Degive & Archinard, 1992; East & Cooper, 1986; Haas, 1990; Tyler & Kelsay, 1990). On the other hand, complaints are cited regarding die appearance and feel of the equipment, having to explain it to odiers, mechanical breakdowns, and adjustment difficulties pertaining to identity and rekindled desires for a complete return of hearing, also cited by Evans (1989) as a risk for parents of child candidates. A number of studies have employed pre- and postoperative measures to evaluate changes in psychosocial variables, but they also focus on posdingually deafened adult implant recipients. While statistically significant positive mean group changes on certain psychosocial measures are reported in several studies, the group trends have limited relevance for preoperative assessment because intersubject variability is so great. The most common positive changes are seen on measures diat address feelings, attitudes, and behaviors regarding hearing and communication specifically, particularly widi adult recipients who lost dieir hearing more recendy and diose who were most frustrated widi their hearing loss to begin widi (Lansing & Seyfried, 1990; Maillet, Tyler, & Jordan, 1995). Poor postsurgical audiological outcomes increase die risk of negative findings on such measures (Haas, 1990). Studies of personality and emotional variables have typically shown no changes after implantation or statistically significant but functionally insignificant mean group changes (Haas, 1990; Knutson, Schartz, Gantz, Tyler, Hinrichs, & Woodworth, 1991). The clinical significance of diese mean group changes must also be questioned since die psychological test scores that were die focus of diese studies were well within die normal range prior to implantation (and remained so afterward) or remained in die pathological range bodi prior to and after implantation. It is also relevant diat some studies found improvements on psychosocial measures to be associated widi the degree of auditory benefit

Psychological Assessments in Cochlear Implantation gained from the implant while others did not (Horn, McMahon, McMahon, Lewis, Barker, & Gherini, 1991; Knutson, Schartz, Gantz, Tyler, Hinrichs, & Woodworth, 1991). This may be a function of too brief follow-up intervals in some studies (Knutson, 1995). Research on psychosocial outcomes with child implant recipients is both rarer and more equivocal. To date, studies of child psychosocial outcomes have tended to focus on the parents, probably because of the comparative difficulty in engaging children in research and the longer time frame expected for manifestation of psychosocial outcomes. Cunningham (1990) found that parents report more satisfaction with the device than they feel their children perceive (the children's opinions were not gathered). In the author's words, "parents tend to place more importance on hearing than their hearing-impaired children do" (p. 380). Similarly, though with adults, Maillet, Tyler, and Jordan (1995) report greater perceptions of benefit from relatives than from implant recipients on some psychosociaj outcome measures. Quittner et al. (1991), using several psychometric measures, report more negative findings in a study of parents whose children had implants. The data suggest that implants do not reduce parental stress in raising deaf children, as some might hope, a finding also relevant to the motivational (incentive) aspect of readiness. The focus and findings of these studies raise questions regarding who benefits more from implantation, parents and families, or the implant recipients themselves. In summary, the psychosocial outcome research suggests that persons who have been deaf the shortest amount of time and those who are the most dissatisfied with their hearing loss are most likely to report improvement on psychosocial measures, but this is not entirely consistent. That persons who have extended experience with deafness and relatively good preoperative adjustment characteristics show the least postoperative psychosocial, and often audiological,' benefit says something important about candidate selection as well as about the phenomenological aspect of informed consent discussed below. Psychosocial research pertaining to children is sorely lacking, with die exception of a few • studies dealing with nonuse that raise issues beyond audiological outcome as relevant in predicting compliance. Family members, be they parents or others, may

