The 6 Stages of Adjustment to Hearing Loss of the Nerve Type

The 6 Stages of Adjustment to Hearing Loss of the Nerve Type

Of the many problems and conditions that can affect the human body, hearing loss of the nerve type is one of the least detectable and the most communicationally segregating and psychologically devastating.

Segregating because it fractures and warps the ability to communicate effectively if one cannot speechread and/or is not assertive enough to speak up and tell others s/he has this impairment.

Devastating because it changes present relationships, places a barrier on new relationships and often strips the individual of his/her dignity, pride and independence.

It is not easily and/or readily recognized as blindness or mobility impairments. It only becomes noticeable to self and others when the individual tries to communicate or to understand a speaker and the words sound garbled.

An individual with a moderate to profound hearing loss of the nerve type may have no difficulties getting where s/he is going but once s/he arrives at his/her destination, the problem begins. His/her problem goes completely unnoticed by others.

Unnoticed for 2 major reasons:

It is not easily detectable by others, and

The individual is not about to admit s/he has hearing loss of the nerve type to others and chance a negative reaction. People don’t have any problem admitting they can’t see and they have no difficulties wearing glasses. The interesting thing I have personally witnessed are those who wear hearing aids will not change their battery in front of other people. Instead they go to the bathroom to do that. While those who wear glasses have no problems whatsoever removing their glasses, holding them up to a light and cleaning them, then putting them back on right wherever they may be.

Why is it so difficult for us to admit we have a hearing loss?

I can provide 4 reasons based on my students answer to that question. The following are the most frequent reasons. And, every individual who has developed hearing impairment of the nerve type can relate to one or all these reasons or a combination of them. In this paper we are talking only about those who have NERVE impairment.

1. The person who has acquired hearing impairment yet continues to hide the problem may be exposing his own pre-biased deep seated feelings about deafness. Unknowingly, by “covering up” the problem… he is keeping the stigma attached. S/he’s ashamed of having this problem or feels ashamed. That feeling is based solely on what s/he has heard others say about it and/or what reactions they have demonstrated. Like anything else if it’s hidden away, and brought out into the open it will create negative reactions. After thousands of years of this vicious cycle of defeat it is still playing its old game of “cover up.”

At one time I collected antique books of any title. One day a friend gave me a book wrapped up beautifully with a nice bow for my birthday. It was well worn hard back copy published in 1648. What a treasure! The title: Deaf and Dumb. And, I think you already know what it talks about. That was in the mid 1600 yet in 2011, although we’ve advanced in technology the social attitudes are still way behind. I don’t think we’ll ever see a book that is titled: Blind and Dumb.

What’s interesting here are similar words by Helen Keller who had both deafness of the nerve type and blindness. This was her statement:

“I have both deafness and blindness and of the two deafness is the worst because it has to do with communication and without communication we have nothing. With blindness I do not see thing’s but with deafness it separates me from others.”

2. Those of us who have had normal hearing and developed a hearing impairment later in life are accustomed to helping others less fortunate; and this may make it difficult to accept anything less than perfect in ourselves. Whereas, we were once in a position to help others, we are now in the position “to be helped”. That, in itself, is the difference between independence and dependence. America is not only youth-oriented but good-health oriented; and, we all want to be a part of that. This attitude has been reinforced by the audio visual media even more so in the latter few years than ever before in history.

3. We have noticed how others treat those who have hearing loss and we don’t like what we see. (This one was the most frequently mentioned)

4. That leads us to believe that people are not very understanding about this problem and even if we admitted it they soon forget and we are back to zero again.

If we, who have hearing loss of the nerve type cannot accept and understand this disability, we cannot possibly expect others to comprehend it. Maybe the answer is within our own attitude and how we viewed hearing impairment in others. In order to get past this problem we need to ask ourselves some questions and the answer will roll to the front of our mental cupboard. The following are some questions and you can ask yourself other questions as well to get to the bottom of why we are so sensitive about our impairment.

Before I developed hearing loss…..

1. how did I view others who had hearing impairment?

2. what did I do to help others who had this impairment?

3. how did I repeat a statement when that someone didn’t hear it the first time said?

4. how many times did I laugh at a joke being told and then told my friend who had hearing impairment and missed the punch line … “He just told a joke.”

5. how much time did I spend with an older individual who couldn’t keep up with the conversation at the Holiday family dinner table?

