The Perceptual Characteristics of Voice-Hallucinations in Deaf People: Insights into the Nature of Subvocal Thought and Sensory Feedback Loops
Joanna R Atkinson (2006) Schizophrenia Bulletin. March 1.
This is not my paper, but I am linking to it as it is critical. Download the PDF here.
Or mirrored here.
Abstract:
The study of voice-hallucinations in deaf individuals, who exploit the visuomotor rather than auditory modality for communication, provides rare insight into the relationship between sensory experience and how ‘‘voices’’ are perceived. Relatively little is known about the perceptual characteristics of voice-hallucinations in congenitally deaf people who use lip-reading or sign language as their preferred means of communication. The existing literature on hallucinations in deaf people is reviewed, alongside consideration of how such phenomena may fit into explanatory subvocal articulation hypotheses proposed for auditory verbal hallucinations in hearing people. It is suggested that a failure in subvocal articulation processes may account for voice-hallucinations in both hearing and deaf people but that the distinct way in which hallucinations are experienced may be due to differences in a sensory feedback component, which is influenced by both auditory deprivation and language modality. This article highlights how the study of deaf people may inform wider understanding of auditory verbal hallucinations and subvocal processes generally.
The Rivermead Behavioural Memory Test is a nice screening test of everyday memory functioning that at first glance seems reasonable to use with prelingually propfoundly deaf people. However there is still a great deal of adjustment to be made to make it usable, and when adjusted the screening cut-offs become unreliable in unpredictable ways.
These are my rough adaptations for deaf subjects. None of these adaptations are standardised, or necessarily any good. But if they are applied consistently then change in memory can be estimated over time. The RBMT screening cutoffs should not be used.
1. Remembering a name
Fingerspell this, but call her Jane Clark.
(This makes it more verbal than sign, being also visual, and is shorter then c-a-t-h-e-r-i-n-e-t-a-y-l-o-r.)
2. Remembering a hidden belonging
This should be fine as it stands.
3. Remembering an appointment
This is OK but the alarm cannot be used, obviously. Try to find a vibrating alarm. Failing that you could just remind them later. If this is attempted remember you must not prompt at all, so you need an empty reminder like “the alarm is going off now.” Record whatever you do for next time.
4. Picture recognition
May cause problems since you need to be sure the responses are names of objects and not mimes of the object use (as this is a common strategy in anomia. Allow fingerspelled or signed words, but be aware of the miming problem.
5. Immediate prose recall
Sheesh… No good. You need to sign it, but you need to have developed a scoring system based on signed concepts rather than written ones… See below for my best attempt so far.
6. Test pictures
See 4 above.
7. Face recognition
Should be fine.
8. Remembering a short route
Fine for deaf people, but hard to administer generally! Make sure the start point is away from both of your original test positions and indicate “start” and “finish” clearly to the subject.
9. Remembering to deliver a message
Fine.
10. Test face recognition
Be clear that you are asking the subject to say if you showed them the face before not if they have seen the face before. Subjects, particularly in BSL, often understand that to mean “do you know this person?”
11. Orientation
(Borrowed from my adapted MMSE, but following the same order as RBMT…) Ask, in BSL:
YEAR WHAT?
MONTH TODAY WHAT? JANUARY FEBRUARY MARCH ETC WHAT?
TODAY, MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY, WHICH?
THIS BUILDING NAME (or number if client’s home) WHAT?
WHAT TOWN THIS?
YOU. HOW OLD?
YOU. BORN. WHEN? (Clarify the year if only birthdate is given.)
BRITAIN GOVERNMENT. PRIME MINISTER (BOSS) WHO? (or NAME WHAT?)
AMERICAN GOVERNMENT. PRESIDENT (BOSS) WHO? (or NAME WHAT?)
The last two are rubbish as they index incidental learning, which is demonstrably lacking for Deaf people. However, they can remain for comparison over time.
12. Date
Fine.
13. Remembering an appointment
See 3 above.
14. Delayed Prose recall
See 5 above.
15. Delayed recall of route
See 8 above.
16. Remembering to deliver a message
See 9 above. Fine.
17. Remembering a name
See 1 above.
18. Remembering a belonging
Fine.
Prose recall:
This needs to be signed fluently and competently. These prompts are really to remind me about the BSL version in my head, so good luck! If you can decode the BSL from these prompts, then remember also that placement is absolutely key in this story.
Immediate recall
Last Monday // where, Brighton // 4 men // each masks have // want rob bank money // one have // gun // gun silver //.
He been shot man // man name Brian // Kelly // self work in bank //
Many people see. // Next day // police // been question question question them // One person – lady been explain // Man, Brave, // he been try punch // man (enumerate) // and fight fight fight.
Delayed recall
Last Monday // where, Brighton // 4 men // each masks have // want rob bank money // one have // gun // gun silver //.
He been shot man // man name Brian // Kelly // self work in bank //
Many people see. // Next day // police // been question question question them // One person – lady been explain // Man, Brave, // he been try punch // man (enumerate) // and fight fight fight.
This is a form of the Mini Mental State Examination amended for use with deaf people who use sign language. The items are intended to represent written English prompts for BSL signs. The BSL vocabulary that you think these prompts represent may well be different to that that I would use. For this reason, as well as the fact that no work has yet taken place to validate this amended scale, all diagnostic conclusions you may draw must be explicitly cautious.
Download it here.
The notes should never be detached from the body of the scale.
Case notes
Cognitive assessment in a deaf patient
Progress in Neurology and Psychiatry36 www.progressnp.com
This modified form of the MMSE is under development and should not be used with any confidence. It is presented with its development notes (below) in order to illustrate certain specific difficulties of interpreting and adapting standard hearing measures for deaf people. Upper case is used to reflect a written English form of British Sign Language (BSL) signed commands as a guide to the assessor. Clinically all items are to be signed in BSL.
Orientation
1. Ask the patient:
• YEAR, WHAT? (1 mark)
• AUTUMN,WINTER, SUMMER, SPRING, WHICH? (1 mark)
• DATE TODAY, WHAT? (1 mark)
• TODAY, MONDAY,TUESDAY,WEDNESDAY,THURSDAY, FRIDAY, WHICH? (1 mark)
• MONTH TODAY,WHAT? JANUARY, FEBRUARY, MARCH, ETC, WHAT? (1 mark)
2. Ask the patient:
• WHAT COUNTRY, THIS (FRANCE, SCOTLAND,AMERICA...)? (1 mark)
• WHAT TOWN, THIS? (1 mark)
(Accept London or Balham, then ask for the other, eg YES, LONDON – BIG – HERE, LOCAL AREA NAME, WHAT?) (1 mark)
• THIS BUILDING NAME (or number if client's home), WHAT? (1 mark)
• THIS FLOOR GROUND, FIRST, SECOND, WHICH? (1 mark)
Memory registration
3. Tell the patient that you want him/her to remember something for you, then name three unrelated objects – BOOK, ORANGE, SHEEP (sign clearly and
slowly).Ask the patient to repeat the three objects (score 3 points if correct first time, 2 if correct second time, 1 if correct third time).Ask patient to
keep the three things in mind. (3 marks)
Attention and concentration
4. Ask the patient to spell their first name or surname backwards, and score 1 point for each correct letter. Use first or second name according to which
one contains five or more letters. (5 marks). Record which name was used, for the purposes of future retesting.You may demonstrate with your own name
or a familiar person’s name, so long as it is at least five letters long.
Memory recall
5. Ask the patient to recall the three objects from test 3. (3 marks)
Language
6. Show the patient two familiar objects, eg a shirt (do not indicate the collar) and a piece of paper, and ask him/her to name them. (2 marks)
7. Ask the patient to repeat a sentence after you:‘CAR, MINE,YESTERDAY, SOMEBODY STOLE.’ (1 mark)
8. Ask the patient to follow a three-stage command:‘THIS PAPER.TAKE USE LEFT HAND, FOLD-IT-IN-HALF. PUT-PAPER-ON-FLOOR.’ (3 marks)
9. Ask the patient to read and follow a written instruction, eg ‘Touch your nose.’ (1 mark)
10. Ask the patient to write a simple sentence.The sentence should contain a subject and a verb and should make sense or
Ask the patient to sign a simple sentence.The sentence should contain a subject and a verb and should make sense. (1 mark)
11. Ask the patient to copy a picture of intersecting pentagons. (1 mark)
Total score: /30
Notes
This test can only be used to test for variation over time of one person’s mental state. It cannot be used to compare one person with another, or to compare one person with a normative sample.
A score above 24 strongly suggests no, or highly unlikely, cognitive impairment.A score below 24 is inconclusive and nothing can be inferred.
Q1.The order of the seasons is important so that people with primacy or recency problems are not disadvantaged by the ambiguity of season/weather for winter and summer signs.
Q3. Items are unrelated both semantically, and also in terms of handshape and location.They are signs that require little in the way of context for the meaning to be clear.
Q4. Client’s name is used, as fingerspelling the name is far more common (forwards) than spelling the English form of common English words. May result in a score greater than five. Only score the first
five letter-responses, eg for Johnson: N, O, S, N, H, J would score five, as would N, O, S, N, H, O, J.
Q6. Be certain that responses are commonly accepted BSL signs and not a mime of the use of the object. Similarly, do not use items for which the BSL sign can be understood as a mime of use, eg ‘pen’
Q8.This does not solve the visual mime of the action element, which would make it easier to more or less copy. Right left orientation, which this partially tests, is very difficult unless right and left is fin-
gerspelt, which has its own difficulties for those with difficulty fingerspelling.Also, consider that signing this action makes a verbal test of working memory into one that is much more procedural.
Q9.This is different from the normal ‘close your eyes’ as some deaf subjects are reluctant to do this as it cuts off communication. Carrying out the command is difficult to distinguish from reading the
command ‘aloud’ in BSL.
Q10. It is important to recognise that word order is of little relevance in a short BSL sentence, eg ‘dog bit leg’ would be acceptable in any order of the three words. Most grammatical inconsistencies
should not count against the patient, in particular missing articles (an, the...). Score 1 if the sentence contains a subject, a verb, and you understand it, eg ‘dog bit leg’. It does not need to be clear who did
what to whom as this is a subtlety of sign language that is not always present. The context is usually the best indicator, emphasis is another.
1.0 Introduction
“What are we entering into?!”
The above are quotations from training staff who have had or who continue to have deaf trainees on their courses. While each appears at face value a little helpless, the spirit with which they were said in fact reflects the opposite. Although it is inevitably important to prepare as comprehensibly as possible for both the trainee’s arrival and continued training, it is similarly vital to accept that complete preparation is a fantasy - to not fret about the challenges the deaf trainee might both face and present to the course, or about the technicalities of communication support, deaf awareness, equal access to resources – to not become so embroiled in the practical challenges that all space for reflection, learning, and indeed training are lost.
It is attitude that counts, not getting it perfect.
The information in this chapter is based upon available literature, interview with deaf trainees and courses who have trained deaf psychologists, and personal experience as a qualified clinical psychologist working with deaf people of supervising deaf trainees. While this chapter will endeavour to provide the reader with as much advice, anecdote and food for thought as is feasible, two caveats exist: That no two deaf people are the same and so no operational checklist for courses will cover all eventualities; and that two interpreters, a notetaker, a palantypist, deaf awareness training and devout adherence to the Disability Discrimination Act themselves do not make a qualified psychologist. Training courses should not deny themselves the space to reflect upon and to enjoy the issues that may arise while facilitating a deaf trainee’s progression through the course.
Until a toad in fun
Said, ‘Pray, which leg goes after which?’
This worked his mind to such a pitch,
He lay distracted in a ditch,
Considering how to run.
1.1 Disability Discrimination Act
While this chapter will emphasise the positively challenging side of training deaf psychologists, there is nevertheless a stick that should not be forgotten: discrimination legislation. In the United States this is the Americans With Disabilities Act (ADA; United States of America, 1990) and in the United Kingdom, the Disability Discrimination Act (DDA; Great Britain, 1995). Both the DDA and ADA require services such as training courses to make “reasonable adjustment” to allow fair and equal access for people with disabilities. “Reasonable” is determined by the size of the service or the size of that service’s budget – and that budget has been defined, in the instance of training courses in the U.S. (ADA), as the total available funds of the academic institution and not of the department alone. There is, therefore, a legal obligation to be accessible and fair, and it is nearly always illegal to deny a request for, for example, interpreter services (Gutman & Pollard, 1999).
1.2 Effects on Training
It has been argued (Gutman, 1999) that training courses benefit from a richness and diversity among their students, across the placements offered, and across the perspectives presented by the student body to itself and to the course. Robert Pollard Jr (2002), has noted also that
deaf trainees are pursued for leadership positions in advance of their hearing colleagues
hearing colleagues of deaf trainees are often strongly and positively affected by the experience and that training programmes are able to demonstrate very visibly their commitment to multicultural initiatives.
It is likely also that deaf trainees will possess skills that will enhance the training experience for their peers; perhaps a significant sensitivity to body language and expression, strengths in communicating in difficult and compromised situations and overcoming isolating and minoritising attitudes. Gutman and Pollard (1999) add that the presence of a deaf trainee, with accompanying communication support, also focuses attention on communication processes – vital when one considers the coal-face of therapy: communication.
2.0 Selection
Processing and shortlisting applicants, arranging and conducting interviews and then reaching a decision about which applications ultimately succeed are all time-consuming and often timetabled with little room for manoeuvre. It is however at this time that the course is first faced with challenges which must be addressed in order to enable a fair opportunity for selection to the deaf applicant. These challenges take time to address properly, but it is also important not to allow what delays may occur to impact negatively on the applicant, for example by expecting the applicant to be interviewed later than everyone else or by forcing a longer wait to hear the result than for the hearing applicants.
2.1 The Interview and Selection Process
Preparation for the interview process mostly concerns communication support. For prelingually profoundly deaf applicants, Sign Language Interpreters are the most likely support to be needed. At interview, as it would be throughout the training experience, it will be important to try to find interpreters with experience of mental health settings and related jargon. More important information regarding the use of interpreters may be found elsewhere in this book. It is important for those involved in selection to be fully apprised of the related issues before interview in order that issues of logistics do not compromise the time available for the applicant to prove herself. Like any tool, one must learn how to effectively use interpreter support, rather than just rely on the purchase of it to cover all the issues.
At interview, supposing that all issues of communication and access are appropriately addressed, it is possible to proceed with the selection process as normal – that is equally and fairly. At a face-to-face panel interview, or a presentation to the panel, it is probable that the presence of interpreters will quickly not be felt. However in any group task, the examiners should be aware of further issues:
Time lag. No matter how promptly the interpreter interprets, the deaf applicant will always be momentarily behind the hearing group members in the flow of the discussion, and examiners can misunderstand this as failure to follow the discussion. How the applicant involves herself in the discussion will likely be noted as part of the appraisal, but should be considered carefully in the context of the interpreting situation. For example, if she appears slightly aggressive by talking over somebody is this a function of being behind in the conversation and needing to claim ‘air-time’? If she appears reluctant to take part is this instead a function of time-lag and an effort to not interrupt, such that her own contribution arrives late and appears incongruous? Group members should be respectful of ‘interpreter-time’ – that is, to monitor their own discussion and to not respond to an utterance until it is clear that it has been interpreted; so dispensing with the iniquity of the time-lag by all experiencing it together. A good chairperson ought to manage this. It is also advisable to schedule additional time for formal selection procedures to allow for the impact of these issues to not disadvantage the applicant.
Interruption. Some interpreters tend to act in addition as advocates for the deaf person with whom they are working. It might be appropriate for the examiners to discuss beforehand with the interpreters and the applicant which of them is responsible for asserting the right of the applicant to take part in the discussion, such that it is possible for the examiners to know if they are evaluating the applicant or the interpreter at the time.
The selection process should always focus on the applicant’s clinical skills and qualifications, not her hearing loss. Questions regarding how she might work with different clinical groups, how she might introduce herself as a deaf clinician, how she might introduce the interpreter, or how to deal with challenges from clients unfamiliar with a deaf clinician are all reasonable. Making assumptions about her clinical limits, making challenging comments about the feasibility of pursuing this career, of treating hearing clients, or of funding for interpreter services would all be inappropriate. Allowing the applicant’s hearing loss, or the support that entails, to influence the decision of whether or not to select would be illegal.
3.0 The Training Experience
While it is desirable for the deafness of our trainee to not take centre-stage and to minimally impact on the training experience of all parties, in order for this to happen as smoothly as possible it is necessary, paradoxically, to face up to it from the start. Throughout training, issues will arise which will bring the deafness to the forefront once again – so in order to limit the chances of this happening it is helpful to address as many issues as possible from the outset. It will be helpful to educate trainees and staff regarding use of interpreters. Deaf Awareness Training ought also to be offered, and can be purchased easily from deafness-related charities and organisations - introducing the idea of deaf people as a cultural and linguistic minority rather than as a disabled group. This shift in perspective provides a discussion point for trainees which contributes positively to their training as well as presenting an important paradigm shift for relating to their deaf peer. Interestingly, while Deaf Awareness Training is best offered by professional providers (as it is of a higher quality, and makes the focus Deaf people in general and not this person), trainees have found that on placements it is better conducted personally, with an interpreter, since then the placement is meeting the trainee in the context of the issues of Deaf Awareness and she is seen to be proactively helping them understand a situation that is likely new to them. Certain training course staff have even attended Sign Language courses in advance of their trainee’s arrival. While this should in no way be seen as an obligation it demonstrates considerable commitment to the trainee, and it is surprising how much conversational Sign it is possible to learn in a relatively short time – reducing the sometimes exhausting need to rely on interpreter support for even the simplest conversation.