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feel greater satisfaction with implant outcomes than the recipient, which raises ethical as well as motivational issues that should be considered in the preoperative psychological assessment. Informed consent at a phenomenological level. Informed

consent at a phenomenological level is here conceived as freedom from undue bias based on ignorance or unfounded beliefs about life with deafness or, more specifically, life with or without a cochlear implant. Such biases are at times revealed in discussions of candidates' or families' motives but more commonly must be elicited through direct inquiry regarding individuals' knowledge base, beliefs, and attitudes about deafness and different adaptations to it. It is common to meet candidates or families of candidates who have never met a deaf adult or learned how different types of deaf adults successfully adapt to hearing loss. When persons do not possess such knowledge, there is considerable' danger that their images of life with or without the implant will be unduly influenced by fantasy or Hollywood or other sensational portrayals of deaf people or will be exclusively determined by what has been referred to as "medical-pathological" or "infirmity" models of deafness (see Dolnick, 1993; Lane, 1990, 1992; Pollard, 1993b; and especially Padden & Humphries, 1988, for broader discussions of this issue.) Brauer (1993) has used Erickson's concept of pseudospcciation to describe the inappropriate dichotomization of life in the "deaf world" versus life in the "hearing world" that some individuals characterize as the essential choice underlying the implant decision. Cochlear Corporation (1994a) even lists "a desire to be part of the hearing world" (p. 3) as a criterion for implantation. One young man, who was referred to me after he requested removal of an' implant he had received six months earlier, indicated that he had been ambivalent about receiving the implant but his father had urged him to proceed since he was soon to graduate from a school for the deaf and would "have to live in the hearing world." He had been implanted through a program that did not require a preoperative psychological assessment. It is not unusual to meet deaf children who believe they will die or regain their hearing by adolescence, apparently because they have never met a deaf adult, a

22 Journal of Deaf Studies and Deaf Education 1:1 Winter 1996 finding also reported by Evans (1989). Adult implant candidates sometimes do not know about television closed captioning or TTYs/TDDs (telecommunication devices for the deaf). It is even more common to meet candidates who are unaware of their legal rights under the Americans with Disabilities Act, or of services or organizations for persons who are deaf that might bring considerable pleasure and enhanced functioning to their lives, apart from the potential benefits of an implant. A balanced, informed decision about pursuing cochlear implantation must be predicated on knowledge not just about the implant and the range of adaptations to it, but also about life without the implant and the range of adaptations to it. Such information is consistent with NIH's (1995) recommendation that "all candidates require in-depth counseling of... alternatives to cochlear implantation" (p. 10). .The medical/professional community can play a powerful role in providing such information and discounting myths about deafness and deaf people. There is a problem inherent in this process, however, if professionals themselves bring uninformed or unduly biased views to implant candidate counseling. A cochlear implant training curriculum marketed to medical professionals, some of whom use it in presentations to the general public and to implant candidates and to their families, contains a slide with the following heading: "Deafness can cause:" and below that in bulleted text, "loss of occupational and educational opportunities," "loss of social opportunity," "isolation," "depression," and "personal danger." To imply, even subtly, that these are the experiences of most deaf persons, or that implants are the treatment of choice to prevent or mitigate such experiences, and especially to infer causality based on hearing loss in the absence of familial, sociocultural, and other considerations, is not only factually dubious, it readily plays into the types of uninformed and negative intrapsychic projections about deaf people described above. Knowing little else about the ordinary lives of deaf people, what parents would leave such a presentation with anything other than the message that, if they love their deaf child, they should pursue cochlear implantation in order to prevent such catastrophes? The frequency of implant candidates' exposure to marketing and media appeals at the emo-

tional level only serves to underscore the importance of consideration of informed consent at the phenomenological level during the preoperative psychological assessment.