You don’t have to share your answers with me. The purpose of these questions is to help you find how caring you were with those around you who had hearing impairment. If you find you were not as caring as you’d like someone to be to you, forgive yourself right now because you can’t change something that happened years ago. But you can change what you would do now and in the future. That’s the key. Don’t look back. That’s what we call “learning” and seeing things from a different light.

More people today have hearing impairment than ever before in history and the teenagers are now being tested for hearing loss due to the musical radios they listen to all day long…directly into their eardrums and it’s louder than the cochlear can handle. Once the hair cells in the cochlear break…one will never hear that sound again….not even with a hearing aid/s. The aid amplifies sound…all sounds but technology has so greatly improved these last few years and I recommend anyone who has hearing impairment in both ear to wear 2 hearing aids. It is also a safety net so one can hear the noises around him/her an should be worn every time one drives a vehicle.

Elizabeth Kubler-Ross (1969) the author of Death and Dying, developed the 5 stages of dying. This development gave us a tremendous insight into the different emotional stages when an individual suffers a major loss. These stages apply equally well to any significant change in a person’s life. The stages developed by Kubler-Ross are as follows:

1. Denial

2. Anger

3. Bargaining

4. Depression

5. Acceptance

And, I have chosen to add one more stage for those who develop hearing impairment of the nerve type……stage 6. Rehabilitation

Like those who are faced with dying, those with progressive nerve loss face the same life threatening problems…..loneliness and rejection and the unknown. The difference between the person dying and the individual who has developed progressive nerve loss is the latter lives on but with a devastating disability.

The degree of reactions to the development of this problem is not necessarily in direct proportion to the degree of loss in hearing. However, the intensity of the reaction is directly related to several factors such as:

1. How much one needs and uses communication his/her daily life;

2. The attitude about self and others;

3. How others relate to them;

4. The ability to be flexible to the need and adaptable to change;

5. The ability to build a strong support system within the social circle s/he is accustomed to;

6. The tolerance level with self and others;

7. Length of time it takes one to admit to self that s/he has this problem;

8. Length of time it takes one to seek professional help;

9. The personal status level; and,

10. Personal communication skills.

Let’s take a look at my favorite American Humanistic Psychologist, Abraham Maslow’s hierachy of needs theory. (1970).

Maslow’s hierachy of needs demonstrates as the individual fulfills his /her needs on one level, s/he arrives at the next higher level. As Maslow’s chart below illustrates, the first 2 levels are the most basic in the human hierarchy chain of events!

Maslow’s Hierarchy of Needs

6. Desire to Know and Understand

5. Need For Self-Actualization

Self-mastery, desire to help others, ability to direct one’s own life, rich

Emotional experiences, a sense of meaning to one’s life.

4. Esteem Needs

Self-esteem, esteem of others, achievement, recognition, dignity,

Appreciation, self-confidence, mastery of oneself and one’s environment.

3. Belongingness and Love Needs

Love, affection, belongingness need for family, friends, group,

Clan, territorial imperative, and community.

2. Safety Needs

Security, stability, dependency, protection, freedom from fear,

anxiety, chaos, need for structure, order, limits, etc.

1. Physiological Needs

Homeostasis, specific hungers such as sex, food, water, air,

Shelter and general survival.

Adapted from Abraham Maslow, Motivation and Personality. (New York; Harper, 1970).

Although the needs on the levels 1 & 2 are necessary to survival they are not sufficient to maintain a satisfactory lifestyle and enable the individual to fit in with society especially if he is a product from a higher level.

I bring this information to your attention only so you can focus on the “why” an individual experiences panic and much difficulty upon acquiring moderate to profound hearing loss of the nerve type. How well one arrives on the higher levels has much to do with his/her ability to communicate with others. When the communication has been severed his/her very psychological well being is threatened and creates panic and sometime full blown panic. If the loss is sudden and severe such as over night or within a few weeks…it can be psychotraumatic!

Stress seems to affect people more profoundly if they feel powerless to control the situation. Thus, the reason more stress is involved for those whose hearing loss is sudden and severe. There is no time to develop a compensatory system. That’s why those who lose hearing in mid life of the nerve type have a difficult time as they are in their prime of life.