Preparation attenuates anxiety, and deaf trainees have pointed out that their own anxieties are considerably reduced by their courses having evidently prepared for, or at least considered, the various issues. A course which is quietly confident in its ability to offer a fair and equal training opportunity demonstrably puts the trainee at ease, while those which are manifestly agitated appear to their trainees to be seeing the deafness first and the trainee second. The trainee can experience course staff continually asking and checking about deafness-related issues to be unsupportive.
3.1 Teaching
As already mentioned regarding selection, communication support will need to be discussed with the trainee and booked in advance of the teaching modules. Sign Language Interpreters are in very limited supply and it will be necessary to book them well in advance and ideally the same people for each lecture of a block of teaching. They most commonly work as single-handed freelance workers but ought ideally to be booked in pairs such that they may support each other and alternate the role of active interpreter. A single interpreter will need a 5-10 minute break every forty minutes and should have a longer break after two hours. Without these breaks the amount of error in the translation reaches significant levels and the deaf trainee can no longer be said to have equal access to the taught material (Kyle & Woll, 1985). One course has pointed out the importance of remembering that two interpreters take up two seats! An extra two bodies can make what was an adequately sized classroom suddenly inadequate. Another course also mentioned that once they had a deaf trainee acoustic difficulties of certain rooms, hitherto unnoticed, became apparent. Sign Language Interpreters will make it their business to properly hear everything said in the room and will interrupt in order to seek clarification. Using a quiet room with good acoustics will limit the amount of interruption from the interpreters.
Lecturers, particularly those visiting from outside, will need to be
- informed that there is a deaf trainee on the course and to consider how that might (or not) influence how they present their session
- provided with information about interpreters and what to expect
- told how to use interpreters and about the need for breaks
- asked to provide copies of their notes and handouts to the interpreters at least the day before the lecture is to be delivered
- given a little deaf awareness information such as advice not to talk while writing on a board, covering the mouth, or while showing a slide unless they are simply reading the contents of that slide.
If slides are to be used, they should not be used in a darkened room. Video presents special challenges to the interpreters, who would be helped by the opportunity to review the tape in advance of the session. Where the use of role-play might seem onerous with interpreters it has in fact been found to be quite straightforward, with fellow (hearing) trainees reporting that the interpreter is not a hindrance.
3.2 Appraisal
Trainee psychologists are usually appraised by written submissions (case reports and essays), process report (discussion and self-appraisal based upon an audio tape of a particular clinical session), and supervision on placement. The process report presents obvious difficulties due to the use of audio tape. With a deaf client the session could be videotaped, although it is hard to clearly record two people signing a conversation in a room. Even if the session were videotaped, while the trainee would be able to go through it and comment on the process, the staff appraising her would be required to rely upon the interpreter for access to the recorded clinical work, and while not immediately prohibitive, a comprehensive discussion of the process of the session requires access to more of the session than just the content. Some courses expect trainees to transcribe the recording for the report. For a deaf trainee this would require a process of translation as well as transcription and I would suggest that the former should be the responsibility of an interpreter. Appraisal more than anything else needs to be demonstrably fair for all concerned. The special nature of the process report indicates that the deaf trainee cannot be appraised in the same way as her hearing peers, and a modality-for-modality trade by way of using video instead of audio does not effectively address the issue. Those courses to have faced this already have found that it highlights the need for a system which judges trainees against equal standards but which makes no stipulation about the means. It may be possible, for example, for a qualified psychologist with signing skills to observe a session and then to discuss process with the trainee and course staff.
3.3 Written Work
It has been suggested (Conrad, 1979) that the median reading age of deaf school leavers is nine. While trainees will have a reading age commensurate with their academic record it is worth considering the context of this statistic.
Deaf signers converse in a language which cannot be written, which differs considerably in grammatical form from the dominant language locally, and which involves some concepts and linguistic structures which cannot easily be translated into English. Because signed languages cannot be written, the first written language of even a native signer will be that of the hearing society in which she lives. Hearing people almost always speak and write the same language and so exposure to written words continues to shape their speech just as everyday exposure to speech shapes and refines their written skills. This mutually beneficial relationship between the verbal and written language is not available to deaf people.
When appraising the written work of a deaf trainee it is important to be clear about what is being appraised. While a person’s written English and the concepts they are conveying are of course significantly related (a concept must be clearly expressed for us to appraise it confidently) they are nevertheless distinguishable in certain ways – for example an intelligent exploration of “scitzophrenia” is no less so because of the dreadful spelling. For courses requiring a good first degree as an entry requirement this issue ought not arise, but for those with different admissions criteria it may. For them it may be worth treating the deaf trainee as a student with English as a foreign language and to adhere to the guidelines and principles already established for that.
With a good interpreter, particularly if the same one is used for supervision as for the direct clinical work, the appraisal conducted by supervisors at the end of placements should be unproblematic.
3.4 Peer Group
Most courses agree that peer-support is an invaluable part of the training experience and, while it cannot be engineered or specifically timetabled, the early days of training are often deliberately moderately paced in order to allow the trainees time to get to know each other and to join as a group. In most cases there will be only one deaf trainee in a cohort and it is easy for that person to become marginalized – she is difficult to talk to, hard to understand, may confront others with their own inevitable misconceptions and politically sensitive attitudes, and is often accompanied by two interpreters. Courses can probably do no preparatory work in this regard, but it is worth being aware of the special effort all the trainees will have to be making in order for them to join effectively as a group. The deaf trainee will be all too familiar with this need, but it remains a difficult though not insurmountable gap to bridge:
I either had to be on the fringe and watch and understand nothing, or be proactive and get involved – ask what the conversation was etc… But then the focus shifted to me, i.e. I became dominant in the conversation. I hated not being able to just passively soak up conversation.
Where there is another signer on the course the benefits are probably obvious (although that person should never be used as a cheap alternative to a qualified interpreter). However there is then a danger that the deaf trainee and fellow signer create their own micro-group talking only to each other – the rest of the group breathes a sigh of relief and chats to itself, leaving a communication vacuum between them. This can also happen with the deaf trainee and interpreters and the trainee would be well-advised to avoid this happening for fear of excluding herself from that important source of informal and moral support – her peers.
A few years of postgraduate vocational training, in which one is often expected to practise what has only just or is yet to be taught, to only do that for a few days a week while also attending taught modules and to somehow produce a large and impressive-looking piece of research, in a field which inevitably causes us to look within ourselves and face whatever might be found is stressful. Courses will be familiar with the ways in which these stressors promote anxiety in the cohort, which manifests in many ways and with a deaf trainee in the group it is perhaps no surprise that that can become the target for feelings actually related to the training experience. For example hearing peers have been noted to become angry if their deaf peer understands a point or passes an assessment and they have not, and it seems clear that they feel threatened by this disabled trainee. Hearing peers may suspect that the deaf trainee reflects tokenism on the part of the course and sometimes these suspicions are aired in anger.
For the deaf trainee most stresses will ultimately be able to be shared with the group as they will be course-related issues of difficult clients, looming deadlines and omnipotent ethics committees. There will, though, be additional stresses of working in two languages at once (since reading and lectured material will be presented in English and sign respectively), of meeting a client for the first time who has not met a deaf person or worked with an interpreter, and of interpreters not arriving when the family has arrived for therapy. It may be the case that such things can only be truly shared by talking to other deaf psychologists, but practically it may perhaps be prudent to allow for such discussions during meetings with the trainee’s tutor or supervisor.
4.0 Placements / Internships
Before the year begins, course staff should have considered whether to provide the deaf trainee exclusively with deaf clients, hearing clients or a mixture. Local constraints of course are the major determinant, but those aside a broader discussion should take place about the competencies which would be expected to be derived from the placements, commensurate with the award at the end of the course, and whether or not they would be gained from only seeing deaf or hearing clients. Courses differ in the competencies they expect to be met in order to confer the particular award of that programme – some for example expect a broad range of clients while others a broad range of presenting problems, of models of therapy, or a combination. A question may be raised of whether or not a trainee who sees only deaf people should only be awarded a qualification which is restricted in terms of only enabling the person to see deaf clients. Ultimately it is incumbent on the course to provide equal and fair opportunity to the deaf trainee to achieve the same qualification as her hearing peers – a qualification which makes no distinction about the hearing status of potential clients. Indeed, hearing trainees who meet only hearing clients during their placements are never awarded qualifications which disallow them from seeing deaf clients. It would therefore be unreasonable to argue that the deaf trainee must see hearing clients on placement in order to then be qualified to meet them in the future.
Courses may consider that fair and equal placement experience would be gained from expecting the trainee to attend exclusively hearing placements, but this makes the error of assuming equality of means yields equality of opportunity, since the experience of a deaf trainee in a hearing placement is not the same as that of a hearing trainee in the same placement. Long debates about equality of experience can be quickly dispensed with by focussing on equality of access to the competencies expected by the exam board. The question to be asked when a placement is to be offered is the same for all trainees, deaf or hearing:
“Given the placements in which this trainee has already worked, would the next one continue to provide fair opportunity to gain the competencies expected of this award?”
The audiometric profile or cultural affinity of the client group is irrelevant. In addition, to dispute a concern that has been aired by certain courses that hearing people would not want to see a deaf therapist, in the experience of those deaf trainees who see hearing clients interviewed for this chapter (and from Pollard Jr, 2002), at the time of writing no hearing client in the UK has ever refused to be seen by a deaf trainee, because she is deaf or indeed for any other reason at all. One trainee made a point of asking, at the end of therapy, what sort of effect if any her deafness may have had:
“One client in particular said that she preferred talking through the interpreter. She had worked with a hearing therapist before and found it made her feel vulnerable and exposed, she clammed up and dropped out of therapy, whereas through the interpreter the conversation was more paced and measured, and as a result she felt safer.”
Although hearing clients have universally responded positively to their deaf therapists, the question is nevertheless raised of whether or not a client has the right to decline to see a therapist on those grounds. The best working answer to this is probably that clients have a right to be informed that their therapist will be deaf but that they may not have the right to reject that therapist (should they wish to). Clients should be informed that their therapist is deaf and often works with an interpreter and this seems to be most sensitively achieved by stating it very simply at the bottom of the first piece of correspondence with an offer to discuss this should the client so wish.
It is helpful for courses to target supervisors thought to have a real interest in supervising a deaf trainee, for example one who is interested in how interpreters might be used imaginatively in structural family therapy, rather than simply pairing up available supervisors with unallocated trainees, and to allow time for those supervisors to take the idea back to their teams for discussion as the team provides the context for the placement experience. An ideal placement would also offer a range of options to the trainee rather than, for example, just a small routine schedule of outpatient clinics, and would have a supervisor who is well integrated themselves into the wider team. Courses have also found it beneficial to highlight to teams that the aim of the placement is parity of outcome in terms of skills and competencies rather than parity of process through the placement. A degree of flexibility and creativity with regards the process of the placement, the opportunities presented, will be necessary to ensure a fair outcome.
4.1 Supervision
Supervisors of course have different styles; some are almost parental in the protection of their charge while others monitor the trainee’s work from some distance and can feel absent. Some may seem controlling, others disinterested. If the course feels nervous about their trainee it may be tempting to locate a placement with a more comforting and protective supervisor. However, while a supervisor who is relatively present and supportive is desirable, one who is overly cautious and protective will likely, unintentionally, undermine and de-skill the trainee by appearing to be doubtful of her competence. The trainee’s confidence will remain at its initial low level for longer than is necessary. Likewise one who appears unsupportive and dismissive may empower the trainee and boost confidence much quicker, but at the risk of expecting her to cope with so much that she drops out of the programme. This is not to say that deaf trainees are more vulnerable or sensitive than hearing ones – but that training is onerous for all trainees and never more so than at the first placement, and the deaf trainee has the additional concern of working psychologically through interpreters with hearing clients. At least one course has addressed this issue by allocating the first (core adult mental health) placement in a broad adult mental health service for deaf people, such that the trainee could face all the usual anxieties and doubts about seeing people clinically without being concerned about interpreter issues, communicating with the supervisor, or working with hearing clients. Ordinary clinical concerns at least partly addressed, the trainee can then move on to a hearing placement with enough cognitive and emotional space to be able to address more clearly the other hearing-deaf concerns.
Notably it appears that it is not just the deaf trainee who fears the first hearing placement – courses who have not trained a deaf psychologist before feel it also, and just as the confidence of course staff is picked up by the trainee who then feels correspondingly more positive, so a confident supervisor and a positive placement experience reassures the course. Clinical placements feel like the acid test for all the preparatory work conducted by teaching staff by way of teaching and assignments, and as such the first placement visit or appraisal can be very beneficial, not just for the trainee but for the course. Also there will inevitably be considerable learning – regarding working with a deaf trainee - on the part of the placement supervisor (and indeed the whole team) and it is important to ensure that there is a mechanism for these experiences and insights to be handed over to the next placement, and back to the course.
5.0 Summary
For a variety of reasons few deaf people have trained as psychologists at this time and so few courses will have faced the issues inherent in training a deaf psychologist. These issues are myriad, and range from the imperative through curious to negligible. This chapter has attempted to provide a starting-point for thinking about and planning the training of deaf psychologists and in so doing has highlighted a variety of issues, concerns, and perhaps philosophical challenges. While it would be no excuse to flagrantly disregard these issues it remains the case that the ultimate aim is the successful training of a psychologist, and to compromise this by focusing exclusively on the deafness would be disastrous.
There is room in this exercise for curiosity, enlightenment and enjoyment – for the deaf trainee, for the hearing peers, and for the course.
6.0 References
Conrad, R (1979). The deaf school child. London: Harper Row
Great Britain. Acts. (1995). Disability Discrimination Act 1995. Chapter 50. London: The Stationery Office Limited.
Gutman V & Pollard RQ (1999) Working with Deaf Interns and Internship Applicants. APPIC Newsletter, November 1999.
Kyle J & Woll B (1985) Sign Language: The study of deaf people and their language. CUP: Cambridge
Pollard Jr RQ (2002) Program for Deaf Trainees: Ten Years of Experience. Personal Communication.
United States of America (1990). Americans with Disabilities Act Handbook. Appendix 0: Title III Highlights (Public Law 101-336). Washington, DC: The US Government Printing Office.
- sleep when they don’t want to and
- can’t sleep when they do.
It is easy for this to happen. We sleep and wake in patterns. Most people prefer to sleep at night and stay awake during the day. Sometimes we start to sleep during the day – maybe because we are ill, or tired. If we sleep during the day, when we go to bed we don’t feel very tired. So, we don’t fall asleep for a long time. Then we either wake up late the next day – so when we go to bed we don’t feel tired again. Or we get out of bed at the normal time, but feel tired in the afternoon because we didn’t get enough sleep. You can see in the diagram that it means a circular pattern starts to happen. This doesn’t always happen. If you have a job, for example, then you have to get up in the morning and you can’t nap in the afternoon – so the cycle is broken and sleep returns to normal.
So how do I sort it out?
Before you do anything you need to decide when your ideal getting-up time is, and when your ideal going-to-bed time is.
The best way:
Don’t sleep in the day. This can be hard, but the worst that can happen is that you feel very sleepy. You may need to wake yourself up early, or stop napping in the day. Or both. The first day is difficult, but the next day is much easier. If you can stay awake all day (between your getting-up and going-to-bed times) you will be worn out at bedtime and you will fall asleep more quickly. When you wake up next morning you will have had a full night’s sleep and you won’t feel tired during the day. It will be easier to stay awake that day and your sleep pattern will return to normal very quickly.
The next best way:
1) I sleep late in the morning. To sort this out you need to get up earlier. If it is hard to just do that straight away – do it in easier steps. Notice what time you usually get out of bed. Then the next day get out of bed one hour earlier. The next day get out of bed another hour earlier. Do this every day until you are getting out of bed at your planned getting-up time. If it is hard, get up at the same time for a few days until you are ready to save another hour. Or you could do it in half-hour steps. The important thing is to keep slowly getting up earlier until you are getting up at your planned getting-up time.
2) I take naps in the day. Get up at your planned getting-up time, and go to bed at your planned going-to-bed time. Also, make a note of how long your naps are, on average. On day one set an alarm to wake yourself up when you have had your usual amount of rest. On day two set the alarm with fifteen minutes less time. On day three set the alarm with another fifteen minutes less. Keep doing this until your naps are so short you don’t bother with them.
3) I sleep late in the morning and I take naps in the day. You need to do number 1 and number 2, but it will be hard to do both at the same time. Measure your nap time and make a note of what time you usually have it. Then concentrate on doing step 1 first so that you get out of bed nearer and nearer to your planned getting-up time. Throughout step 1 keep your nap time and the length of your nap the same. Then when step 1 is finished, do step 2.
Whatever way you do it:
- Never be tempted to go to bed early.
- Never be tempted to get up late, unless it is part of the plan.
- Never be tempted to have a nap, unless it is part of the plan.
But I can’t stay awake!
The biggest thing to stop you achieving a healthy sleep pattern is having nothing to do. It is very hard to stay awake when you feel tired if you have nothing to do. If you can organise things to do for these days it will be much easier to achieve your aim of a healthy sleep pattern.
The Oblique Effect in Orientation Acuity. Vision Research.
