Chapter 4

Deaf Mental Health: Enhancing

Linguistically and Culturally Appropriate
Clinical Practice

Tracey A. Bone

The word “culture” is defined as “a way of life and learned ways of acting, feeling and
thinking based on a group who share common language, beliefs, values, traditions,
social norms, and identity in a society” (Canadian Hearing Society, 2013). Deaf cul-
ture shares all of these sociological criteria including shared language, values, tradi-
tions, social norms, and identity. It is a unique, but defined, culture (Deaf Culture
Center, 2013; Ladd, 2003). Respect for and use of a signed language is the central
defining feature binding and identifying members of Deaf culture. Spoken languages
use words which are produced using the mouth and voice to make sounds and convey
thoughts, ask questions, and express ideas (NIDCD, 2017b). Signed languages are
manual languages that incorporate hand orientation, movement, and positioning
(some signs require one hand, others two hands), as well as facial expression, body
postures, and movement (Perlmutter, n.d.) to communicate thoughts, ask questions,
and express ideas. Signed languages, like spoken languages, have their own structure,
syntax, vocabulary, and grammar. As with spoken languages, there is no single or
universal sign language, rather many countries have their own sign languages and
dialects. Unlike some spoken languages, sign languages have no written equivalent.
Cultures are also broadly defined as individualist or collectivist cultures. These
differ by their view on issues such as identity, loyalty, sense of obligation, and inde-
pendence (Queensland Health, 2008). In individualist communities, such as in dom-
inant hearing communities, independence, self-reliance, personal choices and
opinions, and an “individual-first” attitude prevail. Deaf culture, on the other hand,
is a collectivist culture. In collectivist cultures, members place the needs of the
group first and value group decision making. Community members assist and sup-
port each other, pool resources, have clear insider/outsider boundaries, and share a
loyalty and obligation to their group (Queensland Health, 2008, p. 20). Collectivist

T. A. Bone (*)
Faculty of Social Work, University of Manitoba, Winnipeg, MB, Canada
e-mail: [email protected]

© Springer Nature Switzerland AG 2019 61

M. Zangeneh, A. Al-Krenawi (eds.), Culture, Diversity and Mental Health - Enhancing
Clinical Practice, Advances in Mental Health and Addiction,
https://doi.org/10.1007/978-3-030-26437-6_4
62 T. A. Bone

communities, including the Deaf community, also have their own political and
religious groups, sporting and social clubs, festivals, and other events.
Hamerdinger, Schafer, and Haupt (2016) define members of the Deaf commu-
nity as heterogeneous, with variation in cognitive, social, and emotional develop-
ment, as well as communication preferences. Unlike other minority communities,
whether minority by language or culture, members of the Deaf community are not
bound by invisible geographical lines or fences, and do not necessarily concentrate
in any particular area of a city or province. Deaf people may gravitate to areas where
other Deaf people are, but particularly with the dissolution of common meeting
places like Deaf clubs, and increasing access through technology, there is no formal
“Deaf” geographical area. Given the cohesiveness of the community, members are
more likely to know if another member has a mental health problem. Mental health
stigma is high in the Deaf community because lack of exposure to mental health
information results in limited mental health literacy. Because of the small size of the
Deaf community, exclusion or ostracism from the group is viewed as the “worst
punishment” (Queensland Health, 2008, p.  21). To avoid mental health stigma,
many members hide their mental health problems (Bone, 2018).
Deaf culture is also a high context culture, with members of the Deaf culture
sharing the same cultural experiences (Queensland Health, 2008, p. 23). While one
might assume that being part of a collectivist, high context community might offer
protection between members, Bone (2013) found that members diagnosed with
mental illness were often shunned, as they were deemed to reflect badly on the
entire community.

The Deaf Experience in Mental Health

Members of the Deaf community and culture experience health inequities differ-
ently from other minority communities (Beate, Mette Perly, Von Telzchner, &
Falkum, 2015; Black & Glickman, 2006; Tate, 2008). Research indicates that Deaf
people find it more difficult to establish relationships with health and allied profes-
sionals, and to access mental health services because of audism, lack of understand-
ing of Deaf culture and language, and practical obstacles that prevent equal access
to the health system, including mental health.
The following case example depicts many of the challenges and barriers faced by
Deaf people in accessing mental health services.

 ase Example: Barry’s Story—“My Garbage Can Is Full”

C
(Bone, 2013)

