© 2005 Psychiatric Times. All rights reserved.
The hearing world, including physicians, is prey to misconceptions about deaf
people. For instance, there are large differences between people who grew
up deaf and those raised as hearing who then experienced hearing loss later
in life. The latter group is fluent in English and can communicate by note-writing
and computer keyboard. (The focus of this article is largely on individuals
raised from birth or infancy as deaf.) This article will attempt to add nuance
and complexity to the average psychiatrist's thinking about deaf individuals.
Communication
American Sign Language (ASL) is a complete manual language used by many, but not all, deaf people. Other manual languages are Cued Speech and Signed Exact English (SEE). Not all deaf people have a "full" language system. Because 90% of deaf children are born to hearing parents, some are at risk to not receive any usable language input during critical language-acquisition periods of brain development. Although there is controversy about exactly when the window for language acquisition is open, most would agree that the ages of 3 to 7 are critical. Lacking language input during this time can result in an adult without fluency and competence in any language, including ASL (Sacks, 1989).
There are many myths about how to communicate with deaf individuals. These myths apply especially to those deaf people for whom English may or may not be a usable language. One common misconception is that deaf people are very good at lipreading. This would be true for people who are oral deaf, in that their education has focused largely on speaking and comprehending spoken English. To be an adept speech-reader generally requires fluency in the language, as speech-reading requires knowledge of idioms and predicting what phrases would be most likely to occur in any given context. Moreover, only 30% of English is visible on the lips, and many phonemes look the same. For example, "f" and "v" have an identical appearance on the lips. Some deaf people appreciate total communication, in which both sign and speech are used. In this case, the subject uses cues on the lips to help follow what is being signed.
Another common misconception concerns written communication. To understand writing requires knowledge of English grammar and syntax. The average deaf individual reads English at a fourth-grade level. Psychiatrists should never assume that a written note will be understood by a deaf person unless that individual has demonstrated a facility with English.
Although it is common for health care staff to try to use family members as interpreters, this practice should be avoided for a variety of reasons. For example, the family members oftenlack fluency in sign language and may not be able to express complicated medical terms well. When hearing parents are seeking medical care for a deaf child, they are often very stressed or, in psychiatry, are potentially part of a pathological situation. It is unfair and inappropriate to ask parents to wear two hats in the child psychiatry situation. Also, privacy cannot be maintained if family or friends are interpreting.
The Americans with Disabilities Act (ADA) mandated that reasonable accommodations must be made for individuals with a disability such as deafness. The American Medical Association has indicated that each physician should decide what is the most appropriate method of communication.
This is difficult, since physicians generally have no knowledge of deafness or deaf culture and no ability to accurately assess an individual's best communication system. Thus, best practice is for a deaf patient to inform their physician of their preferred communication system.
Many times this requires an interpreter, for whom the physician is obligated to pay. This can make physicians in small practices loathe to take on deaf patients, as they may lose money once they have billed insurance and paid for an interpreter. In some states, Medicaid has billing codes to cover the cost of interpreting. CPT has interactive therapy codes that can be used when working with an interpreter (90810-90815). Unfortunately, their reimbursement rate is not significantly higher than for regular codes. These codes do not address the reality that the psychiatrist may lose money while seeing a deaf patient.
The practical solution for deaf patients is often to seek care at a large institution, which can absorb the costs of interpreting with less financial hardship. Now such facilities will have to grapple with a 1994 federal court ruling in Florida that mental health care services utilizing interpreters rather than signing therapists violated the ADA (Raifman and Vernon, 1996).
Use of Interpreters
Psychiatrists have many misunderstandings and misgivings about working with interpreters. It is crucial to understand the basics of the interpreter's role. Interpreters are bound by a very strict code of ethics to maintain confidentiality. Thus, it is completely appropriate to disclose some confidential information to an interpreter.
Interpreters prefer to have a preconference with the person who will be meeting with a deaf individual. Since the interpreter will be communicating the treatment plan to the patient, they should be viewed as an integral part of the health care team. Physicians should allocate at least five minutes to speak with an interpreter before beginning a session with a new deaf patient.
In mental health care situations, this is especially crucial, as it is useful for the interpreter to understand what broad differential diagnosis or what broad issues are on the psychiatrist's mind. For example, if the physician is considering the possibility of a psychotic illness, it is very useful to convey this to the interpreter, as they may never have met the individual for whom they are interpreting and will be struggling to master that individual's unique communication style. If that individual has a thought disorder, knowing this will help the interpreter distinguish what is pathological communication and what is idiosyncratic style.
Once the session has begun, the interpreter is only there to convey communication from one language to another. Hearing people typically turn to the interpreter and ask for an opinion, or they refer to the deaf individual in the third person, rather than the second person. Interpreters may not give opinions and will interpret every word that is said in the session, including questions directed at the interpreter.
Communication Techniques
Many of our standard psychiatric questions are very abstract, and if a deaf person has experienced developmental deprivation secondary to deafness, such questions may lead to a deteriorating interview situation. Such deprivation can affect an individual's ability to think abstractly and to acquire concepts and constructs.