Some scientists such as Hans Selye appear to believe that some periodic doses of stress may have some lasting benefits. It may help an individual learn how to deal with the environment from a different perspective and help them find deep in their lowest gut something they didn’t know they had. And, as a result find the strength to survive.

People don’t just grieve over a loved one or a dear friend or favorite pet who has passed away, however, which is a major loss; they also grieve over losing a major sense and losing one’s hearing is an absolute major loss that most cannot possibly comprehend….until it happens. It can be a very painful experience. Looking at it from another standpoint, it can also be very rewarding….that is, if one can find themselves at that point.

I did. It became my life work. I loved teaching Psychology of Hearing, Solutions to Hearing Impairment Social Psychological Aspects and Speechreading which included teaching Body Language, Facial Expression. If I had my life to live over again, I’d teach the same thing.

I can remember when I was very young…4 years of age…I had no idea I couldn’t hear. I thought everyone else was just like me. When I played the gossip game with my friends, I learned the story always changed when it got to me. I solved that problem by being the one that starts the gossip game. No one was pointing their finger at me anymore. But I didn’t know it’s because I couldn’t hear a whisper. A whisper is very high pitch.

My mother was in the hospital most of the time from the time I was 4 to 7. She had cancer of the uterus. And, she wasn’t always feeling her best so she just thought I didn’t listen a times. She was not expected to live beyond 6 months and that was in 1945 but she lived to be 79 and passed away on Easter Sunday in 1994.

She had German measles when she carried me so I was destined to be deaf, blind, mentally retarded or any combination of those. As I got older and had high fevers from childhood diseases, chickenpox, measles, mumps, my hearing got worse. It was the high fever that caused the loss as per the diagnosis in later life. I didn’t know I couldn’t hear so I didn’t have a problem.

But I had an older brother and I took the attitude of anything he could do, I could do better or at least as good. He was 3 years older than me. I can remember he learned to spell the word, “people” and got loads of attention and praise from the family at a holiday dinner. I was watching that closely. And, I got that “aha” feeling. He was 7 and I was 4. I had a nickel saved in my drawer and I made a bee line for that nickel and off I went to buy a tablet. In those days you could buy a whole tablet for 5 cents. I already had a pencil that was about 3 ” long and I sharpened on the sidewalk.

Then off I went in search for a long word. Just any word would not do…it had to be a long word! Apparently, I was walking past a travel agency because across the entire window was a nice long word and I dropped to the hot cement sidewalk, spread out and copied letter by letter….C Z E C H O S L O V A K I A…..then, all the way back home I skipped and memorized that nice long word visualizing the attention and praise I would get for that…I was really going to outshine my brother. When I got home I was ready and I walked up to my mother and my Aunt Lucille and said, “I can spell a word, too.” My brother laughed and said, “what can you spell? Maybe “I” or “Me”….maybe “Cat” and he scrunched his nose up when he said, Cat. He was bent over laughing and holding his willy to keep from peeing his pants. And, my Aunt Lucille said, “What can you spell?” Now that was a hard question because I had no idea what I could spell. But I stuck to my guns. And I said, “I can spell a long word!” My mother said, “Ok, let’s hear it.” And, I started…. C Z E C H O S L O V A K I A. Then I smiled and waited for all the praise. But instead they all started laughing. I never forgot that. I was so hurt… I ran to my bedroom crying. I didn’t realize that no one knew what I spelled and I didn’t know either. But it wasn’t the last time I challenged my brother. I challenged him to the bottom of the hill on a bicycle. I got to the bottom before he did which was my goal, but I wasn’t on the bicycle when I got there! You win some and you lose some and sometimes it depends on how we look at it.

When I was 14 years of age we moved to El Monte ,California and that was the first year the school tested hearing. That was when I found out I had a moderate to severe loss. But, by that time I had developed some very strong compensatory skills. My grades were good…mostly A’s and B’s. By the time I was 18, when I got married, my hearing dropped to a severe to profound level. I dated my husband for a year and 9 months before getting married and my hearing loss was never discussed.

And, each time I had a baby it dropped some more. Anytime one goes into surgery and is given a spinal, or whatever medication they use to put you to sleep, your hearing may be directly affected. I had weak hair cells in my cochlear due to my mother’s German measles. I was very lucky nothing else was affected. After having 3 babies I became profoundly hearing impaired of the nerve type. And, based on my ENT it was more than likely a nerve loss from the very beginning. Most of my hearing loss was in the high pitch range so that means I couldn’t hear most or all of the consonants. Have you ever tried to read a book with all the consonants missing?