Considering the Use of Sign Language Interpreters in Therapy. Conference proceedings. Scroll to C4, or click here for the same information.
Consciousness. Letter to The Psychologist.
Talking Scents. Letter to The Psychologist.
Run With Your Patient. BMJ. (May require a password these days.)
Certified Meaningless. Letter to The Psychologist.
Assertive Community Treatment with Deaf People. (Link to buy the document).
Deafness and the Art of Psychometric Testing. Article in The Psychologist. (Requires BPS login, though not if you click here).
Community Mental Health Teams' perspectives on providing care for Deaf people with severe mental illness. JMH, Vol15, #3, 2006. (Link to purchase the article).
"Clinical Psychology Forum" submissions are not online.
- To-do Lists are prospective. They remind you of what you have not done. Tick items as they are completed but also compile a Done List by always adding tasks to the to-do list that were unplanned but were necessary and completed. This way it becomes retrospective also and actually rewarding.
- Time cannot be managed, work can. Prioritise tasks in a 2x2 matrix with urgency as one axis and importance as the other. These variables are different in important ways.
This is an information sheet I made, available on the Royal Association for Deaf People's website (www.royaldeaf.org.uk)
(you just might not realise it…)
We are
all
"mental". This means that we all are able to think about the world and about the things we do. We are also all emotional. This means that we all feel happy or sad, excited or bored, stressed or relaxed, and so on.
There is more to us than blood to keep us alive, muscles to move us about, and bones to hold us up. Those are the physical parts of us. We also have ideas, beliefs, fears, wishes, dreams, worries, relationships and so on. They are not physical, so to make it easy to talk about them we call them all "mental".
Sometimes our ideas, beliefs, and feelings can start to make life difficult for us. When that happens we have problems - but they are not physical problems. They are problems with the mental parts of our lives.
You might call them "mental health problems"…
Mental Health
What is
mental health
? Well… what is
physical health
?
We are
physically healthy
when we are not ill and when we feel good and fit.
We are
mentally healthy
when we are coping with life, feeling OK about ourselves, and relating well to other people.
We can get unwell or unfit in many different ways -
physical health problems
can be just a small problem like a cold, or a big problem like cancer.
We can get mentally unwell or unfit too -
mental health problems
can be just a small problem like being frightened of spiders, or a big problem like believing wrongly that people want to kill you.
They can be simple like a broken leg or complicated like kidney failure.
They can be simple like a phobia or complicated like schizophrenia.
Probably
nobody
is 100% physically healthy. Some people are weaker than others; some people get out of breath quickly; some people always have a cough. Probably
nobody
is 100% mentally healthy either. Some people get stressed easily; some people worry all the time; some people don't go out much because they are frightened that something will happen. We are
all
physically healthy in some ways and physically unhealthy in others. We are also
all
mentally healthy in some ways and mentally unhealthy in others.
Being Labelled
People worry about being labelled "mentally ill" - but what does this mean? Most people we see who we think are "mentally ill" are on the news. Also, they are on the news because they have done something terrible. We do not see people on the news who have not done anything wrong. So nearly all the people we see who we think are "mentally ill" are on the news and all those people have done something terrible. That's why they are on the news. So people think that all people with mental health problems are dangerous or out of control -
but that's wrong.
Also most people with mental health problems we see on TV have schizophrenia.
But most mental health problems are simple - like stress, feeling depressed, or being scared of something harmless.
Having a problem with your mental health is nothing to be ashamed of - just like having something wrong with you physically is just a part of life
It is a shame that people do not ask for help with mental health problems because they are worried about what other people will think of them. If people talked about their problems more, they would find out that other people have them too and that difficulties with emotions, thoughts and beliefs ("mental health problems") are just a part of life. We all have them and there is nothing to be ashamed of.
Mental Health Problems
Nobody can do everything. If you have a leaking water pipe, a plumber can help you. If you are confused about your money then your bank manager can help you. If you cannot make shelves then a carpenter can help you.
If you find it difficult to feel happy, or to stop feeling stressed, or to stop feeling frightened then therapy can help you.
Some people can fix their own pipes, and some people can sort out their feelings - but there is nothing wrong with asking for help. ("Therapy" means talking to a counsellor, or taking medicine, or joining a group.)
Plumbing problems are about leaking and not leaking. Mental health problems are about coping and not coping. We can have problems coping with stress, with our emotions, with our fears, or with our worries. BUT a leak is easy to see. It is not easy to notice when we are not coping very well.
Emotions, thoughts, beliefs and worries, are all invisible - so it is hard to notice when we are not coping well, and it means we do not really see other people with similar problems either. If your problems upset you, or if they stop you from getting on with life, then it makes sense to ask for help from somebody who understands emotions, beliefs, thoughts, and worries.
That could be a counsellor, a psychologist, a psychiatrist, a psychotherapist… and so on. They mostly help by talking about the problem, because talking makes us think and thinking about the problem helps us to understand. When we understand the problem we can cope better, and when we can cope with it, the problem goes away. Sometimes our GP or a psychiatrist will give us medicine to help us cope. That can help too because medicines can help to calm us down if we are too wound up, or to cheer us up if we are feeling depressed.
Mental "Illness"
Nearly all
mental health problems are problems with emotions, stress, worries, or bad thoughts. These things are normal problems that have become bad enough for the person to have trouble coping by themselves, so they ask for help. A few of us have mental health problems that are so complicated and that upset us and disrupt our lives so much that it is difficult to understand what is going on.
Those problems are called "psychoses" or "schizophrenic illnesses", for example. If you have a problem like this, it is difficult to sort it out by talking about it and thinking about it because 1) the problem is very complicated and because 2) our thoughts become so mixed up that it is hard to think clearly about what is going on.
Doctors usually mean these complicated problems when they say somebody has a "mental illness". Sometimes those problems make it impossible for us to think clearly enough to make decisions for ourselves. Usually we decide when to ask for help and who to ask for it, but if we have a very complicated and serious problem that stops us from being able to decide for ourselves, then certain doctors are allowed to make that decision for us. Even then, they need a social worker and a second doctor to agree with the decision.
Sometimes it is useful to think about a mental health problem as an illness and sometimes it is not. Thinking in this way can be a bit black and white, but that means we can be clear what we are talking about.
Here, we say the people on the right are "ill" and the people on the left are "well".
For physical health and illness this is a good way to think about it. Sometimes with mental health it is useful as well. More often it is useful to think about a mental health problem as being normal but that has started to make your life difficult or unhappy. For example if you are frightened of going out in public that can be normal anxiety, but if it means you never leave your house then it might be a bigger problem.
Here, we don't say anybody is ill or well. We say people have problems that can be small or big. If a person's problem gets so big that they suffer from it, then they can get help. That decision is theirs unless they have very serious problems which mean they are not able to make decisions for themselves.
For most mental health problems it is usually not very helpful to think "am I ill or well?" It usually makes more helpful to think "do I think that I am coping with my life well, or am I having some problems with it?" If you feel like life is sometimes too much, it makes sense to ask somebody to help you cope.
People are scared of these "mental illnesses" because of what they see on the news - but we know that the news does not give us the full picture. Nearly all people with mental health problems have normal, simpler problems and therapy can help them to sort them out.
BUT
Many people decide not to ask for therapy because they are frightened of what other people will think. But really that doesn't make sense - it is like not going to hospital with a broken leg just because other people in the same hospital have scary problems like cancer.
A mental health problem can be anyproblem to do with thoughts, beliefs or emotions - that's what "mental" means - and we should always ask for help if we cannot cope alone.
1) The more severe the mental illness, the more interpreters do more harm than good. Discuss.
2a) Why do we believe a psychotic deaf person who says he hears voices, yet we don't believe the same person when they say they are followed in the street?
2b) Why do we believe the self-report of clients who sometimes cannot reliably report what they had for breakfast that day?
3) SSE is an affront to deaf people and should never be used except for teaching English.
This article has been published in the British Medical Journal (BMJ 2004;329:1176 [13 November], doi:10.1136/bmj.329.7475.1176). So if you are citing it, please do so accordingly. Well... They seem to have had a GCSE student re-write it, so if you want to quote this superior version instead, that would be your prerogative...
Chris was always climbing the fence. It was tall, a mosaic of chain-link and climbing weeds, about eight feet, and surrounded the euphemistic “garden” on three sides – the fourth being a three-storey red-brick ward. The ward was a home of sorts to a dozen people with learning disabilities and challenging behaviour and, similarly, a half-dozen nurses. Chris’s most prominent behaviour was “absconding from the ward”, a curiously circular reason for his admission and an activity he engaged in quite successfully on a daily basis.
Absconding was more often than not preceded by a few minutes of artfully presented nonchalance, entirely cloaking him from the watchful eyes of the nurses posted strategically about the place looking for, and only seeing, those behaviours listed in the various reports and management guidelines currently in action. The abscond itself was never witnessed. By sheer well polished sleight, Chris would fade imperceptibly from the consciousness of the assembled staff and then appear, as if conjured from ether, running full-tilt away from the fence.
The staff would snap into action. Blood, previously thickening in our veins, would course effervescently around our bodies. A unified flock-consciousness would drive us towards our joint and single purpose: to catch Chris and bring him back to within the confines of the fence.
To catch Chris.
Our prey stood in excess of six feet and, with daily practice, had developed both the athleticism and gait of an ostrich. He could turn in an instant and be suddenly careering in a completely different direction with no evident change in speed. He could slow down and speed up with no suggestion of inertia or momentum. His flight, essentially, was Brownian.
We would fly from the ward like light streaming from an opening door. We had a purpose. We had a plan. Roles were never discussed but somehow we knew to break into smaller units and try to bisect Chris’s unknowable path. We would run at break-neck speed towards him as if locked onto him like missiles. We would run orthogonally to limit the available directions he might take. We would unspokenly gather volunteers to the chase as if in a stampede. We would hide behind trees.
Catching Chris, despite the iniquity of numbers, invariably took upwards of an hour. Pursuers would retire from the chase exhausted, or perplexed. Sometimes entire shifts would change over the duration of the hunt. Ultimately, however, Chris would be apprehended in a frenzy of arms, legs and divots, attracting staff and onlookers like flies around a kill. Only partially subdued he would be guided, in a ruck, back to the ward where more often than not he would be carefully watched for the rest of the day while he returned our gaze repackaged as a scowl.
I don’t know how it happened. Nobody remembers, if they ever knew.
Chris had breached the fence again and was high-tailing it across the grounds. Somebody went to fetch him back. The mood was completely different, completely at odds with the usual galvanizing sense of mutual excitement. Perhaps we no longer cared. Perhaps, somehow, we were inspired. Our solitary staff member didn’t pursue Chris. He didn’t barrel after him like a Pamplona bull. He just ran. Within a few minutes he was shoulder-to-shoulder with Chris and running alongside. And they kept running. They ran for a further ten or so minutes and then returned to the ward. Nobody laid a finger on Chris. Nobody said a word. There was a ten-minute run and then home.
There were no absconds after that. Just runs.
Often, however, the assumptions held by staff - and the culture and attitude of the institution - fail to yield the equal access to information and discussion which we would like to believe we foster.
The main area in which we fail is the use of interpreters in meetings.
Staff always try hard to make sure enough communication support is provided by interpreters. This of course is great, and we pride ourselves on this and criticise other services for not providing interpreters themselves. However the way in which we use interpreters gives rise to a major problem which is an inconsistency between philosophy and practice:
1 Hearing staff believe that, regardless of their level of BSL competence, the presence of an interpreter allows them to ignore the signing policy - which usually states, in its simplest form, that all staff should sign when a deaf person is present. Rarely does it say that staff may disregard the signing policy in this instance. So despite the presence of an interpreter all staff should aim to sign in the company of a deaf person.
2 Unfortunately, the vast majority of qualified staff are usually hearing. Thus, the discussion is inevitably led by hearing staff. A problem arises when
i) Those hearing staff are not signing and
ii) They are not respecting “interpreter-time” (the delay between the endings of the spoken utterance and the signed translation). In failing to respect interpreter-time, hearing staff respond to each other immediately after the other person has stopped speaking. This means the deaf people present are not able to contribute to the discussion on equal terms with the speaking people. This is why I am making a distinction between access to the information and access to the discussion. Current practice allows deaf people access to the information, but it is impossible for deaf staff to access and contribute to discussions to the same extent as staff who are not signing.
3 On those occasions that deaf staff do contribute, it is equally important for them to respect interpreter time to allow equal access to those who do not sign.
4 Signing policies often state that everyone’s choice of communication modality and system should be respected. However it is extremely difficult for hearing staff who may want to sign to do so. There are a number of reasons for this:
i) In any meeting there will be hearing staff with a range of signing competencies, and so most staff will be in the presence of others whose signing skills far outshine their own. When those (usually senior) staff refuse to sign, the person who wishes to follow policy and sign for themselves is made to feel ridiculous as they are singling themselves out. Also they inevitably wonder whether their beliefs about signing for themselves are correct - after all senior staff with advanced signing qualifications are not doing so.
ii) When other staff members who can sign are not doing so, a person who believes that he or she should be signing for themselves may often think that the other staff members feel the same, but have other reasons to avoid signing themselves. In my experience a hearing staff member signing for him/herself can project their anger that other people are not signing onto the other staff, and this is then experienced as extreme hostility from the signing hearing staff who choose not to sign. This feeling can be enough to stop the person signing for themselves. It is also possible that other staff actually are hostile to the signing hearing staff member, as they are being confronted with their own guilt about not signing, or their own fears that their signing is not very good.
iii) It inevitably feels strange to sign to a hearing person who does not sign and so does not directly understand what is being said. This is especially so for signing hearing staff. This feeling is compounded by being the only one.
iv) Initially it is difficult to sign while listening to one’s own signing being voiced over as this is both distracting and can be perceived as providing immediate feedback about the quality of one’s signing. However, ignoring the voice over is a skill which is quickly learnt.
5 When hearing staff avoid signing in meetings, their signing skills will suffer.
i) In mental health care most deaf staff are Health Care Assistants and work shifts, so the majority of staff in a meeting will be hearing. Meetings are one of the few places where staff could, in principle, observe their peers signing and this would make the different competencies and styles of signing within the staff group more transparent. In this way staff would be able to realistically appraise their own signing skills. When the only staff seen signing are deaf native signers, one’s confidence inevitably vanishes. With our confidence goes our inclination to sign at all, and an environment is established in which it is impossible to gauge one’s own signing competence by comparison with hearing staff.
ii) Equally, it is impossible for staff to receive objective feedback about their signing competence from the rest of the staff group. Such feedback would be both positive and negative, but both forms are constructive and lead to increased signing competence, increased signing confidence, and increased signing. In this way the vicious circle of lack of feedback leading to decreased confidence leading to less signing leading to less feedback can be reversed into a positive cycle of objective appraisal leading to increased competence leading to increased confidence leading to increased visible signing leading to further appraisal.
What can be done about this?
In my opinion this can lead to an anti-sign culture which is both oppressive and disheartening. Seeing others signing can enable everyone to feel confident about their skills, and to realistically appraise their own weak areas.
There will inevitably always be a number of staff who correctly feel they cannot sign in these situations - but interpreters are available to allow those people access to the meetings. At the moment interpreters are used to avoid exposing our signing skills to peer-review, to (consciously or not) oppress the deaf staff and clients, and to pretend that we are enabling equal access when in fact we are not. We should be using interpreters solely to support those staff who do not yet sign, and we should respect interpreter time in order that those staff have equal access to both the information and the discussion.
It is my view that:
- All staff who can sign, should sign at all times.
- Staff who cannot sign should be trained appropriately and supported.
Therefore all staff who are not attending, or who are not about to attend, a signing course, should be signing for themselves. If they are not, that person’s line manager should address the issues which prevent him or her from signing. This means that all staff with advanced or confident signing skills should be obliged to sign. All other staff should be encouraged to sign - both directly through line management, and indirectly by the culture and attitude of the unit shifting to enable everyone to feel safe enough to sign.
From the Psychology Department Newsletter June 2004.
Using an Interpreter
It is almost entirely true to say that in psychology if you can’t talk to your client you can’t do your job. It is certainly entirely false to say that with an interpreter (of any language) you can get on with your job ‘as normal’. The immediate impact of a third party is probably obvious – dynamically, temporally (with spoken language interpreting, being sequential), and transferentially (particularly with BSL interpreters where the client’s emotional relationship is often more powerfully with the interpreter than the clinician). Alongside these more immediately apparent difficulties lies a more pervasive problem of accurate communication, understanding, and - for want of a better term – empathy. While the relation between language and thought is a complex one, it is nevertheless fairly clear that expressed language in any modality is an encoded version of the concepts intended by the person speaking. Just as the vocabularies of two languages never perfectly correspond, so the vocabulary of one’s own language only approximates the “vocabulary” – the concepts – of our thoughts. When I talk to you I am encoding my thoughts, ideas, beliefs into English. This is a process of translation / interpretation which necessarily loses information. When you read my English you attempt to decode the meaning using the phrasebook of your pre-existing understanding, beliefs and expectations. This again is a process of interpretation. Between my ideas and your understanding of them (even supposing I am making sense, possibly a moot point) there is already considerable potential for miscommunication, and we share a common language. It is likely we share a common “culture” too – that of western psychiatry and medicine (like it or not). When working with a client who speaks a different language from you, the interpretation between those languages is variably, and sometimes considerably, prone to information loss or distortion just from a lack of vocabulary equivalence. In addition, you and the client will likely come from different cultures – ‘culture’ meaning in this case not just sociological and anthropological differences but cognitive and conceptual ones. A Chinese person explaining parenting to you in terms of “guan” is presenting a concept alien to Western Europe and not a part of western psychological parenting work. The biggest pitfall of using an interpreter is assuming that you not only understand what the other person is saying, but also what they mean. This pitfall is not confined to interpreting situations.