When developmental deprivation has happened, the typical psychiatric open-ended questions such as "What brings you here today?" and "How do you feel about that?" can be incomprehensible. In addition, ASL often uses listing as a grammatical feature. Rather than asking, "With whom do you live?" which might be met with blank stares from a developmentally deprived deaf person, the interviewer will have more success asking, "With whom do you live: Mother? Father? Brother?" This becomes very delicate in a forensic evaluation, as one does not want to lead the subject or suggest responses, but one must also at times use listing to cue the kind of answer one is looking for.
Diagnostic Issues
In the middle of this century, there were a variety of psychiatric myths about deaf people. One such example was that deaf people could not suffer depression, as they didn't have enough of a superego to rise to the level of obsessional defenses (Altshuler, 1971). There is a common misconception that deaf people are paranoid. Such paranoia may occur in the elderly who are late-deafened adults. Sensory deprivation of any kind can lead to an increased prevalence of paranoia. This is a very different situation from those people who grew up deaf, who do not have an excess of paranoia.
Deaf people do not exhibit any greater frequency of the major mental illnesses than the general population. Deaf children and adolescents do exhibit some higher levels of behavioral and attention-deficit/hyperactivity disorders, especially those who become deaf secondary to rubella or spinal meningitis.
Psychosis in Deaf Adults
Psychotic deaf people can display disorders of thought form and/or thought content. Disorders of thought content can be diagnosed in a straightforward way, e.g., does the patient feel that the devil is persecuting them, that people are following them, that someone is stealing their thoughts and so on. Disorders of thought form are more difficult to diagnose without being an expert in sign language. Such disorders can include clang associations (rhyming to handshapes in ASL), loose associations, flight of ideas, incoherence, tangentiality and fragmentation. The latter is particularly difficult to sort out in a patient who presents without fluency in sign language.
Hearing people commonly believe that deaf patients cannot experience auditory hallucinations. This is not the case. Deaf patients can hear voices, even if they have been deaf from birth and have never heard sound (Altshuler, 1971; Evans and Elliott, 1981). There is ongoing debate about the neural mechanisms for this, and there is hope that new neuroimaging studies will clarify exactly what is going on in the brain during such events.
Our inpatient unit for deaf people serves the entire Commonwealth of Virginia. Recently, we reviewed psychotic phenomenon noted in our patients over a 10-year period. Tables 1 and 2 show examples of hallucinations in deaf people with schizophrenia. Some psychotic deaf people complained that they see signing, such as Jesus signing to them, a face on the wall signing to them and so on. This is a unique additional psychotic feature that seems to fall between a typical auditory hallucination of communicative input and a typical visual hallucination, which is often more of forms than communicative content. Table 3 shows a breakdown of hallucination subtypes seen in our inpatients.
Multiple lines of research suggest that intrauterine insult during specific gestational periods is associated with a higher prevalence of schizophrenia. Most deaf people do not have hereditary deafness; thus, deafness is either idiopathic or due to a perinatal insult. Therefore, it is not surprising that insults at particular gestational ages may produce both deafness and schizophrenia. Rubella is a classic insult that can produce both conditions (Lim et al., 1995).
Psychotherapy Issues
Deaf adults with adequate ego strengths and communication capabilities have many of the same psychotherapy issues as hearing adults, including relationship, self-esteem and vocational concerns. In some communities, deaf clubs are available and are a preferred social resource for deaf people, and some clubs feature regular use of alcohol. This can be a risk factor for a deaf person prone to substance abuse, as they may have more limited choices for socializing than a hearing individual does.
Some deaf people grow up without adequate access to information available in mainstream culture and can be at risk for not having basic knowledge about AIDS and other sexually transmitted diseases, how feelings affect behavior, how stress affects personal functioning, and other issues. At such times, psychoeducation can be extremely valuable, but therapists may need to begin at a more basic level than they would ordinarily.
Frequently, deaf people need support from their therapist in affirming their deafness as not merely a sensory deficit. The therapist affirming and encouraging the effective use of sign language by family members and active participation in deaf culture activities by the deaf person can enhance self-esteem and responsible self-care. Deaf culture offers positive identifications and group identity to many deaf adults.
Dr. Haskins has worked at the Mental Health Center for the Deaf for 13 years
and is coordinator for the American Psychiatric Association Caucus of Psychiatrists
Working with Deaf and Hard of Hearing Persons.
References
Altshuler KZ (1971), Studies of the deaf: relevance to psychiatric theory. Am J Psychiatry 127(11):1521-1526.
Evans JW, Elliott H (1981), Screening criteria for the diagnosis of schizophrenia in deaf patients. Arch Gen Psychiatry 38(7):787-790.
Lim KO, Beal DM, Harvey RL Jr. et al. (1995), Brain dysmorphology in adults with congenital rubella plus schizophrenialike symptoms. Biol Psychiatry 37(11):764-776.
Raifman LJ, Vernon M (1996), Important implications for psychologists of the Americans with Disabilities Act: Case in point, the patient who is deaf. Professional Psychology: Research and Practice 27(4):372-377.
Sacks O (1989), Seeing Voices: A Journey into the World of the
Deaf. Berkeley, Calif.: University of California Press.