Barry (not his real name) was born hearing to a two-parent family in the early
1960s. All members of his immediate and extended family were hearing. Barry’s
infancy and early childhood were uneventful, as he achieved all milestones for
4  Deaf Mental Health: Enhancing Linguistically and Culturally Appropriate Clinical… 63

normal physical development, including speech and language development

(NIDCD, 2017a, p. 3). He entered pre-school, developed appropriate relationships
with his classmates, and continued to achieve all expected speech and language
milestones.
When Barry was 5 years of age, he contracted meningitis which resulted in mod-
erate sensorineural hearing loss (SNHL). As Barry’s family had no prior experience
or knowledge of deafness, they were ill equipped to deal with the unique challenges
of Barry’s deafness.
Barry was fitted with hearing aids and his family sought to maintain Barry’s
hearing identity: as did Barry himself. The family continued to communicate orally
with Barry, and he continued to attend the dominant school system. Barry did not fit
in. His hearing aids provided some amplification, though not enough to understand
class lessons, or understand his friends, and this difference led to bullying. Though
he often missed parts of conversations, his heard it when his classmates called him
“retarded,” because that they said loudly. He started to fall behind in school.
At family dinners, Barry struggled to understand conversations. He asked what
his family was being talked about, but was told “we’ll tell you later.” Later never
came. He continued to grow as isolated in his own family as he was in school
because of a lack of shared communication.
Barry became increasingly angry with his isolation and began to fight with his
classmates. When Barry was 14, the school principal suggested Barry move to a
school for the deaf. Barry’s grades had continued to decline each year because of
communication challenges. He had also started to experiment with alcohol to man-
age his isolation, and skipped classes to avoid the near-daily communication con-
flicts. One day he arrived at school intoxicated, which bolstered his confidence but
not his hearing. He misinterpreted the verbal comments from a school representa-
tive. Embarrassed, Barry stormed out of the classroom. He was frustrated, but had
no one to talk to about any of it.
Barry was moved to the local School for the Deaf. As he had had no prior expo-
sure to American Sign Language, however, his transition was difficult. Though in a
School for the Deaf, he was again isolated from both his peers and teachers because
of a lack of common language.
At home, his family resisted his new “deaf” identity. His parents refused to learn
sign language because they were embarrassed by what they viewed as “hand flap-
ping.” They discouraged his use of sign language in public as they felt it drew atten-
tion to him. His parents’ reaction to his deafness made him self-conscious about
who he was. His drinking escalated, as did his violence with others.
Barry fell into a state of depression when a long-term relationship deteriorated.
He finally visited a walk-in clinic, but had difficulty making himself understood by
the receptionist and physician because of a lack of common language. The physi-
cian examined him via spoken and written English, even though Barry had requested
an interpreter. The doctor diagnosed Barry and gave him a prescription. As there
was no shared method of communication, Barry understood neither the diagnosis
nor medication regime. He stopped the prescription 2 days later as he was confused
by the side effects of the medication he was experiencing.
64 T. A. Bone

Misunderstood and untreated, Barry continued to feel isolated, angry, and

confused until he saw a new physician who invited a sign language interpreter into
the appointment. For the first time, Barry was able to participate fully in an assess-
ment for his symptoms. He was finally able to tell someone about his isolation, his
experiences with bullying, his failures in employment, and his use of alcohol to
manage all that he was coping with. He told the doctor that he felt like all the “crap”
he had experienced would “fill a garbage can, maybe two”; but up until then, with-
out a common language to discuss his feelings with a professional, he had “no way
to empty the garbage cans”.
Though the case of Barry is fictitious, his experiences noted above are commonly
reported by members of the Deaf community when seeking mental health services
by professionals not familiar with Deaf culture or, in the case of North America,
American Sign Language (ASL).

Understanding Hearing Loss and Its Impacts

According to the World Health Organization (WHO), approximately 5% of the

world’s population have disabling hearing loss, which equates to some 466 million
people (432 million adults and 34 million children) worldwide (2018, p. 1). Onset
of deafness that occurs prior to language, otherwise known as pre-lingual deafness,
occurs in approximately 7/10,000 people (Fellinger, Holzinger, & Pollard, 2012).
Normal hearing is defined as a hearing threshold of 25 decibels (dB) or better in
both ears. A person not able to hear at this threshold is said to have hearing loss.
Hearing loss can range from mild to severe. Queensland Health, Australia (2008),
created a Deafness Continuum (see Fig. 4.1). Along this continuum, those with no