Interpreters can work in a variety of different ways, the simplest model of which being a notional continuum of verbatim translation to interpretive meaning - or from a word-for-word level through noun-phrase, sentence, paragraph levels to whole document/speech/session levels. The lack of lexical correspondence between two languages renders verbatim interpretation a nonsense, and the other end of the continuum leads to practical difficulties. However the model is useful when considering what you want the interpreter to do.
Psychosis
Conducting a psychological assessment of a psychotic client using an interpreter is arduous. The only time it does not feel that way is if you are not aware of the complications that the interpretation is bringing to the assessment. Interpreters constantly tread a line between ‘telling you what the person said’ and extracting meaning from the utterance and presenting that – and you don’t know which they are doing! Quite often the absence or distortion of meaning is the clinically relevant feature, but it is the task of the interpreter to understand and, quite professionally, they may clarify and clarify with the client until meaning is found in the language when potentially there was none there to start with. With no clear word-for-word translation possible, how can one interpret word salad, for example? Conversely, if the client appears to make no sense how can thought disorder be distinguished from communication difficulties or difficulties of interpretation? Without an interpreter there are still, of course, two interpreting processes going on…
Voices
Nascent employees of the Deaf Directorate almost always learn within a matter of days that prelingually and profoundly deaf people with psychotic disorders hear voices. In a service that, upon recruitment, immediately deskills us, fascinating titbits such as this are survival aids. This assertion is rarely questioned, and much has been written about the neuronal activity of deaf hallucinating psychotic people, the phenomenology of deaf psychotic voices, and so on. Perhaps obviously to those outside of this field, the assertion makes no sense. Clinically I have rarely if ever managed to have a (one to one) conversation with a deaf person said to hear voices where the deaf person has been able to describe the pitch, timbre, vocabulary, volume, or location of the voice. Even if there were some way of demonstrating (with a magical functional MRI) that the person really was experiencing an English-speaking female voice of rather low volume, telegraphic prosody, commenting on her clothes from behind her - volume, prosody, the gender of the voice and auditory location are not things that a prelingually profound deaf person could reliably report upon.
Could it be that asking specific questions about such symptoms gives the client (deaf or hearing) a lens through which to evaluate quite probably chaotic and confusing internal experiences? Why do we trust the report of a prelingually profoundly deaf person on the nature of their psychotic experiences when that same client, at the same time, is not able to reliably report upon where they think they are or who they are talking to? Psychotic experiences may well be (who knows?) the cognitive equivalent of dropping all the pages of your thoughts in a puddle and reassembling them, soggy, in the wrong order. The process of encoding those experiences must be even more prone to misrepresentation than non-psychotic mental phenomena. In the context of a clinical interview, deliberately or otherwise asking questions which are even only slightly leading (“Do you sometimes hear a voice that seems to come from nowhere?”) is equivalent to showing a Rorschach blot and asking “Do you see a bat?”
The ABC model of voices suggests the voice is an activating event triggering beliefs about it. Quite possibly the voice is delusional as well. But what’s the difference?
As examples, we never hear of patients (non-detained) saying that they are going home for the weekend – instead it is always that x is requesting leave and is that OK. We know that it is not our decision and that x can go whenever he likes, but the default perspective that we are in charge of / responsible for other people when we are actually just offering a service they can take or leave I think is damaging. It is worse still if x really thinks he has to ask, and not just that it is being reported in the language of the MHA.
Also we hear a lot in discussions of non-detained patients that “well we can’t detain him” as if there is an air of regret around that! It scares me that we have to think on our feet about ways to cope with the fact that we can’t just force the person to comply. That somebody is undetainable is a good thing, in my opinion, and that people who are detainable are so for reasons that are awful for them (that is, they need detention in their own best interests for specific reasons, that they are horribly ill and pose a risk to themselves or others.) If we regret that a person may not be detained, that suggests that we are losing the ability or the willingness to work with people collaboratively and that would be terrible.
I would be the first to roll my eyes at the political over-correctness of identity politics, for example levering in the word “people” after politically sensitive adjectives makes my flesh creep, however my concern here is that language use not only reflects, but influences our mind-set and attitude towards the people we work with, most powerfully in the way trainees, students and new staff absorb assumptions that it appears from our language that we make.
“Figure of room, occupancy in a field of general space occurs.”
Verbatim translation of a sentence meaning “it has plenty of room” in Shawnee (an American Indian language). Kyle & Woll (1985).
An Interactional Handicap:
A paradox has been pointed out (Vernon and Brown, 1964) that deafness increases the probability of emotional problems by increasing tension and frustration, yet also gives rise to a barrier to communication that rules out the possibility of psychological assessment and treatment. Although many assessment techniques are inappropriate (Vernon & Andrews, 1990) and false-positive as well as false negative diagnoses are common (Monteiro, 1989) it appears probable, given appropriate assessment instruments and techniques, that deaf people show comparable rates of prevalence as hearing people for many psychological complaints such as anxiety disorders, depression, substance misuse, somatoform disorders, paranoid, schizoid, schizotypal, compulsive and histrionic personality disorders, and schizophrenia (Vernon & Andrews, 1990; Schein & Delk, 1974). Thus, Vernon and Brown’s (1964) initial premise is shown to be false and the paradoxical nature of the observation no longer applies - however, as a powerful means of indicating the central difficulty for a hearing therapist without facility in the appropriate sign-language it remains effective - it points towards communication as the main handicap resulting from deafness which influences access to psychology and other services. Following this, Elliott et al (1987) point out that communication is both expressive and receptive and as such the disability of the client (the deafness) gives rise to a handicap experienced by the client, the therapist or both. I would argue that communication is necessarily an interactional process, even in the presence of considerable time-delay between expression and reception, that it is the functional coincidence of expression and reception, and so that the above handicap is necessarily experienced by both parties.
This distinction may be further illustrated by considering an example of a hearing therapist and a hearing client, the difficulty in this example being that the therapist speaks only English and the client speaks only Japanese. The ‘disability’ if we may call it that, is clearly symmetrical - each is unable to communicate in the language of the other. A therapeutic situation involving an English-speaking therapist and a British Sign Language-using client may be compared in many important respects to this example, and enables us to move away from the idea of overcoming a disability to enabling communication between two parties who use different language-systems. Although BSL is the fourth major language of the United Kingdom (after English, Welsh and Gaelic) there are just three mental health services in this country providing their services in BSL, and very few psychologists, or other mental health professionals, who are able to communicate in BSL at any level, yet alone fluently. Also, the in-service components of most training courses for psychologists, psychiatrists, nurses and so on make access to such courses for potential deaf professionals particularly arduous, if impossible. How then may non-BSL-using professionals and BSL-using clients overcome this barrier to communication, and thus to services which are clearly needed ?
Breaking the Sound Barrier
It is sometimes assumed that a deaf person will be able to understand spoken English if the speaker were to speak slowly enough, speak louder and exaggerate lip movements (Roe & Roe, 1991). More enlightened people may stress the importance of speaking naturally, if a little clearer, in order to maximise the success of the lip-reader, and indeed in this situation many deaf people are able to understand spoken English with almost flawless accuracy. However, many other deaf people are not able to comprehend spoken English by this means - perhaps unsurprising in the absence of continued aural exposure to the grammar, syntax, vocabulary and idiom of the language. Jeffers and Barley (1975) have estimated that approximately 60% of English speech sounds are indiscriminable or invisible without the accompanying sound, consisting one half of the vowels and diphthongs and three-fifths of the consonants. Roe and Roe (1991) calculate from this that a fluent English speaker who loses his or her hearing could only be expected to distinguish 40% of spoken communication, although they do not elaborate whether this refers to spoken communication at a phonemic level, a word level, or a noun-phrase or sentence level. Equally, meaning derived from inflection and stresses is inaccessible to the lipreader. It can be assumed therefore that a prelingually profoundly deaf person without continued aural exposure to the language could not be expected to reach this level of understanding of spoken English. The utility of this approach in a therapeutic situation therefore is highly questionable for most clients. For a client unable to express spoken English, the question is also begged of how to confirm understanding, and of how this approach facilitates communication in the direction of client to therapist. Of course it does not.
In the absence of more appropriate means to bridge this gap in communication, some therapists have resorted to written communication, that is, passing written notes between therapist and client. The fact that this cumbersome method is generally inappropriate for psychological assessment and treatment requires no further elaboration, especially when one considers the reduced exposure to the syntax and so on of English alluded to above.
Other ways to bridge the gap include using a friend or member of the family to act as interpreter, or for the therapist with a basic understanding of BSL to attempt pidgin signed-English. The use of a friend or family member introduces issues of confidentiality, and the presence of that person is likely to have a detrimental effect on the process of therapy and the therapeutic relationship, while the attempt to engage in signed communication without a critical degree of fluency and confidence can only serve to frustrate the client as difficult material has to be discussed in terms simple enough for the therapist to understand. The therapist may also be perceived as being less skilled, in exactly the same way as deaf people have been misdiagnosed as learning disabled as a result of difficulties communicating with non-signing professionals. Hindley (1993), in his albeit small sample, found that using a qualified interpreter was preferable to attempting pidgin signed-English oneself. Indeed, apart from fluency in BSL oneself, it would be difficult to argue that any other alternative is preferable to using a qualified interpreter.
Use of an Interpreter:
The use of an interpreter in enabling a deaf person to access mental health services gives rise to a number of issues which should be considered when embarking upon such service provision. Roe and Roe (1991) divide these concerns into three groups: those centred on the client, those centred on the therapist, and those centred on the interpreter:
Client-centred issues:
Although the interpreter is usually seen as a facilitator rather than an encumbrance, it is possible that in psychological therapy, when the material discussed is often of a personal, highly charged nature, the client will begin to perceive the interpreter as an intrusion, albeit a necessary one (Stansfield, 1981). Also registered interpreters in this country are obliged not to “give advice or offer personal opinions in relation to topics discussed or people present...” and to interpret “without anything being added or omitted from the meaning” (C.A.C.D.P., 1996). This may be seen as indifference by a client who is unaware of this professional standard. It can be seen that from this position it would be less likely for the client to commit 100% to the process of therapy and to be more guarded. Ironically, as a result of this the interpreter therefore can to a degree become a hindrance to the therapy (although this process may of course be addressed within the therapy itself.) In this way the perceptions that the client has of the interpreter lead to issues within the sessions which would not otherwise have arisen. It is possible also that the interpreter may be seen as allied to the therapist, although further professional standards rule against this consciously occuring. The optimum seating arrangement when using an interpreter is for the client and therapist to sit opposite each other and for the interpreter to sit next to and slightly behind the therapist such that both therapist and interpreter may remain in the client’s field of vision simultaneously. From this arrangement one may imagine a client feeling somewhat outnumbered. Alternatively, the interpreter may be seen by the client as allied with him or her despite the seating arrangements, as it is the interpreter with whom the client appears to be communicating. It is of course necessary for the client to maintain eye-contact with the interpreter when the therapist is speaking, which may serve to compound this effect.
Already it becomes apparent that the client may develop feelings towards the interpreter which may need to be addressed or considered during the therapy. Whether transferential or not, these feelings are especially likely to develop because the interpreter is professionally obliged to give away no personal information or opinions (Menninger, 1958) and it is possible for the therapist to be implicated in these feelings as well. For example, the client may resent the need for an interpreter in order to access appropriate services otherwise freely available to hearing people. Stansfield (1981) suggests that this resentment may lead to mistrust of the interactions between therapist and interpreter - the client would thus be less likely to feel safe or contained enough to explore emotionally charged material. Trust becomes compromised.
Padden and Humphreys (1988) point out that the deaf community is small and very tightly knit, and that interpreters and the members of that community often know each other very well. The deaf community is also characterised by the speed with which news travels within it. It is possible therefore that the client will know the interpreter already (calling into question the appropriateness of using that particular interpreter), but even if this is not the case the client may reasonably feel uncomfortable about disclosing difficult personal material to somebody who may have regular social contact with other members of the deaf community. The ethical position of confidentiality of the interpreter as well as the therapist, then, should be made clear in the initial session (”Interpreters shall treat as confidential any information which may come to them in the course of their work including the fact of their having undertaken a particular assignment” C.A.C.D.P., 1996).
It can be seen how, despite considerable ruling by the professional body for interpreters (the C.A.C.D.P. - Council for the Advancement of Communication with Deaf People), even the most conscientious interpreter cannot help but become more involved in the therapeutic milieu than the clearly defined role of faithfully translating between the two languages.
Therapist-centred issues:
Millie Stansfield (1987) emphasises this apparent dissolution of professional boundaries when she points out that one of the main vehicles for change is the therapeutic relationship itself. Simply by being present, the interpreter enters into that relationship and impacts heavily upon it, for example at the most basic level of changing a therapeutic dyad into a triad (Hoyt et al, 1981). Thus, any interaction between the therapist and the interpreter becomes a part of the process and dramatically affects the therapeutic relationship(s). The presence of the interpreter may also directly affect the therapist by giving rise to feelings which otherwise would have remained absent. Schlesinger and Meadow (1972) describe the “shock-withdrawal-paralysis” reaction experienced by therapists faced with a deaf client when otherwise established skills and techniques are suddenly unable to be used. Feelings of being deskilled and helpless occur which clearly have an effect on the nature of the relationship. I suggest that this reaction is not alleviated by the presence of an interpreter - indeed that it may be that the therapist fantasises that the interpreter will actually alleviate such feelings but when this is found not to be the case the reaction is only increased. Therapists used to individual therapy and to an environment in which, although they contain both parties, the boundaries and environment are largely controlled by the therapist, will find that the interpreter - with the aim of facilitating optimum communication - will suggest changes to otherwise comfortable and familiar aspects of the process and environment. For example, suggestions may be made regarding the seating arrangements (mentioned above) and the lighting, communication will inevitably be slower than usual as information is translated back and forth - interrupting the usual flow, and ideally the interpreter should take a break after approximately half an hour. The reason for this break is that after this time the error-rate of the interpretation increases to statistical significance (Brasel, 1976), but this can lead to a sense of intrusion felt by the therapist as the hour is broken. All of this may be perceived by the therapist as an ‘expert in deafness’ taking control away and drawing attention to his or her own shortcomings.
Similarly, the therapist’s own degree of understanding of BSL may be a double-edged sword. A therapist with no facility in Sign may wonder, as may the client, about the accuracy with which the interpreter is proceeding. Many English forms take longer than one would expect to portray in BSL, while others are suspiciously short. This and the seemingly constant eye-contact between client and interpreter can serve to isolate the therapist and increase the sense of paralysis. However, a therapist with some understanding of BSL who nonetheless is not fluent enough to competently conduct one-to-one therapy in that language without an interpreter may experience a quite separate difficulty. It is recommended (C.A.C.D.P., 1996) - and indeed polite - to look at the client at all times, even though that person may naturally turn to look at the interpreter. If the therapist is able to understand a proportion of the signed material this can be extremely distracting as attention is drawn away from the spoken interpretation to which attention should be directed. This effect is compounded by the facts that the interpreter should be seated slightly behind the therapist, and so seems a disembodied voice, and that the client will often vocalise variably clear words. It is not easy using an interpreter, and the fantasy of a rescuer from the shock-withdrawal-paralysis is soon shown to be false.
Interpreter-centred issues:
Many of the above concerns may equally be viewed as interpreter-centred, however, there are further issues which may reasonably be aired here. Mention has been made of seeming dissolution of professional boundaries and distortion of the therapeutic relationship. Elliott et al (1987) suggest, indeed assume, that the therapist will meet with the interpreter before meeting with the client to discuss issues such as these - clarifying the role of the interpreter, the expectations of the therapist and developing ways to deal with misunderstandings during the session for example. In particular they recommend such pre-session contact so that a system of covert signals may be set up. On occasion it is necessary for an interpreter to explore a number of translations of a particular concept and it would be up to the therapist to decide whether further exploration of an important concept was merited, or could be moved from. Evans et al suggest a signalling system for this, and during psychometric testing for the description by the interpreter of errors made by the client - and they argue that this leads to increased trust between the therapist and interpreter which serves to reduce a few of the concerns outlined above regarding alliance and isolation. It is recommended (Stansfield, 1987) that the client be informed of these meetings, but not of their content. The effect of this on the client’s perceptions of the role of the interpreter and the trust felt regarding both interpreter and therapist can only be guessed. Roe and Roe’s (1991) comments - that it would be better to address issues of communication and confidentiality, and for the interpreter to step out of role as communication facilitator (if necessary) in front of the client such that otherwise extant mistrust and suspicion may be alleviated - are relevant here. I would further add that it may be more productive, if not healthier, for roles to be collaborative rather than secretive, and to be honestly complex and variable rather than artificially and falsely straightforward. That is, if the interpreter is required to step out of role (for example to comment on non-verbal communication) it is better achieved within the session with an apparent crossing of boundaries, with corresponding increase in trust. I would argue that the boundary around the interpreter’s role is not being crossed in this instance, but being clarified as more complex than could be hoped for. If the interpreter is to be presented to the client as simply facilitator of communication, that person should only be used as such.