Conceptualizing Assessment and Intervention Given these complex considerations regarding readiness for cochlear implantation and the multidimensional nature of motivation and informed consent, it follows that few implant candidates "walk through the door" fully prepared for the procedure from a psychological perspective. This is not to imply that one cannot; the last candidate I assessed was nearly a textbook case of readiness in all the above respects. However, the majority of candidates present in some earlier stage of readiness. It is not suggested that such individuals be denied consideration for implantation. Rather, the implant team, and especially the psychologist, must initiate a partnership with the individual, and his or her significant others, where it is understood that there is more to learn, consider, and evaluate before the final decision about candidacy can be made. Assessment in this context is both an evaluation and an intervention procedure. Shea and Domico (1993) discuss the importance of preoperative sessions with the psychologist in establishing informed consent with parents of child candidates, while Evans (1989) discusses the psychologist's role in preparing the child. Spitzer (1993) describes the utility of psychosocial measures in fostering preimplant counseling. In practice, psychological assessments often move back and forth between objectives related to data collection and objectives related to education or counseling. It is common for candidates and their families to present with oversimplified or distorted perceptions about cochlear implants based on material they have been exposed to in the popular media. I have met several individuals who liken their supposition of the average postsurgical outcome to "understanding voices, but they sound like Donald Duck," a highly inaccurate caricature also reported by Shea and Domico (1993). Media stories about implant "stars," those with exceptional audiological outcomes (e.g., Hewitt, 1992), often foster inaccurate expectations. The "star" term, which

Psychological Assessments in Cochlear Implantation also appears in the professional literature, has the additional drawback of carrying overtones equating audiological outcome with personal/social value. Similar feelings can be stirred in relation to postimplant expectations regarding voice/aural telephone use, frequently spotlighted in reports of implant stars and photographs in the consumer literature (e.g., Cochlear Corporation, 1994a). When candidates are unduly influenced by such portrayals, voice/aural telephone use must be contrasted functionally and psychologically with their understanding of TTY/TDD and relay service telephoning. The nature of the intervention needed when problems like the above arise can readily expand from simple information to counseling or even psychotherapy. Two of the most common educational interventions needed are clarification of terminology used in this field and reconsideration of candidate perceptions that arose from misunderstandings of such terminology. Implant candidates and their families frequer '. misunderstand literature geared toward cons-j .icrs. The central problem lies in professional versus lay connotations of terms such as hear, which, in the literature, is often used to indicate the lowest level of sound awareness—detection of sound—not speech comprehension or sound identification, as many persons assume. For individuals who have not experienced hearing loss (e.g., parents of child implant candidates), the word hear often conjures a unidimensional construct, like volume on a radio, where one hears nothing, hears a little, hears a lot, etc The critical issues of sound quality and the functional utility of sound perception are more rarely appreciated but essential to comprehending literature and professional consultation regarding cochlear implants. It is a necessary intervention, therefore, to ensure that candidates and their families have this capability, at least to the degTee that they can adequately digest consumer-oriented literature (e.g., Cochlear Corporation, 1993, 1994a, 1994b). A partial listing of relevant terms would in-

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detection to open-set speech comprehension with or without visual cues) and the range of implications for audition in everyday life situations.

Methodological Considerations The above conceptualizations of purpose and other issues in the psychological assessment of cochlear implant candidates will allow most examiners to proceed readily to the selection of evaluation methodologies. There are too many choices and situational factors in this regard to discuss in detail here. Instead, a few suggestions and illustrations are offered based on the methodologies we find useful at our facility.

Preliminary Data Collection

The candidacy process should include review of any mental health records and previous psychological evaluations. In the case of child candidates, this should include triennial psychological assessments, the Individual Education Plan, and other relevant school documents. Persons sometimes contact implant centers expressing interest in candidacy but fail to follow through with the forwarding of records or other early requests. Unless otherwise indicated, this should be interpreted as indicting questionable motivation for undergoing the procedure. We send prospective candidates a seven-page questionnaire (eight, for parents of child candidates) that forms the basis for the implant team's initial considerations regarding medical, audiological, and psychological aspects of candidacy, readiness, and informed consent. Though the wording of the two forms differs slightly (e.g., "you" vs. "your child"), the questions are nearly identical. The content covers medical, audiological, communication, and psychosocial topics. The parent form contains a few extra questions regarding education and communication history. The majority of questions are open ended, allowing candidates greater clude: hear, sound information, detect, awareness, perception, freedom of expression. Broader, less structured rerecognize, distinguish, identify, and comprehend. Consumsponses are often more interpretively rich. Like comers must also comprehend the distinctions between pliance with the request for records, the turnaround literature reports of postimplant performance on a vaspeed, thoughtfulness, and tone of responses to the riety of audiologist-administered tests (e.g., pure tone questionnaire are relevant to judgments of motivation,