Fig. 4.1  Deafness Continuum Queensland Health, (2008) Guidelines for Working with People
who are Deaf or Hard of Hearing. Part 1: Deafness and mental Health, p. 8. Used with
permission
4  Deaf Mental Health: Enhancing Linguistically and Culturally Appropriate Clinical… 65

hearing loss use a spoken method of communication and maintain a “hearing”

identity. Those with some hearing loss that impacts oral communication may main-
tain an identity as a “hearing person with a hearing loss.” They often view their
hearing loss as a disability. Persons in this group may use an assistive device such
as a hearing aid if there is loss in one ear, or hearing aids if they experience bilateral
hearing loss, or even a cochlear implant to enhance their hearing in an attempt to
facilitate spoken communication. These individuals usually maintain their identity
in hearing culture and values. Some individuals experience hearing loss post-lin-
gually (i.e., after having gained the ability to communicate in spoken language);
they are referred to as “late-deafened.” Some within this group maintain a hearing
identity, while others may participate in varying degrees within the Deaf commu-
nity, including gaining fluency in signed language.
Disabling hearing loss generally refers to hearing loss greater than 40 dB in the
better hearing ear in adults, and hearing loss greater than 30 dB in the better hearing
ear in children (WHO, 2018). Deaf and hard of hearing children often have addi-
tional disabilities. In the USA, a 1999 study (Van Naarden, Decoufle, & Caldwell)
reported additional conditions such as learning disabilities (9%), developmental
delay (5%), specific learning disabilities (8%), visual impairment (4%), and autism
(2%) (as cited in Fellinger et al., 2012). It is further reported that the absence of
early auditory stimulation and delay in acquiring language appear to affect various
neurocognitive processing domains, such as “auditory and visual working memory,
attention and inhibition” (Pisoni, Conway, Kronenberger Horn, Karpicke, &
Henning, 2007). These factors can contribute to higher experiences of mental health
problems.

 odels of Deafness: Medical Model (Deaf) Versus 

M
Socio-­Cultural Model (Deaf)

There are two primary views of deafness. The medical model views hearing loss as
a “sensory deficit,” and thereby a pathological condition or disability that requires
remediation (Queensland Health, 2008, p. 8). This group of people may be defined
as hard of hearing, or (lower case d) deaf. Some use spoken language and speech
reading, often incorrectly referred to as lipreading, in combination with a hearing
aid, communication device, or a cochlear implant to communicate. These individu-
als often maintain a hearing identity, and view their deafness as a disability. They do
not identify with the Deaf community (Canadian Association of the Deaf,
Terminology, 2015a). The medical model privileges competency in a spoken lan-
guage as the desired means through which to achieve cognitive development and
competency in communication (Munoz-Baell & Ruiz, 2000). In the medical model,
deafness is viewed as a source of stigma.
66 T. A. Bone

The socio-cultural model defines deafness or degree of hearing loss not as a

disability or handicap but rather as only one factor of human uniqueness and diver-
sity (Queensland Health, 2008). The degree of audiological hearing loss is less
important, with individuals viewing their loss as a cultural rather than medical term.
In the socio-cultural model, hearing loss is viewed as a cultural factor that identifies
individuals as members of a distinct culture and value system organized around a
signed language. These individuals identify their deafness as part of a “cultural-
linguistic experience” (Queensland Health, 2008, p. 9) that is a source of pride and
cultural identity. Individuals who identify as members of this distinct culture and
community are characteristically identified through the use of the word “Deaf”
(uppercase D). The World Federation of the Deaf defines Deaf identity as “belong-
ing to a cultural and linguistic community who uses sign language as a mother
tongue or natural language to communicate” (Campaign Key Messages—Deaf
Identity, 2016).
The exact number of Deaf Sign Language users in Canada is unknown. One
reason is there has never been a consistent definition of the word “deaf” or Deaf
used in nationwide census studies (CAD, 2015a). The Canadian Association of the
Deaf attribute some of the confusion to the wording of the questions used in national
censuses. The wording may not be consistently understood by members of the Deaf
community, resulting in inconsistent responses to the census questions. While the
exact number of culturally Deaf people in Canada is unknown, the CAD estimates
that there are approximately 3.57 million people with hearing loss and 357,000
culturally Deaf people in Canada (CAD, 2015b).

 ental Health and the Deaf Community: Contributing

M
Factors

Research indicates that approximately 90% of deaf children are born to hearing
parents (Mitchell & Karmer, 2004), parents who often have had no prior exposure
to deaf people, deaf culture, or a signed language. Hearing loss does not in itself
predispose deaf children to mental health problems. The language and communica-
tion environment of the family, however, is a significant factor affecting the psycho-
social well-being of deaf children. Those deaf children who lack effective two-way
communication within the family are “four times” more likely to be affected by
mental disorders, and are more likely to be victims of school maltreatment than
those living in families with effective communication (Fellinger, Holzinger, Sattel,
Laucht, & Goldberg, 2009). Further, Fellinger et al. (2009) found that lack of a com-
mon language within the family contributes to a lifetime diagnosis of any psychiat-
ric disorder, as well as an increased risk of depression in those who had been “teased,
maltreated by classmates and isolated” (p. 635). As one’s ability to communicate
4  Deaf Mental Health: Enhancing Linguistically and Culturally Appropriate Clinical… 67