In terms of psychometric testing, I feel an argument may be made at least for meeting with the interpreter beforehand - and likely for some time - in order to agree on appropriate translation of material and psychologist response. This should be carried out in some detail and may require an exchange of knowledge in that the interpreter will require a basic understanding of psychometric testing, and the psychologist will need to be somewhat versed in deaf issues, language and culture. The interpreter must understand the standardised administration (although it will inevitably be departed from as part of the stipulation is often that instructions are verbally presented), and the psychologist will need to understand if certain items are unhelpful by virtue of being culturally irrelevant, or because the very act of asking the question in BSL gives the answer away. For example the question “how are a ball and a wheel alike?” could not be used as the Signed administration would trace circular figures in the air, divulging the answer (Stansfield, 1981).
The cultural validity of standardised tests, or structured interviews, highlights another way in which the interpreter works apparently outside of straightforward linguistic translation. A good interpreter will communicate not just the spoken words of the therapist, but also the non-verbal and affective content as well. Many concepts do not translate smoothly from one culture to another, and the question is raised therefore of the degree to which the interpreter re-frames the spoken communication to fit most appropriately into the other culture. Gaviria et al (1984) - in a Peruvian study - outline four ways in which culture impacts on the validity of an instrument or technique standardised on a different cultural group and their observations and categorisations are relevant to Deaf and hearing cultures: Semantic validity demands that words in the original and translated versions carry the same meaning; technical validity requires that the very substance of the translated instrument carry the same meaning and familiarity, and yield similar expectations, as the original - the interpreter in Hindley’s (1993) study considered for example a face-to-face interview to be foreign to deaf children; criterion validity requires that items, questions or comments refer to similar normative concepts between the two cultures, and conceptual validity demands more directly that questions asked actually relate to concepts within that culture. If we (reasonably) assume a knowledge of, and familiarity with, Deaf culture from the interpreter, it is clear that all of these concerns are areas in which that person may be of help.
As alluded to above, it is equally desirable for the interpreter to be versed in mental health issues, the process of therapy and so on. Monteiro (1989) sees this as a requirement in that so much of therapy occurs outwith the spoken utterance, the interpreter needs to be aware not only of where the translation from therapist to client is going (ie translating culturally as well as literally) but also of where the translation is coming from - the therapeutic rationale behind the utterance. An interpreter I have worked with, for example, suggested ways in which she may interpret therapeutic silence. Monteiro suggests that an interpreter without such an understanding may even act to the detriment of the therapy.
Such a background is clearly advisable, but, although not arguments against this practice, certain considerations should be borne in mind. To refer back to comments made above, an interpreter with a grounding in mental health issues may be perceived by the therapist as even more threatening and intrusive. Also, an interpreter with such an understanding may find it quite difficult to work with a therapist who acts in a way which conflicts with the way in which the interpreter would act in the other role; and therapeutic approaches or techniques may be perceived erroneously by the interpreter and worked into the translation, conflicting with the approach then actually taken by the therapist.
Summary:
A number of issues have been highlighted above, concerning potential reactions to the therapeutic triad of the client, the therapist and the interpreter. Certain of these issues can only be addressed with opinion, either from the literature or myself, while others remain simply highlighted. However, the aim here is not to provide answers to these concerns (since there are probably none which are irrefutable) - rather it is to provide a compendium of concerns which challenge the fantasy that using an interpreter will overcome all of the issues raised when a non-BSL-using therapist and a BSL-using deaf person work together in therapy. Some of these concerns are conspicuous in their absence in the verbatim translation of a Shawnee phrase at the head of this text.
Overall, however, it should be noted that apart from the therapist being fluent in BSL, the preferred means of conducting therapy with a signing deaf person is through an interpreter versed in issues of mental health.
References
Brasel B.B. (1976) “The effects of fatigue on the competence of interpreters for the deaf.” In H.J. Murphy “Selected readings in the integration of deaf students at C.S.U.N.” Centre on Deafness series (No.1). Northridge: California State University.
Council for the Advancement of Communication with Deaf People “C.A.C.D.P. Directory 1996/1997” C.A.C.D.P., Durham.
Elliot H., Glass L. & Evans J.W., eds (1987) “Mental Health Assessment of Deaf Clients: A Practical Manual.” Little, Brown & Co, Boston.
Gaviria M., Pathak D., Flaherty J., Garcia-Pacheco C., Martinez H., Wintrob R. & Mitchell T. (1984) “Designing and adapting instruments for a cross-cultural study on immigration and mental health in Peru.” Paper presented at the American Psychiatric Association Meeting. In Hindley P. (1993) “Signs of Feeling. A prevalence study of psychiatric disorder in deaf and partially hearing children and adolescents.” RNID, London.
Harvey M.A. (1982) “The Influence and Utilization of an Interpreter for Deaf Persons in Family Therapy.” American Annals of the Deaf 7, 821-826.
Hindley P. (1993) “Signs of Feeling. A prevalence study of psychiatric disorder in deaf and partially hearing children and adolescents.” RNID, London.
Hoyt M.F., Siegelman E.Y. & Schlesinger H.S. (1981) “Special Issues Regarding Psychotherapy with the Deaf.” Am J Psychiatry 136:6.
Jeffers J. & Barley M. (1975) “Speechreading (lipreading).” Charles C. Thomas. Springfield, Illinois. In Roe D.L. & Roe C.E. (1991) “The Third Party: Using Interpreters for the Deaf in Counseling Situations.” Journal of Mental Health Counselling 13(1) 91-105.
Kyle J.G. and Woll B. (1985) “Sign Language. The study of deaf people and their language.” Cambridge University Press. Cambridge.
Menninger K. (1958) “The theory of psychoanalytic technique.” Harper and Row,New York.
Monteiro B.T. (1989) “Pitfalls in Diagnosis” Unpublished. Supra-regional Department of Psychiatry for the Deaf, Whittingham Hospital, Preston, Lancs.
Padden C. & Humphreys T. (1988) “Deaf in America: Voices from a culture.” Harvard University Press. Cambridge, MA.
Roe D.L. & Roe C.E. (1991) “The Third Party: Using Interpreters for the Deaf in Counseling Situations.” Journal of Mental Health Counselling 13(1) 91-105.
Schein J. & Delk M. (1974) “The deaf population of the United States.” National Association for the Deaf. Silver Springs, Md.
Schlesinger H.S. & Meadow K.P. (1972) “Sound and Sign: Childhood Deafness and Mental Health.” Berkely. University of California Press.
Stansfield M. (1981) “Psychological Issues in Mental Health INterpreting.” RID Interpreting Journal, 1 18-31. In Roe D.L. & Roe C.E. (1991) “The Third Party: Using Interpreters for the Deaf in Counseling Situations.” Journal of Mental Health Counselling 13(1) 91-105.
Stansfield M. (1987) “Therapist and Interpreter: A working relationship.” Paper presented at the Mental Health and Interpreting Conference, Annapolis, MD. In Roe D.L. & Roe C.E. (1991) “The Third Party: Using Interpreters for the Deaf in Counseling Situations.” Journal of Mental Health Counselling 13(1) 91-105.
Vernon M. & Andrews J. (1990) “The Psychology of Deafness. Understanding Deaf and Hard of Hearing People.” Longman, NY.
Vernon M. & Brown D.W. (1964) “A guide to psychological tests and testing 1 procedures in the evaluation of deaf and hard-of-hearing children.” Journal of Speech and Hearing Disorders, 29, 414-423.
There are very very few psychometric instruments available for use with prelingually profoundly deaf people. When testing such people therefore, there is a great deal to be borne in mind.
The most important point to consider is that of the validity and reliability of the tests used, both in and of themselves, and as a result of any changes that would need to be made to the formal administration in order to communicate the task to the client. Four main questions can help with this:
1. Does the test consist of verbal test items or performance items? Verbal items are inappropriate for deaf people, particularly prelingually deafened. Such people usually have difficulty with English syntax and vocabulary independent of cognitive function, as a result of English being a purely visual (and unspoken, and therefore considerably less frequently encountered) language for deaf people. Deaf people’s mean reading age (compared with hearing peers) has been estimated to be at the 3rd or 4th grade level irrespective of intellectual function.
2. Do instructions for the test require verbal communication? This is important even if the tasks themselves are considered to be “performance” tasks. For those measures that offer little or no flexibility in the way in which instructions are presented (such as the WAIS-III), departure from the formal administration departs also from the standard administration with the normative sample and comparison with that sample then becomes misleading in ways that cannot be predicted or allowed for. The same problem is more frequently met when comparing hearing people tested in the formal manner with those tested with more flexible instruction.
3. Do any test items discriminate against (or for) an individual with an auditory impairment? Test items may discriminate directly or indirectly against, or for, deaf people. Those that discriminate against are more common, but both for and against present problems of comparison with a normative sample. An immediately obvious example would be from the Vineland Social Maturity Scale which contains an item “Makes Telephone Calls”. Clearly this would underestimate the individual’s functioning. Perhaps less obviously, but equally critical, an attempt to address the cultural validity of this item by converting it to “Makes Minicom (Textphone) Calls” still underestimates the ‘true’ level of functioning since a deaf person’s experience of using a textphone differs entirely from a hearing person’s with a telephone (in terms of when one is first seen used, how often they are seen on TV, and so on.) Similarly there is some evidence that BSL users are advantaged when using the block tapping tasks (such as Corsi’s) – but advantaged in such a way that disappears when the person sits alongside the examiner instead of opposite.
4. Are deaf people included in the normative sample provided by the test developer? Apart from a very select handful of tests the answer to this question is always no. Norms for deaf people are rarely provided. There are good arguments for and against comparing this deaf person with deaf or ‘hearing’ norms, and the answer depends on the reason for testing. However there is only ever an argument for ‘hearing’ norms if that normative sample contained deaf people in equal proportion to the population of concern and that the results from that sub-sample are demonstrably as reliable as those of the hearing subjects. Such norms are rarely if ever established, and prelingually profoundly deaf people are more likely to be formally excluded from the normative study. The interpretation of results of clients who do not mirror individuals for whom the test was designed must therefore be explicitly cautious.
These main areas make the assumption that communication with the client, in sign, is unproblematic – that is, that the assessor is able to sign. When that is not the case, further issues of the reliability of the interpretation are raised:
5. How reliable is your communication support? The ability of the interpreter(s) must be stated in the report and considered when interpreting the results. Even if the interpreter is Level IV accredited and a registered Sign Language Interpreter, which ought really to be the only acceptable standard for psychometry, the reliability of the interpretation will decline significantly after 35 minutes. Two interpreters should be used and regular breaks should be introduced (which can itself conflict with a formal test administration). Interpretation will always add to the error in the estimated level of function, and it is impossible to say whether it contributes to an over- or an under-estimation. The extent of this error is, in part, a function of the competence of the interpreter(s).
6. How reliable is perfect communication support for this measure? Even if the communication support is 100% perfect (and this is in truth only available in our imagination) then it is important that each item of each test be discussed in advance with the interpreters. (There is no such thing as a perfect translation. There can be a best translation but that is hard to find and is only a “working-best” until a better one is noted in the future.) However, even supposing perfect interpretation, the assessor must be fully aware of the nature of the signed administration in order that the psychometric equivalence of the standard and the signed administration of that item can be judged. For example, the Similarities subtest of the WAIS-III contains the question, in English, “In what way are a coat and a suit alike?” It is fairly easy to translate this into a British Sign Language equivalent with little debate. However the nature of the most common signs for coat and suit make it self-evident that both are articles of clothing – a response which receives maximum points. Conversely the signs ‘rhyme’ in terms of both being bimanual and symmetrical, sharing the same location in space, employing very similar movements, and handshapes differing only in terms of thumb position. It could be argued that these phonological similarities are unreasonably misleading and/or that they imply alternative false answers (the location of both signs is commonly used for emotions) in a way that the spoken English items do not.
These concerns all contribute unknown amounts of error to the estimated level of whatever psychological construct is under scrutiny (such as intellectual function). In addition the ways in which these concerns may be addressed (that is by departing from standard administration in a variety of ways) also contribute error to the estimate. The magnitude of this error and the overall direction of it are both unknowns and lower the reliability of the obtained results.
The validity of obtained results remains in question when the normative sample is exclusively hearing.
Generally, examiners should be advised to:
• Assess the deaf person with support from qualified British Sign Language Interpreters.
• Discuss each item of each test in advance with the interpreters, and afterwards such that any instances of note may be raised and accommodated in the interpretation of the results.
• Consider which, if any, tests to use in the light of points one to four above.
• Interpret results with extreme caution in the light of points one to six above.
• Make each of these shortcomings explicit in the report such that future readers will not jump to erroneous conclusions.
• And generally to assume that obtained results reflect a hypothetical minimum value, and never imply a ceiling to the individual’s ability or potential.
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Deafness, partial or complete loss of hearing, may be described in a number of ways including severity, time of onset, and aetiology. The British Society of Audiology (BSA, 1988) provide audiometric descriptions of the severity of deafness as follows:
Descriptor... Hearing loss:
Mild deafness... 20 - 40dB
Moderate deafness... 41 - 70dB
Severe deafness... 71 - 95dB
Profound deafness... 96+dB
*dB loss in the better ear on pure tone audiometry, average across 250, 500, 1000, 2000, and 4000 Hz. The intensity of conversational speech lies within the range 60 - 70 dB.
Hearing loss may result from a number of different causes such as prenatal rubella, meningitis, prematurity, complications of Rh factor, ototoxic drugs, syphilis, mumps, Ménière’s Disease, and exposure to noise (Vernon & Andrews, 1990). Although, as shall be discussed, it is important to consider the aetiology of presenting deafness, the many causes may be divided into four categories as follows (O’Rourke, 1990): a) Conductive losses, which are those which result from a mechanical problem such as malformation of the ear. Because intensity at all frequencies is reduced, amplification can be beneficial. b) Sensori-neural losses which involve the cochlea and/or the auditory nerve and so affect fidelity as well as intensity, resulting in distortion. c) Mixed losses, which are those with both conductive and sensori-neural elements, and d) Progressive loss, which is a rare type that worsens over time (Freeman et al, 1981).
Finally, and perhaps most importantly, time of onset has a significant effect on the degree to which the hearing impairment becomes a disability, in that severe or profound deafness occurring before one year of age can significantly affect the acquisition of spoken language (Hindley, 1993). Kitson and Fry (1990) state both the incidence and prevalence of prelingual profound deafness to be 1 per 1000. Following from Basilier’s (1972) definition of ‘social deafness’ - ‘deafness which with the best hearing aids available (that the person will use) does not allow understanding of speech through the ears well enough to take part in a brisk conversation’ - Kitson & Fry (1990) describe a more practical system of categorisation:
1. Prelingual (congenital or acquired before language development)
a) Profound (no speech reception through the ears)
b) Partial (some difficulty in speech reception)
2. Postlingual (acquired after language development)
a) Profound
b) Partial.
It is this classification which will be adopted below. However, when discussing the psychological implications of the impairment, it is important also to consider the cultural aspects of deafness, including the use of sign language, lip-reading or cued-speech, and membership of organisations for deaf people (Hindley, 1993). As has recently become standard practice, the essay will refer as far as possible to deaf people, who identify themselves as members of the deaf culture, as Deaf with a capital D, leaving deaf with a lower-case d for those people who may or may not identify with Deaf culture but do have a hearing impairment. It will be assumed that Deaf people communicate in a sign-language, while deaf people may or may not. Except where indicated, ‘deaf’ or ‘deafness’ will refer to prelingual profound deafness.
In this study of prelingual profound deafness, the question of whether there is a psychology of deafness, and what that means, will be addressed. The different ways in which deafness impacts on psychopathology will be discussed, and various responses or solutions to this considered.
The Impact of Deafness:
“Deafness before the acquisition of language [is] a greater affliction than blindness.”
Helen Keller (1929)
A brief look at the literature pertaining to this field quickly gives the impression of deafness as a uniform condition, and of deaf people as an unvarying population. This is clearly not a true picture. However, as a result, it can be inferred that there is a psychology of deafness, distinct from that of hearing people, which either compares deaf with hearing populations, assuming hearing norms, or adopts norms of ‘deafness’ thus homogenising a demonstrably diverse group. Neither of these conclusions are particularly satisfactory. There are specific difficulties of cross-cultural study which will be outlined later, however, Cole (1991) provides a practical perspective in that
“What makes it possible to talk about a psychology of deafness is that for many Deaf people their experiences have a lot of important factors in common and we can study the psychological effect of these factors.”
Cole proposes a model that assumes a normal development throughout childhood and adolescence, which is encroached upon by a variety of experiences associated with deafness. These experiences include the deafness itself, and so the model becomes, to the pedant, somewhat tautologous, however the above model, as a rule of thumb, is a useful maxim to adopt when thinking about the impact of deafness on psychology and psychopathology. This impact may reasonably be expected to take any of three forms: i) The aetiology of the deafness may bring with it further concomitant disorders or experiences, ii) the deafness per se may give rise to a describable psychological effect, and iii) the deafness may itself lead to an intermediate factor which results in a psychological effect. This essay will consist of an exploration of these three forms. It will become apparent that the distinction between ii) and iii) is impractical, and so will be discussed together (Aspects of Deafness.)