24 Journal of Deaf Studies and Deaf Education 1:1 Winter 1996 unless English fluency limitations or other circumstances are complications. The content of many responses, of course, is directly relevant to informed consent at the technical and phenomenological levels. Inquiries as to why questions were left blank can be as informative as the content of completed questions. Space does not allow listing of each question that has relevance to the preoperative psychological assessment. Among the most useful pertaining to readiness and informed consent are: "What do you hope your life will be like after implantation?" "What do you predict your life will be like after implantation?" "What do you think your life will be like if you do not have a cochlear implant?" "What would you consider an unacceptable implant outcome?" and "What would you consider a barely acceptable implant outcome?" Each of these five questions is followed by a reminder to consider academic, vocational, family, social, emotional, romantic, and any other relevant areas in responding. The grouping and phrasing of the questions forces the respondent to consider both subjective and objective frameworks for postimplant outcomes as well as to envision a range of possible outcomes and associated feelings about them. Careful analysis, and later discussion with the candidate, of differences between the contrasting questions has proved extremely useful in evaluation and intervention related to motivation and informed consent. Other questions that directly aid the psychological assessment include the following: "How has deafness affected your social life?" "How has deafness affected your relationships with your spouse, family, friends, co-workers, etc?" "What is your primary motivation for improving your communication abilities?" "Please describe the degree and nature of contact you have had with other deaf individuals, especially deaf adults." "Please describe the degree and nature of contact you have had with cochlear implant recipients." "What do others in your life (e.g., spouse, children, siblings, significant others) think about the implant and its potential outcome?" "What do you know about the sociocultural controversy surrounding cochlear implantation?" "How would you characterize the view of the national deaf community?" and "What is your view?" The last topic reflects our team's opinion that knowledge of this controversy, and consideration of the views and issues involved, is requisite for informed consent.

A recent candidate manifested numerous problems in his responses to the questionnaire. He responded "none" to a question inquiring about previous mental health difficulties, which was later found to be grossly untrue. He predicted that life after the implant would be "more successful!!" and "less discriminitive [sic]!!!" The expectations and affect behind these answers were of obvious concern. His flip response regarding an unacceptable implant outcome was "looking like a robot! ha!" His primary concerns about life without the implant were dealing with "the same old boring relay services" and "stupid people who don't understand the general concept of deafness." There is little likelihood that the implant would free him from such experiences, and the affect behind these responses reflected considerable anger, suggesting a need for psychological intervention. In contrast, another candidate offered these conservative responses to questions regarding postsurgical hopes and expectations: "awareness of sound that. . . could apply to everyday activities," "to be able to bring in enough sound to help me lipread better," "to be able to hear other things, doorbells, etc., would be a bonus," "there is, to me, no unacceptable outcome. Any improvement in my hearing would be welcomed." Between these extremes were the responses of a candidate who spotlighted feelings of depression following his hearing loss while simultaneously using language that raised questions regarding the appropriateness of his postimplant expectations. "My social life is gone," he wrote, later indicating that his postoperative hope was "to be happy again . . . very happy once again." He expected the implant would allow him "to hear again"; "I'm hoping 6 month [sic] time to hear and communicate well once again." The meaning of "hear" and "communicate" in his responses, and the expectations behind them, prompted considerable educational intervention during the psychological assessment, for he indeed meant "hear" in the vernacular sense of fully functional audition. The concern regarding depression became an additional psychological issue. Another illustration of questionnaire responses prompting an educational intervention involved a candidate's complaints regarding "not hearing [the] alarm [and] doorbell." Review of this response during the psychological assessment prompted a much appreci-

Psychological Assessments in Cochlear Implantation ated consultation regarding assistive devices, about which this candidate knew very little.