Let’s get back to grieving now…..It’s important to understand the process of grieving over hearing loss and to allow yourself the privilege of expressing and feeling the pain to yourself and others. Sometimes it is in the suffering that brings us to a climax where more understanding of ourselves and others take place. The true lesson in learning about empathy may be accomplished during this process. For it is within this personal experience where we reach deep down inside ourselves and tap natural reserves we never dreamed we had.

Not everyone travels through these stages in the exact same pattern; some people skip stages or get stuck in a stage for a long time and / or repeat stages. Each person travels through these stages at a different speed. But one thing every person who suffers a hearing loss has in common is s/he will find him/herself in one or more of these stages at one time or another prior to arriving at rehabilitation. When you understand these stages you can tell almost exactly where you, your family member or friend is in these stages.

Let’s talk about the different stages and let’s begin with Stage 1: Denial

A person enters this stage at about the time he has acquired a mild to moderate loss. If he/she has a sudden severe loss he will not enter this stage, instead he enters somewhere between stages 2 and 3. S/he moves at a faster speed and simply bypasses this stage. If the hearing loss is sudden and severe one may experience acute panic, suffer from anxiety and become nervous and frustrated when others don’t cooperate or forget you have a loss of hearing, and if you don’t find any immediate effective solutions.

Unlike those who have progressive hearing loss over a long period of time, this individual more than likely will seek help immediately. He has no time for denial of the problem or time to develop any sophisticated compensatory skills. S/he may admit s/he has hearing impairment to him/herself and others but it hurts deeply. S/he’s in mourning.

It hurts because s/he is being forced involuntarily to admit something is amiss about him/herself. S/he has found no options and not enough time to recover from the initial shock of the loss of a major sense. S/he feels the impact with far more intensity than the individual with a progressive loss over a long period of time.

S/he may even skip right past the Anger stage (or experience it lightly) and head straight for hte bargaining stage and depression. S/he moves through these stages faster but on a more profound level of intensity.

The Denial stage provides a useful function in that it allows you to buy more time to recover, blame others why you can’t hear…everyone mumbles…, from the initial shock of learning that your hearing is no longer “perfect”. It is the longest stage for most people. And too many people actually wallow in that stage. They refuse to admit something is wrong with them.

It is within this stage where one may begin developing a highly sophisticated compensatory response system. This system serves the individual so well it not only makes it more difficult for others to notice the hearing loss, but it also eventually convinces the individual that s/he just needs to be more attentive to details and that s/he does a splendid job.

• The compensatory response system may include:

• Looking at the speaker more;

• Asking for repeats but pretending a distraction was the cause of not hearing;

• Guessing at and assuming what was said;

• Watching gestures and body language;

• Acting too busy and/or feigning illness and tiredness to cover up when s/he didn’t hear; and,

• Accusing everyone of mumbling.

In this stage you’re very much aware of the problem but you hide the truth from yourself and others for as long as possible. You are buying time.

If your hearing never gets worse than mild to moderate loss then you may never experience the following 3 stages….that is, if you don’t have nerve loss.

If you don’t have nerve loss then you may skip to the acceptance stage. But for the person with nerve loss, then it becomes noticeable worse and you might enter the next stage. With family and friends now telling you more often that you have hearing loss may create anger and enter a battle with them through arguments that set up stress in a relationship.

Stage 2: Anger

This stage serves as a vent and is a “non-cooperative” time during the adjustment period.l Anyone who expresses anger is expressing a dissatisfaction of a personal need and in this stage anger is expressed in all directions:

• externally ; and

• internally.

Feelings fluctuate between resentment of others and frustration with self. At this point, hearing loss has been admitted to self only but not accepted and it certainly has not been admitted to others. You now acknowledge you have a hearing problem but it is not your fault. You are now angry at the world and may find yourself ….

• asking other to repeat in a rude way; or

• accusing others of mumbling or speaking too softly; or

• leading others to think it is their fault you don’t hear…they don’t speak up or don’t articulate; or

• acts very indignant when someone suggests you try an aid/s…heavens forbid; or

• does most of the talking so you don’t have to listen.

Do you know anyone like that? It’s easy to identify people with hearing loss by their habits and it’s easy to locate what stage they are in as a result.