Concomitant effects of certain aetiologies of deafness:
It is estimated that 50% of deaf people are deaf as a result of trauma, and many of those are likely to have suffered some degree of brain damage (Kitson & Fry, 1990). Hindley (1993) describes how powerful the effect of brain damage is in the aetiology of psychiatric disorder, citing among others Seidel et al (1975), Shaffer et al (1975) and Brown et al (1981), and the means by which this effect may occur are described as:
“...impairment of intellectual function, specific learning disabilities, associated social disadvantage, social stigma associated with handicap, the effects of brain damage on temperament, and the effects of anticonvulsant drugs.”
Hindley (1993)
Of these mechanisms, it can be seen that some involve the direct effects of brain damage, such as specific learning disabilities, while others are concerned with secondary results, such as the effects of social stigma or drugs. However, be they direct or otherwise, they are all means by which concomitant brain injury may impact on a person’s psychological functioning. Vernon & Andrews (1990) describe how trauma which results in profound deafness can occur as a result of a number of conditions (described above) and these conditions may give rise to further problems not necessarily directly related to the deafness. Outlined below are two examples of such conditions:
Rubella.
During pregnancy, the otherwise fairly harmless rubella virus can have pervasive and traumatic effects. It quickly assaults the layers of embryonic tissue and reduces cell division in the developing body parts such as the ear, brain, eye, and heart. Vernon (1969) describes the prevalence of deafness due to rubella in his sample of 1,468 as 139, that is, 9.5%. In examining the IQ distribution of post-rubella deaf children, he identified a mean IQ of 95.3 with a standard deviation of 16.8, significantly less than the general population, and it is suggested that post-rubella deaf children do not succeed educationally as well as their deaf peers (Vernon et al 1980). Feldman et al (1971) distinguished an increase in aphasia among rubella-deafened children, which would also compound communication problems resulting from the deafness, and Chess (1977) identified an increased incidence of autism. Also implicated in rubella are psychosis and behaviour disorders such as poor impulse control, excitability, rigidity, distractability, instability, and emotional shallowness (Trapp & Himelstein, 1972; Chess & Fernandez, 1980; Vernon, 1969). Although these effects should be borne in mind, Vernon and Andrews (1990) stress the importance of realizing that the majority of prenatally rubella-deafened persons are, however, behaviourally within the normal range.
Meningitis.
Meningitis is an infection of the membranes surrounding the brain. It deafens between 3 and 10% of its survivors and is the leading cause of postnatal profound hearing loss (Raivio & Koskiniemi, 1978; Vernon, 1967a&b). Also, as a result of the introduction of antibiotic treatment, the proportion of those deafened by meningitis being so before the acquisition of language is increasing. This is because once the early symptoms may be verbalised, antibiotic treatment may be quickly instituted, whereas the prelingual infant may only be recognised as meningitic once the disease is somewhat advanced. Vernon & Andrews point out that at this stage, even if treatment enables survival, the chance of sequelae such as deafness is greater, especially as, unfortunately, some of the drugs used for treatment have ototoxic effects (Hindley, 1993.)
Vernon (1969) has found the mean IQ of post-meningitic deaf children to be 95, and that 34% had an IQ of less than 90. (He also states that from a study of 26 meningitic deaf children aged between 7 and 12 months, the mean IQ was 91.50 and the percentage of those ‘mentally retarded’ [sic], 34.6%.) It was also identified that 38% of the post-meningitic deaf sample had additional major disabilities including, in order of prevalence, aphasia, learning disability, emotional disturbance and cerebral palsy, and that these were more likely following an early onset. Of the 8.3% that were dropped from school for ‘emotional disturbance’, 29.3% had problems such as aggression, hyperactivity, poor impulse-control and distractibility, psychosis, or anxiety as a reaction to aphasia.
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Other aetiologies which may have concomitant effects include prematurity and complications of Rh factor, which both appear to correlate with lower IQ, aphasia, and emotional disturbance, prematurity also being implicated in schizophrenia.
It can be seen from the above studies how the aetiology of a hearing impairment may itself increase the probability of further, psychological, problems, which may be considered in isolation from the deafness. That is, certain sequelae of a particular disorder may manifest in a person whether or not deafness is also indicated, and should not be interpreted as alleged ‘symptoms of deafness.’ However accompanying deafness must be acknowledged as it may influence the effect of that symptom, as well as the processes of assessment and treatment (see Implications for Services, below).
Aspects of Deafness:
Deafness per se:
A number of different authors have suggested that, among other things, concrete thinking, impulsivity, rigidity, and lack of insight, are the direct results of deaf enculturation (Altshuler, 1971; Misiaszek et al, 1985; Kitson & Fry, 1990.) The term coined by Basilier (1964) for describing these behaviours - surdophrenia - which literally translates as ‘deaf mind’ - suggests that such behaviours are characteristic of deaf people in general, but there are a number of reasons why the term is unhelpful (BC Swaans Joha, 1991):
• It implies that surdophrenia is a mental illness, and is therefore confusing.
• The criteria and characteristics are inadequate.
• The literal translation implies that all deaf people necessarily suffer from mental health problems.
• The deaf community find it offensive.
The surdophrenic condition was simultaneously described by Rainer et al (1963) as ‘Primitive Personality’ although Vernon (1978) uses this term to describe deaf people who have been inappropriately provided for, such as those who live dependently and overprotected with their parents and who, when those parents die, have to face the double trauma of bereavement and independent living for which they are not prepared. Although the label suggests a particular personality type, as well as being pejorative, Vernon’s use of it implies a problem not of a personality type unique to deaf people, but of a failure to adequately provide for the specialised needs of the deaf person. Perhaps as a result of the over-representation of deaf people in mental illness hospitals (that is by a factor of about 10 - Denmark, 1966) or by the assumption that no speech indicates no language which indicates no thought (Cole, 1991), it seems as if there has been an assumption of a problem or personality type peculiar to deaf people. The literature seems to imply that this assumption is unfounded, for example Vernon’s (1978) use of Primitive Personality above being read as service deficiency, or John Denmark’s (1985) description of problems related to deafness: Denmark describes 250 patients referred to a specialist psychiatry department for deaf people, underlining the need for such specialised services. The problems of these patients are categorised into three types - those suffering from mental illness, those with problems related directly to deafness, and those with communication disorders (which will be discussed later.) Of the prelingually deaf people studied, all of the problems related directly to deafness were behavioural and adjustment problems resulting from the communication difficulties of being deaf in a predominantly hearing world and/or family. It would not be valid to infer from this that such adjustment problems were necessary sequelae of deafness as there are certain other conditions the fulfilment of which effect the presence or extent of the problem; for example being raised in a predominantly oralist milieu, as Higgins (1987) demonstrates how deaf people from an oralist background are more likely to have a negative-self image, while those from Signing backgrounds are more likely to have a positive self-image.
Rather than supposing that deafness results in its own unique set of psychological problems, it may therefore be more constructive to look at how the experiences of deaf people differ from those of the hearing, and then it may be possible to deduce reasons for those differences.
Comparative rates of prevalence:
In order that one may examine such differences, to explore the possible effects of being born deaf on psychopathology, and to identify any clinical evidence for a psychology of deafness, it will first be necessary to examine rates of prevalence. Vernon & Andrews (1990) provide perhaps the most comprehensive analysis of the comparative prevalence rates of non-psychotic and psychotic behaviours between deaf and hearing people. The following is a brief summary. Where observation is based on research, this will be indicated, otherwise it may be assumed that it is based on Vernon’s 1969 paper, or his clinical experience:
Learning disability: There is a similar distribution of IQ scores for both deaf and hearing populations, although Brill (1963) has shown genetically deaf people to have higher mean IQs than the general population. The main problem is one of poor assessment measures, as described later.
Attention Deficit Disorders: There is a higher prevalence of attention deficit disorders among deaf people, as a result of the brain damage or endocrine disorders associated with the aetiologies of deafness (Vernon, 1969).
Substance Misuse: Patterns of the misuse of drugs and alcohol are said to be similar for deaf and hearing populations. Hooten (1978) suggests isolation, unemployment and stress could lead to increased levels of alcoholism in deaf people as they are more prone to these, while Altshuler and Rainer (1970) propose that lack of depression (see below) would reduce the prevalence of drinking problems. Overall, the rates of substance misuse are no different from the general population.
Anxiety Disorders: Obsessive-compulsive disorder, anxiety, post-traumatic stress and phobias occur as frequently among deaf as hearing people.
Somatoform Disorders: According to clinical experience, these are no more prevalent in deaf than hearing populations.
Paraphilias: No research data exists on prevalence rates, but Vernon’s clinical experience suggests no difference between deaf and hearing people.
Disorders of Impulse Control: Impulsiveness seems to be found more often in those people who are deaf as a result of organic factors. Harris (1976) and Levine and Wagner (1974) showed that there is no more impulsiveness in deaf people who have early exposure to sign language, deaf parents, or high levels of academic achievement, so, a lack of these factors may raise the likelihood of problems with impulse control.
Paranoid, Schizoid, and Schizotypal Personality Disorders: There appears to be no increased risk of schizoid and schizotypal personality disorders among deaf people. Neither is there an increased risk of paranoid personality disorder despite there being significant mention of connections between deafness and paranoia in the literature, such as DSM III (Spitzer, 1980) and Cooper (1976). Cooper goes on to distinguish between pre- and post-lingual deafness, describing a clearer relationship between post-lingual deafness and paranoia - perhaps as a result of increased (possibly reality based) suspiciousness, or of misunderstanding (Kitson & Fry, 1990.)
Histrionic, Narcissistic, and Borderline Personality Disorders: Vernon and Andrews describe Histrionic Personality Disorder as being no different in deaf than hearing people, although they admit a lack of research data. Narcissism may have an increased prevalence among deaf people, but there is no explanation other than its possibly being caused by naivety. This naivety could reflect a number of the common experiences of deaf people outlined by Cole (1991) - lack of experience, lack of knowledge, and lack of incidental information being picked up which is critical to the development of what many would refer to as ‘common sense.’ The presence of Borderline Personality Disorder in deaf people does not appear to be mentioned in any literature, while its significant absence is described by Grinker (1969). It is stressed that this absence may be due more to diagnostic difficulty than nonoccurrence.
Avoidant, Dependent, Compulsive and Passive-Aggressive Personality Disorders: The social dynamics of deafness (which are not described) are said to result in a higher prevalence of both Avoidant and Dependent Personality Disorders among deaf people. Compulsive Personality Disorder is no more common, while Passive-Aggressive Personality Disorder is implied to be more prevalent as a result of failures of communication with authority figures, leading to direct, impulsive ways of acting out (which leads to more trouble), which becomes a passive compliance with an underlying resistance. This seems a rational hypothesis, but, reasonably, the increased prevalence is only implied.
Schizophrenia: Kitson and Fry (1990) suggest that schizophrenic psychoses are found equally among deaf as hearing people, quoting Altshuler & Sarlin (1963), although they point out that there are no reliable figures - possibly as a result of problems in diagnosis. Similarly, Vernon and Andrews describe how the proportion of hospital admissions for deaf people for schizophrenia is about the same as for hearing (presumably meaning the proportion of deaf to hearing schizophrenic admissions is the same as the proportion of deaf to hearing people in the general population; the description is ambiguous.) However there are more deaf schizophrenic people in hospitals than hearing (Basilier, 1964) probably as a result of communication problems impeding the monitoring of treatment, and the concurrent misdiagnosis of paranoia or learning disability resulting in admission to more long-stay chronic wards. As an illustration of this, Timmermans’ (1989) study found the average stay in hospital to be 148 days, while deaf inpatients remained for 19.5 years (Kitson & Fry, 1990).
Depression: Altshuler (1971) suggests that depression is rare in deaf people, possibly as a result of deaf children not being so exposed to parental and societal pronouncements, leading to a less developed super-ego and so less depression; that is, it is “suggested that hearing is required for normal development of object relations and conscience.” (Kitson & Fry, 1990.) Kitson and Fry go on to suggest that Deaf people with normal language development (in sign) do not appear to suffer delayed personality development, but that this population is too small to effectively study. Evans and Elliot (1987) suggest, also, that “contrary to a commonly held belief about deafness, depression is fairly common in our prelingually deaf patients, particularly in the self-referrals seen in our satellite clinics” - suggesting that referral and presentation patterns may mask depression in this population.
Autism: Autism has not been shown to be any more or less prevalent among deaf than hearing people unless the cause of the deafness was prenatal rubella, in which case the prevalence is 7.4%, compared to 0.7% for the general population (Chess, 1977; Chess & Fernandez, 1980.)
Certain themes are evident in this summary. Perhaps most striking is that, given appropriate assessment tools, there is no reason to suggest that prevalence rates for deaf people are any different than those for hearing people on at least a half of the above disorders, including schizophrenia, certain personality disorders, and anxiety disorders. Of those that are different, two show reduced rates - possibly due to presentation rates and referral pattern, problems of diagnosis, or maybe developmental issues, while six show increases in prevalence - some as a result of common organic aetiology, and others as a result of social factors such as being overprotected or isolated, and frustrating failures of communication. Certain issues of neuropathology have been discussed above, and so will not be dealt with again here, however, the main explanation for certain prevalence rates would therefore seem to be the many different experiences associated with deafness which may impact upon issues of psychopathology. Cole (1991) collates these as follows:
Deafness and background variables:
Age of onset
Degree of deafness
Speed of loss
Time of diagnosis
Deaf or hearing parents
Parental attitudes
Individual Character
General environment
Other problems (physical, intellectual etc.)
Experiences:
Type of education
Attitudes of professionals
Attitudes of parents
Communication
Separation
Friendships
Information input
Deaf or hearing world
Stigma
Lack of experience
Lack of knowledge
Limited role models
Fear
Over protection
Consequences:
Feeling rejected
Isolation
Lack of identity
Identity confusion
Relationships
Fear & anxiety
Depression
Lack of control / power
Hard work
Employment
Training
Self image
Self esteem
Confidence
Limited opportunities
Limited social roles
The categorisation of certain items in these lists is debatable, for example some may argue that parental attitudes and time of diagnosis are a resulting experience, and indeed the distinction between experiences and consequences could seem a little arbitrary. However, they provide an excellent aide memoire for items which the professional should consider, and Cole describes how they relate as follows: “Background variables to do with deafness, the individual’s characteristics, particular family circumstances and the wider social environment interact to dictate the individual’s experiences, some of which can be influential in determining their psychological functioning.” She points out that many of these experiences emphasise disability and goes on to describe in detail how development may progress differently for a deaf person, which demonstrates quite clearly how it is the combination of deafness and the environment which impacts on psychological functioning, rather than the deafness per se. There are probably three main aspects from these lists which psychological services should consider: professionals and their attitudes, issues of communication, and deaf or hearing world (culture), for these may have serious implications for assessment and the process of intervention.
Implications for services:
Issues of communication:
“Language influences the assessment process more than almost any other variable...”
Orr et al (1987)
Alice Thacker (1990), a specialist speech therapist in hearing impairment and psychiatry, provides two explanations for the over-representation of deaf people in mental health services described above: the first is a failure to detect the hearing loss at all, such that certain limitations resulting from the deafness such as impoverished vocabulary, rigid structure and little linking of themes are interpreted, for example, as poverty of content, poor insight and withdrawal. The second is a failure to adapt diagnostic procedures and management appropriately. This is pointed out well by Monteiro (1989) who describes how “it is extremely difficult to diagnose even physical illnesses without effective communication between patient and doctor.” Clearly, a psychological assessment can be rendered almost impossible without effective communication between therapist and client, which, as Monteiro describes, can render the assessor feeling deskilled and helpless and so, under pressure to offer an opinion, often makes an assessment which has little established basis.
One answer to this problem could be the use of an interpreter. However, this also affects the assessment or therapy session in a number of ways (Orr et al, 1987). For example, the presence of an interpreter turns a dyadic process into a triadic one which Hoyt et al (1981) point out may dilute and distort the relationship, complicating transference issues, and make the interpreter become a centre of authority. Also the interpretation is never a literal word-for-sign conversion as most sign languages, like spoken ones, have different grammatical structures and inferences attached to the concepts. Therefore, the interpreter’s job is also to try to capture the hints and flavours of the conversation, which necessarily introduces that person’s history, expectations, and understanding of psychological concepts into the situation - to accommodate this, Orr et al emphasise the necessity of using an interpreter with expertise in the mental health situation. There is also a question of confidentiality.
If the psychologist chooses to use sign language, it is clearly important that that language can be used fluently. Orr et al point out that it is easy to slip from ASL or BSL (American and British Sign Language) into signed English, which differs in syntax, thereby unintentionally changing the meaning. It is also necessary to recognise that deaf clients may have variable abilities in the chosen method of communication as a result of a changing educational and familial background. Thus, if for example BSL is the predominant language of choice for a particular client, it may not be the case that that person is fluent in that language, and so may also slip into other signed systems, or indeed other means of communication altogether. Even the most fluent professional would have to be extraordinarily skilled to effectively follow such a conversation. Similarly, though, as a result of a varying background many deaf people are able to adapt their language to the situation. Orr et al, however, describe how this can lead to tension, stress, frustration, misunderstanding, and constriction. Schlesinger and Meadow (1972) point out, also, that communication difficulties can be used as a resistance by clients, for example by signing too rapidly, looking away, or selectively misunderstanding troubling material.
Issues of Assessment:
“Misdiagnosis of deaf patients is common. Many are labelled mentally retarded or schizophrenic as a result of their language disability due to deafness, not the actual presence of retardation or psychopathology.”