Sessions with the Psychologist Because educational or other interventions probably will be necessary, the psychological assessment should be scheduled as soon as the individual appears likely, from an audiological and medical perspective, to be an implant candidate. The candidate should be familiar with the purposes and open-ended time frame of the psychological assessment prior to the first session. This information is best provided in informational materials sent to candidates by the implant center and during the initial consultations with the audiologist and otolaryngologist. Sessions should begin with a discussion of communication preferences. Few candidates I have met can sign; the majority require communication through a combination of speech, speech reading, and writing. I typically sit at a computer with the candidate, typing the majority of my comments, or at a table, using printed documents already prepared on the basis of reviewing the candidate's preoperative questionnaire and medical records. When our conversation strays from the prepared text, I revert to writing or typing. Speechreading alone is virtually always too arduous and incomplete for such an important and protracted conversation. Aplin (1993a) suggests useful topics to cover in assessment interviews. Shea and Domico (1993) offer an excellent topic list for child candidates. Hellman et al. (1991) list specific interview questions useful with child candidates and their families (see also Quittner et al., 1991). I follow this general outline of topics and objectives: (a) psychiatric history and mental status exam, (b) review of questionnaire responses, (c) discussion and assessment of motivation, in both its connotations; (d) discussion and assessment of informed consent at both technical and phenomenological levels, and (e) psychometric assessment in support of (a) above. Often, departures from this outline are necessary as topics or data arise that require further investigation or stimulate educational or counseling interventions. Assessment and intervention regarding motivation and informed consent involve adult candi-

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dates' significant others whenever possible. This can take place in conjoint or separate sessions but should not supersede assessment of the candidate in these regards. A prepared, bright, articulate adult candidate who manifests a sound degree of readiness and mental health might accomplish all of this in one very long session, but this is quite rare. Most adult candidates require at least two sessions and often more. Assessment of child candidates takes considerably longer, because parents and child should be seen in separate as well as conjoint sessions and because critical information about the school environment is also necessary. The need for a thorough psychiatric history and mental status exam relates to potential exclusion from or delay of implant candidacy for mental health reasons as well as to less urgent objectives. One candidate I interviewed had a history of recurrent major depression that had been treated with ECT, which could not be readministered if she had a depressive episode after im-" plantation (Cochlear Corporation, 1993). Three candidates I have assessed had histories of feeling suicidal, another was psychotic, and several have been clinically depressed at the time of initial presentation. The history and mental status findings may also elicit recommendations regarding personal counseling or modification of the way in which postoperative rehabilitation services will be rendered. Regarding specific interview techniques, I find ituseful to provide candidates and their families with annotated versions of Cochlear Corporation's (1994a, 1994b) "X)nsumer brochures, wherein I have written comments for the purposes of later discussion or to clarify terminology or phrasing that is likely to be misinterpreted. Asking how candidates first heard about cochlear implants, and the development of their interest in and knowledge about them from that day until the present, is often helpful in the assessment of motivation. Discussion of the candidate's social and occupational or school support system is critical and should include consideration of what significant others believe and feel about the candidate's potential implantation. At the technical level of informed consent, directly ask for a description of the equipment, its functioning, and the surgery and rehabilitation process in the candidate's own words, as well as a description of average, unusually good, and unusually poor postoperative

26 Journal of Deaf Studies and Deaf Education 1:1 Winter 1996 audiological and communication outcomes. Contrasting these descriptions with answers to the questionnaire can be useful. At times, they differ markedly due to changes in mood, circumstances, or knowledge since the time they responded to the questionnaire. There should be overt discussion of the implant and body image, especially with teens and young adults. Careful consideration must be given to candidate or family member hopes or assumptions that extend beyond the generally accepted givens of audiological and communication outcomes and begin to touch upon educational, vocational, or social outcomes, not only because of the potential relation of these topics to the phenomenological level of informed consent, but also because of the presently meager research database regarding these larger issues (Brauer; 1993; Knutson, 1995; Pollard, 1993a, 1993c).