As one loses faith in others to help him, he begins desperately seeking ways to make a change, to help himself without having to admit to others he has a hearing loss. But with every turn he gets the same external response that clearly confirms the problem again. In the process he becomes…

• disappointed in self; and,

• loses his self esteem; and,

• loses his sense of humor; and,

• then becomes angry with himself.

The realization of the problem has now been supported by the family, friends and self.

This is a period of turmoil, like a fox chasing his tail. e runs in circles but as a result he eventually makes a break to move on. And, some move is better than no move at all. The decision to move on opens the door to new experiences. Unlike indecision, which keeps you in a no growth pattern.

Stage 3: Bargaining

This stage may go on for years. He has finally recognized the presence of the loss but still may not be willing to do anything about it. it’s become like a boil…it hurts too much to touch. The individual becomes desperate and despondent. He begins bargaining with God, self and others and usually in that sequence.

God

1. “God, if you give me back my hearing I’ll never ask for another materialistic thing.”

2. “God, if you give me back my hearing I’ll never have another extramarital affair again…I’ll be faithful to the end.”

For those of you who remember Danny Thomas a TV entertainer of the ’50′s – ’70′s I believe. He was losing his popularity and he bargained with God that if God would bring him back to where he was before, he’d build a hospital for sick children.” He regained his popularity and built St. Jude Hospital for children. What a bargainer he was! But his word was good!

Self

1. “If I stop smoking and drinking maybe that will improve my hearing.”

2. “Maybe if I change my diet and lose some weight it will take the pressure off my ears.”

Others

1. “If you would just stop mumbling, I could understand you better!”

2. “If you would just speak up I culd understand very well!”

3. “There is absolutely nothing wrong with me…the problem is out there.”

And, after the bargaining comes the excuses:

1. “I know I don’t hear perfectly…but it’s not that bad …yet!”

2. “I’m not old enough to wear a hearing aid!”

3. “I have a nerve impairment and aids will not help my problem.”

4. “I don’t know anyone who likes to wear an aid/s.”

5. “I get along just fine without an aid/s.”

6. “Hearing aids cost too much money.”

7. “My friend has a hearing loss and he gets along just fine without an aid. And, I can do the same!”

He continues to buy more time with compromises and excuses and as long as he continues to negotiate he will find himself regressing slowly back to sate 2, Anger. He’s now angry and disappointed in God, Self and Others. Angry because what he’s doing doesn’t seem to be working in his favor. This time his anger becomes profound and internalized. Internalized anger leads to depression.

Stage 4: Depression

This is the most difficult period. a time when he reaches his lowest ebb in the process of the adjustment. He probably has even lost more hearing by now. He may listen to what others have to say but he’s not sure he wants to do anything about it anymore. He is now in limbo. It’s the grieving period. A period of negativity where he feels some or all of the following at one time or another during this stage:

• A feeling of inner emptiness;

• Life seems hopeless;

• Withdrawal from family and friends;

• A feeling of giving up …so what’s the use?

• A feeling of being left out of the fun by family and friends;

• The inability to sleep or would rather sleep all the time;

• A loss of appetite or compulsive eating habits;

• A loss of self esteem and poor self image;

• Becomes emotional (cries a lot and easily);

• Thinks and talks about all the things he can’t do; and,

• in worse cases….

• Nothing to live for anymore; and

• Suicidal feelings which may include writing notes or even attempts.

In his deepest level of depression and introspection…this is where he does most of his real deep thinking and observing ….he’s at his lowest ebb and begins to ask himself questions and providing his own answers.

• Why me?

• Of all the millions of people out there….why me?

• What did I ever do to deserve this?

• How did I get in this lonely boat anyway?

• Why aren’t people more understanding?

• Why doesn’t someone help me?

It is in answering that final question and attempting to answer that he realizes that he, himself, is someone and he can help himself. Even though he may not have an answer to all those questions, he is asking the right questions that lead him to that final question and his answer. He is now learning to adjust. It is within this step that he begins to accept his fate. And, so quietly slips into the 5th stage…tired and worn out physically, but he has a whole new set of tools to work with now.

Stage 5: Acceptance

This is the stage of mixed emotions and the body is in somewhat of a shock. He feels trapped. It’s a highly progressive stage, however…when he finally realizes that to help himself he must take appropriate steps and follow through with action. He must do it himself. He may still feel that residue of his past experiences from anger, stage 3, to depression, stage 4, but they will be short lived now.