RR Grinker (1969)
As described by Monteiro (1989), there are a number of ways in which communication issues can affect assessment and diagnosis. One is that psychopathology is inferred when in fact there is none, as proposed by Thacker (1990), above, while another is that presenting psychopathology may be missed. The former is further described by Hoyt et al (1981) who demonstrate that “what may appear to be unusual or distorted thinking may actually be a normal and appropriate locution in ASL” and by Evans and Elliott (1981) who report “the tendency to overdiagnose schizophrenia as a wastebasket classification when confronted by a gesticulating, excited patient who cannot be understood.” Denmark (1966) has also written that “the inability in the deaf to express dissatisfaction or anger in the normal way, or quickly enough, by emotionally tonal verbalisation, often leads to the physical display of such feelings. To those without a knowledge of the psychology of the deaf person these reactions, at times explosive in nature, are incomprehensible and may be mistaken for the manifestation of mental illness.”
Neither positive nor negative misdiagnosis is helped by the standard classification systems such as DSM-IV which often unavoidably have to use symptoms based on a mostly hearing population. As illustration, Evans and Elliott (1981) demonstrated how of the fifteen signs and symptoms of schizophrenia they identified from three separate classification systems, six were present in non-psychotic as well as psychotic deaf people. (This paper therefore provides a good working system for identifying schizophrenia in deaf people.) Thus, even without overriding communication difficulties, strict diagnosis, for those who demand it, becomes problematic in and of itself.
Similarly, of course, assessment tools and psychometric tests are more often than not equally bound up in a hearing milieu. F.R. Zieziula (1982) describes four critical questions to be addressed when selecting a test for use with a deaf person:
1. Does the test consist of verbal test items or performance items ? Prelingually deaf people will usually have difficulty with English syntax and vocabulary, indeed, the mean reading level for this population is estimated to be at a third- or fourth-grade level. Performance on verbally loaded test items will therefore be clearly impeded.
2. Do instructions for the test require verbal communication ? Even if the test items are performance-based, the instructions often are strictly verbal. Sometimes, the test developer will allow alternative instruction procedures, which may make translation into sign language a viable option, but even then, the validity of the results must be questioned (see issues of culture, below).
3. Do any test items discriminate against people with an auditory impairment ? Some test items relate to an individual’s ability to hear and function in a hearing world. For example behaviour items in the Vineland Social Maturity Scale include “makes telephone calls” and “talks in short sentences” while the Minnesota Multiphasic Personality Inventory includes statements such as “my hearing is apparently as good as that of most people.”
4. Are hearing impaired people included in the normative sample provided by the test developer ? This can include a separate normative sample of hearing-impaired people, or even whether deaf people are included in the general normative sample. (Which sample is more appropriate is a matter for debate, and would probably depend on the purpose of testing.) When a test does not satisfy this criterion, interpretation of results should be made very cautiously. Indeed, most tests do not - of those that do, Zieziula identifies the WISC-R Adaptation by Ray (Ray 1979), the Stanford Achievement Test (Hearing Impaired Edition), the Geist Picture Interest Inventory: Deaf: Male Form (Geist, 1962), and the Hiskey-Nebraska Test of Learning Aptitude (Hiskey, 1955), to which Orr et al (1987) add the Leiter International Performance Scale (Leiter, 1948).
Issues of Culture:
It is the shared experience of being deaf, described by Cole above, which, partially, determines members of the Deaf community (Higgins 1987), and, while the above criteria relate to the communication issues surrounding deafness, there are also factors of cultural validity to take into account when testing Deaf people. A useful analysis of cross-cultural testing is provided by Flaherty et al (1988) who identify five sorts of validity which should be achieved: The first is Content Validity in which each item of the test is examined to ensure relevance to the culture. The second is Semantic Validity where items in the translated, or otherwise adapted, version of the test continue to mean the same thing after translation (a useful test of this being back-translation where the item is translated back into the original language and examined for equivalence.) Technical Validity is that in which the method of data collection affects the results in different ways, depending on the culture.(Hindley (1993) points out that the interpreter in his research considered a face to face interview to be foreign to deaf children.) Criterion Validity is concerned with whether the test items refer to the same concepts in each culture, and Conceptual Validity considers whether the test items relate to concepts that are not alien to the culture.
While Flaherty et al’s study is concerned with research tools, the issues therein are still as pertinent for the hearing professional working at any level with Deaf people. No attempt has been made here to define Deaf culture, as attempts to define any culture must necessarily be so precise as to be lacking depth, or so general as to be uninformative. Higgins (1987) provides a clearer picture, but for the purposes of service provision, recognition that a client may identify with the Deaf culture should render the professional receptive to whatever that may mean for that client.
Summary:
Deafness has been described above in a number of ways, for example in terms of time of onset, severity and aetiology. The question of whether there is a ‘psychology of deafness’ has been discussed and the various means by which a hearing impairment has been said to influence psychopathology identified - common aetiology, aspects of deafness per se and experiences of deaf people. Many different authors have described this in as many different ways, including the assertion that deafness leads in and of itself to a particular type of person - which seems to be both unfounded and unnecessary. The most practical explanation seems to be one in which deafness can result in different experiences from those of hearing people, and it is this combination of experiences which impacts upon psychopathology. This is not to say that deaf people all share a unique homogenising set of life events, but that there is a set of experiences resulting from being deaf, a subset of which may apply to a particular person. It is also clearly important to consider the cause of the hearing impairment, as this may play a critical role in presenting psychopathology.
Three considerations to observe as a hearing professional when working with a deaf person have been discussed. Communication issues, once identified, may be addressed in a number of different ways, though none of these is without its drawbacks; formal assessment is plagued with pitfalls which cause the assessor to rely almost entirely on qualitative rather than quantitative measures; and Deafness as a culture also has pervasive effects on both formal tools and informal understanding.
To conclude, the question of whether there is a psychology of deafness, of whether prelingual profound deafness affects psychopathology, becomes less meaningful once one acknowledges a culture of deafness. Indeed, when one attempts to delineate a psychology of deafness, recognition of culture becomes unavoidable.
In the absence of comprehensive psychology services, of deaf psychologists, and of appropriately standardised assessment tools, other than by developing as thorough an understanding of deafness as possible the main answer when working with a deaf client must be to be truly client-led.
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Orr F.C., DeMatteo A., Heller B., Lee M. & Nyugen M. (1987) “Psychological Assessment.” in “Mental Health Assessment of Deaf Clients: A Practical Manual.” Elliot H., Glass L., Evans J.W., eds. Little, Brown & Co, Boston.
Rainer J.D., Altshuler K.Z., Kallman F.J., & Deming W.E. (1963) “Family and mental health problems in a deaf population.” New York State Psychiatric Institute, New York.
Raivio M., & Koskiniemi M. (1978) “Hearing disorders after Haemophilus influenza meningitis.” Archives of Otolaryngology 104: 340-344
Ray S. (1979) “An adaptation of the Wechsler Intelligence Scale for Children - Revised for the deaf.” Northwestern State University of Louisiana. Natchitoches, La.
Schlesinger H.S. & Meadow K.P. (1972) “Sound and Sign: Childhood Deafness and Mental Health.” Berkely. University of California Press.
Seidel U.P., Chadwick O., & Rutter M. (1975) “Psychological disorders in crippled children: a comparative study of children with and without brain damage.”Developmental Medicine and Child Neurology 17: 563-573.
Shaffer D., Chadwick O., and Rutter M. (1975) “Psychiatric outcome of localised head injury in children.” In Porter R., and Fitzsimmons D.W., eds “Outcome of severe damage to the central nervous system.” pp191-214. CIBA Foundation Symposium No.34. Elseiver-Excerpta Medica-North-Holland, Amsterdam.
Spitzer R.L. (ed) (1980) “Diagnostic and Statistical Manual of Mental Disorders (3rd edition)” Washington DC, American Psychiatric Assciation.
Stein L., Mindel E., Jabaley T., eds “Deafness and Mental Health.” Grune & Stratton, New York.
Swaans Joha B.C. (1991) “Proceedings of the European Society for Mental Health and Deafness, Second International Congress.”
Thacker A. (1990) “Giving deaf clients more than lip service” Speech Therapy in Practice - SPECIAL SUPPLEMENT .
Timmermans L. (1989) “Research Project for European Society for Mental Health and Deafness.” Proceedings of the European Congress on Mental Health and Deafness, Utrecht: 87-91.
Trapp E.P., & Himelstein P. (1972) “Reading on the exceptional child” pp379-396, (chapter by M. Vernon) Appleton-Century-Crofts. New York.
Trybus R.J. & Jensema C. (1976) “The development, use, and interpretation of the 1973 Stanford Achievement Test, Special Edition for Hearing Impaired Students.” Report of proceedings of the forty-seventh meeting of the convention of American instructors of the deaf.” Government Printing Office. Washington DC.
Vernon M. (1967)a “Meningitis and deafness: The problem, its physical, audiological, psychological, and educational manifestations in deaf children.” The Laryngoscope 10: 1856-1974
Vernon M. (1967)b “Tuberculous meningitis and deafness.” Journal of speech and hearing disorders 32: 177-181
Vernon M. (1969) “Multiply Handicapped Deaf Children: Medical, Educational and Psychological considerations.” Reston, Virginia: Council of Exceptional Children.
Vernon M. (1978) “Deafness and Mental Health: Some theoretical views.”Gallaudet Today, 9: 9-13.
Vernon M., Grieve B.J., & Shaver K. (1980) “Handicapping conditions associated with the congenital rubella syndrome.” American Annals of the Deaf 125: 993- 996
Vernon M. & Andrews J. (1990) “The Psychology of Deafness. Understanding Deaf and Hard of Hearing People.” Longman, NY.
Zieziula F.R., ed (1982) “Assessment of hearing-impaired people. A guide for selecting psychological, educational, and vocational tests.” Gallaudet College Press, Washington DC 20002.
Verbatim translation of a sentence meaning “it has plenty of room” in Shawnee (an American Indian language). Kyle & Woll (1985).
An Interactional Handicap:
A paradox has been pointed out (Vernon and Brown, 1964) that deafness increases the probability of emotional problems by increasing tension and frustration, yet also gives rise to a barrier to communication that rules out the possibility of psychological assessment and treatment. Although many assessment techniques are inappropriate (Vernon & Andrews, 1990) and false-positive as well as false negative diagnoses are common (Monteiro, 1989) it appears probable, given appropriate assessment instruments and techniques, that deaf people show comparable rates of prevalence as hearing people for many psychological complaints such as anxiety disorders, depression, substance misuse, somatoform disorders, paranoid, schizoid, schizotypal, compulsive and histrionic personality disorders, and schizophrenia (Vernon & Andrews, 1990; Schein & Delk, 1974). Thus, Vernon and Brown’s (1964) initial premise is shown to be false and the paradoxical nature of the observation no longer applies - however, as a powerful means of indicating the central difficulty for a hearing therapist without facility in the appropriate sign-language it remains effective - it points towards communication as the main handicap resulting from deafness which influences access to psychology and other services. Following this, Elliott et al (1987) point out that communication is both expressive and receptive and as such the disability of the client (the deafness) gives rise to a handicap experienced by the client, the therapist or both. I would argue that communication is necessarily an interactional process, even in the presence of considerable time-delay between expression and reception, that it is the functional coincidence of expression and reception, and so that the above handicap is necessarily experienced by both parties.
This distinction may be further illustrated by considering an example of a hearing therapist and a hearing client, the difficulty in this example being that the therapist speaks only English and the client speaks only Japanese. The ‘disability’ if we may call it that, is clearly symmetrical - each is unable to communicate in the language of the other. A therapeutic situation involving an English-speaking therapist and a British Sign Language-using client may be compared in many important respects to this example, and enables us to move away from the idea of overcoming a disability to enabling communication between two parties who use different language-systems. Although BSL is the fourth major language of the United Kingdom (after English, Welsh and Gaelic) there are just three mental health services in this country providing their services in BSL, and very few psychologists, or other mental health professionals, who are able to communicate in BSL at any level, yet alone fluently. Also, the in-service components of most training courses for psychologists, psychiatrists, nurses and so on make access to such courses for potential deaf professionals particularly arduous, if impossible. How then may non-BSL-using professionals and BSL-using clients overcome this barrier to communication, and thus to services which are clearly needed ?
Breaking the Sound Barrier
It is sometimes assumed that a deaf person will be able to understand spoken English if the speaker were to speak slowly enough, speak louder and exaggerate lip movements (Roe & Roe, 1991). More enlightened people may stress the importance of speaking naturally, if a little clearer, in order to maximise the success of the lip-reader, and indeed in this situation many deaf people are able to understand spoken English with almost flawless accuracy. However, many other deaf people are not able to comprehend spoken English by this means - perhaps unsurprising in the absence of continued aural exposure to the grammar, syntax, vocabulary and idiom of the language. Jeffers and Barley (1975) have estimated that approximately 60% of English speech sounds are indiscriminable or invisible without the accompanying sound, consisting one half of the vowels and diphthongs and three-fifths of the consonants. Roe and Roe (1991) calculate from this that a fluent English speaker who loses his or her hearing could only be expected to distinguish 40% of spoken communication, although they do not elaborate whether this refers to spoken communication at a phonemic level, a word level, or a noun-phrase or sentence level. Equally, meaning derived from inflection and stresses is inaccessible to the lipreader. It can be assumed therefore that a prelingually profoundly deaf person without continued aural exposure to the language could not be expected to reach this level of understanding of spoken English. The utility of this approach in a therapeutic situation therefore is highly questionable for most clients. For a client unable to express spoken English, the question is also begged of how to confirm understanding, and of how this approach facilitates communication in the direction of client to therapist. Of course it does not.
In the absence of more appropriate means to bridge this gap in communication, some therapists have resorted to written communication, that is, passing written notes between therapist and client. The fact that this cumbersome method is generally inappropriate for psychological assessment and treatment requires no further elaboration, especially when one considers the reduced exposure to the syntax and so on of English alluded to above.
Other ways to bridge the gap include using a friend or member of the family to act as interpreter, or for the therapist with a basic understanding of BSL to attempt pidgin signed-English. The use of a friend or family member introduces issues of confidentiality, and the presence of that person is likely to have a detrimental effect on the process of therapy and the therapeutic relationship, while the attempt to engage in signed communication without a critical degree of fluency and confidence can only serve to frustrate the client as difficult material has to be discussed in terms simple enough for the therapist to understand. The therapist may also be perceived as being less skilled, in exactly the same way as deaf people have been misdiagnosed as learning disabled as a result of difficulties communicating with non-signing professionals. Hindley (1993), in his albeit small sample, found that using a qualified interpreter was preferable to attempting pidgin signed-English oneself. Indeed, apart from fluency in BSL oneself, it would be difficult to argue that any other alternative is preferable to using a qualified interpreter.
Use of an Interpreter:
The use of an interpreter in enabling a deaf person to access mental health services gives rise to a number of issues which should be considered when embarking upon such service provision. Roe and Roe (1991) divide these concerns into three groups: those centred on the client, those centred on the therapist, and those centred on the interpreter:
Client-centred issues:
Although the interpreter is usually seen as a facilitator rather than an encumbrance, it is possible that in psychological therapy, when the material discussed is often of a personal, highly charged nature, the client will begin to perceive the interpreter as an intrusion, albeit a necessary one (Stansfield, 1981). Also registered interpreters in this country are obliged not to “give advice or offer personal opinions in relation to topics discussed or people present...” and to interpret “without anything being added or omitted from the meaning” (C.A.C.D.P., 1996). This may be seen as indifference by a client who is unaware of this professional standard. It can be seen that from this position it would be less likely for the client to commit 100% to the process of therapy and to be more guarded. Ironically, as a result of this the interpreter therefore can to a degree become a hindrance to the therapy (although this process may of course be addressed within the therapy itself.) In this way the perceptions that the client has of the interpreter lead to issues within the sessions which would not otherwise have arisen. It is possible also that the interpreter may be seen as allied to the therapist, although further professional standards rule against this consciously occuring. The optimum seating arrangement when using an interpreter is for the client and therapist to sit opposite each other and for the interpreter to sit next to and slightly behind the therapist such that both therapist and interpreter may remain in the client’s field of vision simultaneously. From this arrangement one may imagine a client feeling somewhat outnumbered. Alternatively, the interpreter may be seen by the client as allied with him or her despite the seating arrangements, as it is the interpreter with whom the client appears to be communicating. It is of course necessary for the client to maintain eye-contact with the interpreter when the therapist is speaking, which may serve to compound this effect.
Already it becomes apparent that the client may develop feelings towards the interpreter which may need to be addressed or considered during the therapy. Whether transferential or not, these feelings are especially likely to develop because the interpreter is professionally obliged to give away no personal information or opinions (Menninger, 1958) and it is possible for the therapist to be implicated in these feelings as well. For example, the client may resent the need for an interpreter in order to access appropriate services otherwise freely available to hearing people. Stansfield (1981) suggests that this resentment may lead to mistrust of the interactions between therapist and interpreter - the client would thus be less likely to feel safe or contained enough to explore emotionally charged material. Trust becomes compromised.
Padden and Humphreys (1988) point out that the deaf community is small and very tightly knit, and that interpreters and the members of that community often know each other very well. The deaf community is also characterised by the speed with which news travels within it. It is possible therefore that the client will know the interpreter already (calling into question the appropriateness of using that particular interpreter), but even if this is not the case the client may reasonably feel uncomfortable about disclosing difficult personal material to somebody who may have regular social contact with other members of the deaf community. The ethical position of confidentiality of the interpreter as well as the therapist, then, should be made clear in the initial session (”Interpreters shall treat as confidential any information which may come to them in the course of their work including the fact of their having undertaken a particular assignment” C.A.C.D.P., 1996).
