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.
This is taken from my chapter in "Deafness in Mind: Working Psychologically with Deaf People Across the Lifespan" Edited by Sally Austen, Susan Crocker. Available here.
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.
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
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.
1.0 Introduction
“You cannot know what you are entering into.”
Counselling Psychology Training Course Director
“What are we entering into?!”
Clinical Psychology Training Course Director
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.
Deaf trainee
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.
The centipede was happy, quite,
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.
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.
Mrs Edmund Craster (1847)
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.
Deaf trainee
The trainee will often also feel that she is the last to know everything and this may have make her feel on the fringes of the group at best.
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.”
Deaf trainee
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.
Many sleep problems are simply that people
- 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.
Links to the few online things with my name on.
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.
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.