• He may still get the poor me’s occasionally but not as profound or as long in duration;

• He may still feel guilty about how he handled himself, expressed his rage, accusations of others “inadequate speech…mumbling, etc.”;

• He may feel guilty about having put his family and friends through all this;

• He may even feel embarrassed about having the loss in the first place;

• He may feel humiliated by not doing something about it sooner to help himself; and,

• He may even ask himself why he didn’t do this in the first place!

He kicks and licks himself throughout this period. He’s reached deep inside and he found more answers and strength to cope as well as empathy for others who may have problems. He’s put his false pride aside now and he no longer feels the same about the problem. His attitude is more positive now about himself, the problem and others. It is about this time when he decides to enter a rehabilitation program, a speechreading class or a self-help group. He may even decide to see an Ear Specialist or an Audiologist.

Stage 6: Rehabilitation

The higher degree of acceptance, the more effective his effort will be in creating opportunities to lead a near normal life. In this stage he begins investigation of the options available to him and this may include the following:

1. Seeing an Ear Specialist, ENT and with an open mind believing what he has to say and following up on his recommendations; and,

2. Seeing the Rehabilitation Specialist to develop coping skill, awareness of options available, and understanding the problem. Learning how to regain, retain and maintain the comfortable lifestyle he once took for granted.

As acceptance is slowly acknowledged it becomes a part of the person’s existence. The strength to fulfill his life, independence and dignity by following through the newly learned strategies. The need to view himself as in control of his own life is great.

Even after the arrival at this stage, there may be more periods of regression. Having the present knowledge and skills will assist the individual in working himself back to this level at a more rapid pace. Once he realizes that his liberation lies in acquiring the knowledge of understanding the disability, learning precisely what his needs are and how to fulfill and maintain those needs he will finally accept the fact that, although he may always have the disability, but the handicap can be overcome.

These stages are normal growth patterns when an individual acquires a major loss. Anyone who acquires hearing loss should be able to progress through these stages that are necessary to his needs within a year. In the past many people have taken as long as 25 years or more to work through these stages and thereby, prolonging the cure. The longer it takes to go through these stages the more intense and profound the feelings. And the more stress it places on the body. This is not to mention what it does to close family members and friends.

Although it’s important to experience these emotions it’s also equally important to keep the duration period at a minimum to relieve stress. This can be done if the individual would see his ENT immediately after the first sign of a loss, hoever slight. This would be in the Stage 1 level. It is during this period when the individual should consider entering a rehabilitative program and learn as much as possible about the problem before it becomes progressively worse and before being stressed out. A well-structured program would provide the individual with the following:

1. Development of realistic expectations for what can be gained from rehabilitation;

2. To stimulate the patient to move from his present level of message perception to a higher level;

3. To encourage the individual to compensate and work through his social-psychological and communicational problems more effectively;

4. To provide the individual with an understanding of hearing loss and how he hears;

5. To assist the individual in the acceptance of and responsibility for the disability on a comfortable level with self and others;

6. To assist the individual in learning independent and interdependent skills;

7. To acquaint the individual with resources available for follow-up upon completion of the program;

8. To motivate the individual to follow-up on these available resources to improve communication skills; and

9. To encourage effective supportive skills by family members and friends.

Another check up may be forthcoming 6 months to a year later while still in Stage 1 or advancing to the final stage and bypassing all the painful stages one puts themselves through unnecessarily.

Although the rehabilitation program will not prevent the loss from getting progressively worse. In a sense, it is a true alleviation and it will serve as a “bridge” and shorten the duration periods and intensity in Stages 1 through stage 3 and partially eliminate the intensity of Stages 4 & 5. People with acquired hearing loss of the nerve type must take responsibility for their own rehabilitation. And, I believe most are willing to do so. That’s what the Rehabilitation program is all about. Trying to solve the problem by oneself can be a long and painful experience. One does not need this much pain and suffering to find his way back to an acceptable lifestyle.

I believe by looking at the Maslow hierachy one can see why the individual with nerve type loss loses so much of his/her lifestyle and this sets up stress. They feel the loss of friendship, chit chat, belonging to a group equally, conversation that bounces back and forth. It is all these things that pull friendships together and binds them.

 
 
 

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