It can be seen how, despite considerable ruling by the professional body for interpreters (the C.A.C.D.P. - Council for the Advancement of Communication with Deaf People), even the most conscientious interpreter cannot help but become more involved in the therapeutic milieu than the clearly defined role of faithfully translating between the two languages.
Therapist-centred issues:
Millie Stansfield (1987) emphasises this apparent dissolution of professional boundaries when she points out that one of the main vehicles for change is the therapeutic relationship itself. Simply by being present, the interpreter enters into that relationship and impacts heavily upon it, for example at the most basic level of changing a therapeutic dyad into a triad (Hoyt et al, 1981). Thus, any interaction between the therapist and the interpreter becomes a part of the process and dramatically affects the therapeutic relationship(s). The presence of the interpreter may also directly affect the therapist by giving rise to feelings which otherwise would have remained absent. Schlesinger and Meadow (1972) describe the “shock-withdrawal-paralysis” reaction experienced by therapists faced with a deaf client when otherwise established skills and techniques are suddenly unable to be used. Feelings of being deskilled and helpless occur which clearly have an effect on the nature of the relationship. I suggest that this reaction is not alleviated by the presence of an interpreter - indeed that it may be that the therapist fantasises that the interpreter will actually alleviate such feelings but when this is found not to be the case the reaction is only increased. Therapists used to individual therapy and to an environment in which, although they contain both parties, the boundaries and environment are largely controlled by the therapist, will find that the interpreter - with the aim of facilitating optimum communication - will suggest changes to otherwise comfortable and familiar aspects of the process and environment. For example, suggestions may be made regarding the seating arrangements (mentioned above) and the lighting, communication will inevitably be slower than usual as information is translated back and forth - interrupting the usual flow, and ideally the interpreter should take a break after approximately half an hour. The reason for this break is that after this time the error-rate of the interpretation increases to statistical significance (Brasel, 1976), but this can lead to a sense of intrusion felt by the therapist as the hour is broken. All of this may be perceived by the therapist as an ‘expert in deafness’ taking control away and drawing attention to his or her own shortcomings.
Similarly, the therapist’s own degree of understanding of BSL may be a double-edged sword. A therapist with no facility in Sign may wonder, as may the client, about the accuracy with which the interpreter is proceeding. Many English forms take longer than one would expect to portray in BSL, while others are suspiciously short. This and the seemingly constant eye-contact between client and interpreter can serve to isolate the therapist and increase the sense of paralysis. However, a therapist with some understanding of BSL who nonetheless is not fluent enough to competently conduct one-to-one therapy in that language without an interpreter may experience a quite separate difficulty. It is recommended (C.A.C.D.P., 1996) - and indeed polite - to look at the client at all times, even though that person may naturally turn to look at the interpreter. If the therapist is able to understand a proportion of the signed material this can be extremely distracting as attention is drawn away from the spoken interpretation to which attention should be directed. This effect is compounded by the facts that the interpreter should be seated slightly behind the therapist, and so seems a disembodied voice, and that the client will often vocalise variably clear words. It is not easy using an interpreter, and the fantasy of a rescuer from the shock-withdrawal-paralysis is soon shown to be false.
Interpreter-centred issues:
Many of the above concerns may equally be viewed as interpreter-centred, however, there are further issues which may reasonably be aired here. Mention has been made of seeming dissolution of professional boundaries and distortion of the therapeutic relationship. Elliott et al (1987) suggest, indeed assume, that the therapist will meet with the interpreter before meeting with the client to discuss issues such as these - clarifying the role of the interpreter, the expectations of the therapist and developing ways to deal with misunderstandings during the session for example. In particular they recommend such pre-session contact so that a system of covert signals may be set up. On occasion it is necessary for an interpreter to explore a number of translations of a particular concept and it would be up to the therapist to decide whether further exploration of an important concept was merited, or could be moved from. Evans et al suggest a signalling system for this, and during psychometric testing for the description by the interpreter of errors made by the client - and they argue that this leads to increased trust between the therapist and interpreter which serves to reduce a few of the concerns outlined above regarding alliance and isolation. It is recommended (Stansfield, 1987) that the client be informed of these meetings, but not of their content. The effect of this on the client’s perceptions of the role of the interpreter and the trust felt regarding both interpreter and therapist can only be guessed. Roe and Roe’s (1991) comments - that it would be better to address issues of communication and confidentiality, and for the interpreter to step out of role as communication facilitator (if necessary) in front of the client such that otherwise extant mistrust and suspicion may be alleviated - are relevant here. I would further add that it may be more productive, if not healthier, for roles to be collaborative rather than secretive, and to be honestly complex and variable rather than artificially and falsely straightforward. That is, if the interpreter is required to step out of role (for example to comment on non-verbal communication) it is better achieved within the session with an apparent crossing of boundaries, with corresponding increase in trust. I would argue that the boundary around the interpreter’s role is not being crossed in this instance, but being clarified as more complex than could be hoped for. If the interpreter is to be presented to the client as simply facilitator of communication, that person should only be used as such.
In terms of psychometric testing, I feel an argument may be made at least for meeting with the interpreter beforehand - and likely for some time - in order to agree on appropriate translation of material and psychologist response. This should be carried out in some detail and may require an exchange of knowledge in that the interpreter will require a basic understanding of psychometric testing, and the psychologist will need to be somewhat versed in deaf issues, language and culture. The interpreter must understand the standardised administration (although it will inevitably be departed from as part of the stipulation is often that instructions are verbally presented), and the psychologist will need to understand if certain items are unhelpful by virtue of being culturally irrelevant, or because the very act of asking the question in BSL gives the answer away. For example the question “how are a ball and a wheel alike?” could not be used as the Signed administration would trace circular figures in the air, divulging the answer (Stansfield, 1981).
The cultural validity of standardised tests, or structured interviews, highlights another way in which the interpreter works apparently outside of straightforward linguistic translation. A good interpreter will communicate not just the spoken words of the therapist, but also the non-verbal and affective content as well. Many concepts do not translate smoothly from one culture to another, and the question is raised therefore of the degree to which the interpreter re-frames the spoken communication to fit most appropriately into the other culture. Gaviria et al (1984) - in a Peruvian study - outline four ways in which culture impacts on the validity of an instrument or technique standardised on a different cultural group and their observations and categorisations are relevant to Deaf and hearing cultures: Semantic validity demands that words in the original and translated versions carry the same meaning; technical validity requires that the very substance of the translated instrument carry the same meaning and familiarity, and yield similar expectations, as the original - the interpreter in Hindley’s (1993) study considered for example a face-to-face interview to be foreign to deaf children; criterion validity requires that items, questions or comments refer to similar normative concepts between the two cultures, and conceptual validity demands more directly that questions asked actually relate to concepts within that culture. If we (reasonably) assume a knowledge of, and familiarity with, Deaf culture from the interpreter, it is clear that all of these concerns are areas in which that person may be of help.
As alluded to above, it is equally desirable for the interpreter to be versed in mental health issues, the process of therapy and so on. Monteiro (1989) sees this as a requirement in that so much of therapy occurs outwith the spoken utterance, the interpreter needs to be aware not only of where the translation from therapist to client is going (ie translating culturally as well as literally) but also of where the translation is coming from - the therapeutic rationale behind the utterance. An interpreter I have worked with, for example, suggested ways in which she may interpret therapeutic silence. Monteiro suggests that an interpreter without such an understanding may even act to the detriment of the therapy.
Such a background is clearly advisable, but, although not arguments against this practice, certain considerations should be borne in mind. To refer back to comments made above, an interpreter with a grounding in mental health issues may be perceived by the therapist as even more threatening and intrusive. Also, an interpreter with such an understanding may find it quite difficult to work with a therapist who acts in a way which conflicts with the way in which the interpreter would act in the other role; and therapeutic approaches or techniques may be perceived erroneously by the interpreter and worked into the translation, conflicting with the approach then actually taken by the therapist.
Summary:
A number of issues have been highlighted above, concerning potential reactions to the therapeutic triad of the client, the therapist and the interpreter. Certain of these issues can only be addressed with opinion, either from the literature or myself, while others remain simply highlighted. However, the aim here is not to provide answers to these concerns (since there are probably none which are irrefutable) - rather it is to provide a compendium of concerns which challenge the fantasy that using an interpreter will overcome all of the issues raised when a non-BSL-using therapist and a BSL-using deaf person work together in therapy. Some of these concerns are conspicuous in their absence in the verbatim translation of a Shawnee phrase at the head of this text.
Overall, however, it should be noted that apart from the therapist being fluent in BSL, the preferred means of conducting therapy with a signing deaf person is through an interpreter versed in issues of mental health.
References
Brasel B.B. (1976) “The effects of fatigue on the competence of interpreters for the deaf.” In H.J. Murphy “Selected readings in the integration of deaf students at C.S.U.N.” Centre on Deafness series (No.1). Northridge: California State University.
Council for the Advancement of Communication with Deaf People “C.A.C.D.P. Directory 1996/1997” C.A.C.D.P., Durham.
Elliot H., Glass L. & Evans J.W., eds (1987) “Mental Health Assessment of Deaf Clients: A Practical Manual.” Little, Brown & Co, Boston.
Gaviria M., Pathak D., Flaherty J., Garcia-Pacheco C., Martinez H., Wintrob R. & Mitchell T. (1984) “Designing and adapting instruments for a cross-cultural study on immigration and mental health in Peru.” Paper presented at the American Psychiatric Association Meeting. In Hindley P. (1993) “Signs of Feeling. A prevalence study of psychiatric disorder in deaf and partially hearing children and adolescents.” RNID, London.
Harvey M.A. (1982) “The Influence and Utilization of an Interpreter for Deaf Persons in Family Therapy.” American Annals of the Deaf 7, 821-826.
Hindley P. (1993) “Signs of Feeling. A prevalence study of psychiatric disorder in deaf and partially hearing children and adolescents.” RNID, London.
Hoyt M.F., Siegelman E.Y. & Schlesinger H.S. (1981) “Special Issues Regarding Psychotherapy with the Deaf.” Am J Psychiatry 136:6.
Jeffers J. & Barley M. (1975) “Speechreading (lipreading).” Charles C. Thomas. Springfield, Illinois. In Roe D.L. & Roe C.E. (1991) “The Third Party: Using Interpreters for the Deaf in Counseling Situations.” Journal of Mental Health Counselling 13(1) 91-105.
Kyle J.G. and Woll B. (1985) “Sign Language. The study of deaf people and their language.” Cambridge University Press. Cambridge.
Menninger K. (1958) “The theory of psychoanalytic technique.” Harper and Row, New York.
Monteiro B.T. (1989) “Pitfalls in Diagnosis” Unpublished. Supra-regional Department of Psychiatry for the Deaf, Whittingham Hospital, Preston, Lancs.
Padden C. & Humphreys T. (1988) “Deaf in America: Voices from a culture.” Harvard University Press. Cambridge, MA.
Roe D.L. & Roe C.E. (1991) “The Third Party: Using Interpreters for the Deaf in Counseling Situations.” Journal of Mental Health Counselling 13(1) 91-105.
Schein J. & Delk M. (1974) “The deaf population of the United States.” National Association for the Deaf. Silver Springs, Md.
Schlesinger H.S. & Meadow K.P. (1972) “Sound and Sign: Childhood Deafness and Mental Health.” Berkely. University of California Press.
Stansfield M. (1981) “Psychological Issues in Mental Health INterpreting.” RID Interpreting Journal, 1 18-31. In Roe D.L. & Roe C.E. (1991) “The Third Party: Using Interpreters for the Deaf in Counseling Situations.” Journal of Mental Health Counselling 13(1) 91-105.
Stansfield M. (1987) “Therapist and Interpreter: A working relationship.” Paper presented at the Mental Health and Interpreting Conference, Annapolis, MD. In Roe D.L. & Roe C.E. (1991) “The Third Party: Using Interpreters for the Deaf in Counseling Situations.” Journal of Mental Health Counselling 13(1) 91-105.
Vernon M. & Andrews J. (1990) “The Psychology of Deafness. Understanding Deaf and Hard of Hearing People.” Longman, NY.
Vernon M. & Brown D.W. (1964) “A guide to psychological tests and testing procedures in the evaluation of deaf and hard-of-hearing children.” Journal of Speech and Hearing Disorders, 29, 414-423.
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2017
- Oct 6, 2017 Redundancy Oct 6, 2017
- Oct 4, 2017 I am leaving the academy Oct 4, 2017
- Jun 14, 2017 Language Therapy Reporting Jun 14, 2017
- Mar 9, 2017 The Ugly Duckling Mar 9, 2017
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2016
- May 27, 2016 A Guide To Working With The Deaf Community In The UK May 27, 2016
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2015
- Sep 17, 2015 SSE and Franglais Sep 17, 2015
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2014
- Dec 15, 2014 How to Develop Language Dec 15, 2014
- Sep 11, 2014 A very quick bit on autism and deafness Sep 11, 2014
- Jul 7, 2014 On opportunities to socialise Jul 7, 2014
- Jun 25, 2014 On Priority Jun 25, 2014
- Jun 5, 2014 Deaf voices and speech perception Jun 5, 2014
- Jan 23, 2014 About the author... Jan 23, 2014
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2013
- Dec 4, 2013 Dr Jim's Little Red Book Dec 4, 2013
- Apr 18, 2013 Cochlear Implants and Deaf Children of Deaf Parents Apr 18, 2013
- Mar 29, 2013 In Favour of a Specialist Deaf Neurology Centre Mar 29, 2013
- Jan 22, 2013 Incidence and Prevalence of Mental Health Problems in Deaf People Jan 22, 2013
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2012
- Nov 29, 2012 Deaf Awareness Exercise Nov 29, 2012
- Oct 9, 2012 The Mask Of Benevolence Oct 9, 2012
- Oct 4, 2012 In advance of the rebuild Oct 4, 2012
- Sep 13, 2012 A Natural Language Sep 13, 2012
- Mar 14, 2012 Oral / BSL ... Medical / Cultural II Mar 14, 2012
- Mar 14, 2012 Oral / BSL ... Medical / Cultural Mar 14, 2012
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2011
- Jul 13, 2011 I-Sign and David Cameron Jul 13, 2011
- Jun 8, 2011 Sign Supported English Jun 8, 2011
- Jun 6, 2011 How Long Have You Been Signing? Jun 6, 2011
- May 17, 2011 Cued Speech May 17, 2011
- Apr 12, 2011 Regarding Deaf Executive Staff Apr 12, 2011
- Jan 20, 2011 Interpreters as fish Jan 20, 2011
- Jan 13, 2011 Comunication Policy for the Deaf Workplace Jan 13, 2011
- Jan 12, 2011 Mainstreaming Jan 12, 2011
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2010
- Dec 21, 2010 Deaf People Can Do Anything Dec 21, 2010
- Oct 17, 2010 Pure Tone Audiometry Oct 17, 2010
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2009
- Mar 23, 2009 Autistic Spectrum Disorder Mar 23, 2009
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2007
- Sep 20, 2007 Contact details for specialist mental health services for Deaf people Sep 20, 2007
- Jun 6, 2007 Exploring the perceptual characteristics of voice-hallucinations in deaf people Jun 6, 2007
- May 31, 2007 Thoughts on Intellectual Assessment May 31, 2007
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2006
- Sep 27, 2006 Do Profoundly Prelingually Deaf Psychotic Patients Really Hear Voices? Sep 27, 2006
- Jul 13, 2006 Communication and Approximation Jul 13, 2006
- May 16, 2006 Relaxation Therapy with Interpreters May 16, 2006
- May 5, 2006 The Perceptual Characteristics of Voice-Hallucinations in Deaf People May 5, 2006
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2005
- Nov 24, 2005 Deafness and The Art of Psychometric Testing Nov 24, 2005
- Nov 7, 2005 Rivermead Behavioural Memory Test Nov 7, 2005
- Aug 21, 2005 Mini Mental Status Examination Aug 21, 2005
- Jul 29, 2005 Training Deaf Psychologists Jul 29, 2005
- Feb 8, 2005 Sleep Management Feb 8, 2005
- Jan 28, 2005 Online Publications Jan 28, 2005
- Jan 12, 2005 Time Management Jan 12, 2005
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2004
- Oct 11, 2004 What is Mental Health? Oct 11, 2004
- Sep 1, 2004 Provocation Sep 1, 2004
- Aug 31, 2004 Run With Your Client, Not After Aug 31, 2004
- Aug 31, 2004 Hearing Staff in Deaf Services Aug 31, 2004
- Aug 31, 2004 Interpreters, Psychosis, and Voices Aug 31, 2004
- Aug 31, 2004 Mental Health Act Language Aug 31, 2004
- Aug 27, 2004 What are the effects of using interpreters in therapy with British Sign Language users ? Aug 27, 2004
- Aug 27, 2004 Psychometric Assessment of Deaf People Aug 27, 2004
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1997
- Aug 1, 1997 Prelingual Profound Deafness and Psychology Aug 1, 1997
- Aug 1, 1997 What are the effects of using interpreters in therapy with British Sign Language users? Aug 1, 1997
- Jan 1, 1997 Index Jan 1, 1997