Psychometric Assessment A thorough review of the complexities and recommended procedures in psychometric assessment of persons who are deaf is beyond the scope of this article (see Braden, 1994; Elliott, Evans, & Glass, 1987; Pollard, 1993b; Vernon & Andrews, 1990; Ziezulia, 1982). • Although reports of psychological testing can be found in the implant literature, few address the matter in relation to clinical preoperative assessment; most deal with postlingually deafened adults in specific experimental protocols. The assessment of deaf children is even more complex and less frequently described. The following brief suggestions are offered. Some studies recommend screening for neuropathology. Though numerous tests can be used for such screening, a combination of the Symbol Digit Modalities Test (SDMT) (Smith, 1982), reportedly the most sensitive instrument for this purpose, and the ReyOsterrieth Complex Figure Test (see Lezak, 1983) might be considered. When indicated, negative findings can be followed up with additional instruments in accordance with the Boston or process model of neuropsychological assessment (Lezak, 1983). Assessment of general intellectual ability is the most common psychometric procedure reported in the implant literature. The lack of a predictive relationship between IQ_and postimplant audiological outcome has

been discussed. It is nevertheless relevant to evaluate general intellectual ability because of the potential relevance of such findings to candidate exclusion or, more commonly, to modification of procedures for ensuring informed consent and conducting postoperative audiological/communication training if intellectual ability is limited. The use of the revised Wechsler Adult Intelligence Scale (WAIS-R) (Wechsler, 1983), has been most common, particularly the performance subtests, which are more likely to produce valid data with deaf adults than the verbal subtests (assuming the instructions are adequately communicated). Raven's Progressive Matrices test (Raven, Court & Raven, 1983) has been used, as well. In contrast to the WAIS-R, it is shorter and independent of language skills, except for comprehension of the instructions. The Kaufman Brief Intelligence Test (K-BIT) (Kaufman & Kaufman, 1990) might also be considered. Quick to administer, it has a Vocabulary subtest and a nonverbal (except for the instructions) Matrices subtest. The K-BIT is satisfactorily correlated with the WAIS-R, though caution should be used when considering the utility of the Vocabulary portion with persons who are deaf. Aplin (1993a, 1993b) recommends inclusion of a test of reading ability, noting that reading materials provided to implant candidates often require considerable reading proficiency. The Peabody Individual Achievement Test (Dunn & Markwardt, 1970) has a Reading Comprehension subtest that is rapidly administered and avoids the speech/audition biases of phonetically based reading tests. Evans (1989) discusses the importance of language evaluation with child candidates, in part to assess their abilities to discuss informational and personal issues during preoperative counseling. The Minnesota Multiphasic Personality Inventory (MMPI) (Hathaway & McKinley, 1943) has been used to evaluate personality and social-emotional functioning in a number of outcome studies (Haas, 1990; Knutson, Schartz, Gantz, Tyler, Hinrichs, & Woodworth, 1991; Spitzer, 1988). Its utility in preoperative assessment is limited by its eighth-grade reading level, deafness content biases, and primary function as a test of broad personality characteristics. The Personality Assessment Inventory (PAI) (Morey, 1991), a somewhat misnamed test that actually addresses a range of com-

Psychological Assessments in Cochlear Implantation mon Axis I and Axis II psychopathology symptoms and related treatment planning concerns, is more useful. Its fourth-grade reading level and considerably shorter length are also advantages over the MMPI. Consideration should also be given to using the Health Opinion Survey and the CPHI, given emerging reports of their utility in predicting postoperative audiological outcomes.

Conclusion The importance of preoperative psychological assessment in cochlear implantation is clear from the frequency of such pronouncements in the literature and in light of the issues and illustrations discussed above. This is especially true when the potential intervention utility of the psychological assessment is appreciated. This article provides a conceptual framework for the preoperative psychological assessment, a framework not found elsewhere in the literature—a rationale that in turn drives considerations regarding the foci and methods used during the assessment. Although topical foci and methods will vary according to the circumstances of different candidates, there should be no variation in the conceptualizations of purpose, readiness, motivation, and informed consent described herein, nor should there be variation in the evaluator's resolve to thoroughly understand and, when necessary, act or take a stand on such issues for the good of the consumer.

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