with family and peers is critical to self-awareness, self-esteem, and identity, early-­
age challenges with communication must be considered when studying the mental
health concerns of Deaf people. Studies (Fellinger et al., 2009) suggest strong links
between a lack of effective two-way communication as children with poor social
engagement, behavioral challenges, and mental health.
Hill and Nelson (2000) found that linguistic isolation and “daily systemic dis-
crimination” (Executive Summary, p. i) can occur if the deaf child lacks fluency in
the dominant spoken language, and the child’s family, friends, and/or community
are unable to communicate in that deaf child’s visual language. Austen (2006) added
that the ongoing challenges of living among a larger society with a language one
will never gain full fluency in significantly contribute to the ongoing emotional and
personal challenges for the deaf child. These all escalate the child’s risk for mental
illness. The literature also suggests that these issues increase the deaf child’s risk for
childhood physical and sexual abuse, which contributes to a higher incidence of
severe stress and trauma in deaf children (Fellinger et al., 2009). As a result, lan-
guage and communication approaches used in the home as well as the school envi-
ronment must be taken into consideration when examining mental health problems
in Deaf communities.
Barnett, McKee, Smith, and Pearson (2011) found low health literacy of Deaf
people resulting from language barriers that limit access to common health informa-
tion otherwise accessible to the dominant hearing community; communication bar-
riers which interrupt the patient–physician relationship; and, for some, the existence
of a comorbid health issue contributes to health access inequities. Inadequate access
to mental health promotion and prevention information (Cabral, Muhr, & Savageau,
2013; McKee, Barnett, Block, & Pearson, 2011), misdiagnosis due to inadequate
communication with hearing professionals (Bone, 2013; Iezzoni, O’Day, Killeen, &
Harker, 2004), and a mental health delivery system that is culturally insensitive and
poorly prepared to serve this population also contribute.
As reported in a US study, communication challenges within health-related set-
tings result in “fear, mistrust and frustration in health care encounters” (Kuenburg,
Fellinger, & Fellinger, 2016). These often lead to misunderstanding in the assess-
ment or diagnostic phase, as well as the therapeutic phase (Kuenburg et al., 2016).
Misdiagnosis can also occur if a hearing professional applies intelligence tests, per-
sonality tests, neuropsychological or other psychological screening tools developed
and validated based on verbal communication skills, without appreciating that many
Deaf adults often have a reading comprehension of grade 4–5 (Lowrie & Kerridge,
2015). Many Deaf people whose first or preferred language is a signed language are
“medically underserved” (Barnett et  al., 2011, p.  2235). Agency participants in
Mathos, Lokar, and Post’s (2011) study agreed that their lack of mental health per-
sonnel familiar with Deaf language and culture was the most significant challenge
to providing quality mental health services to this population.
68 T. A. Bone

 ridging the Communication Divide: Sign Language

B
Interpreters

The Canadian Association of the Deaf reports that the inclusion of sign language
interpreters is the most efficient way to bridge the communication divide between
non-signing health professionals and members of the Deaf community (CAD,
2015c). Signed languages are visual-gestural languages that are used as the primary
or preferred language of many Deaf people in the USA, Canada, and around the
world (Gallaudet University, 2018). These are manual languages that use specific
hand shapes and movements, though also engage the eyes, eyebrows, facial expres-
sions, and body posture to convey meaning (NIDCD, 2017a).
Signed languages are not universal, with over 250 distinct sign languages, dia-
lects, or other sign systems identified around the world (Gallaudet University, 2018).
Each signed language has its own structure, syntax, vocabulary, and grammar, dis-
tinct from spoken languages (Perlmutter, n.d.).
Canada has two official languages, English and French. Of those reporting a
“non-official language spoken at home” in the most recent Canadian census (2016),
9080 people identified sign language as their single, non-Aboriginal “Language
spoken at home”; and 18,430 reported sign language as one of the languages “spo-
ken at home” (Statistics Canada, 2016). There are also regional dialects such as
Maritimes Sign Language (MSL). The United Nations Convention on the Rights of
Persons with Disabilities (2006) formally recognizes sign languages and confirmed
these languages’ rights, protections, and equal status to spoken/written languages in
the signatory countries, which include Canada.
The CAD views artificially developed systems as a form of cultural oppression
and discourages their use by non-deaf people (CAD, 2015d). These “artificially
invented” systems of manual communication are designed around the grammar and
sentence structure of spoken language rather than signed languages naturally devel-
oped by Deaf people themselves. They are viewed as pseudo “sign languages” by
the Deaf community. Examples of these are Sign Exact English, Cued Speech, and
Signed English (CAD, 2015d).
There are a number of behavioral factors commonly associated with signed lan-
guage. Eye contact is a fundamental feature of signed languages (Metro South,
2016). Initiating and maintaining eye contact indicates continued attention with the
person speaking. A lack of eye contact or breaking eye contact is significant, as it
suggests a lack of interest in the speaker. In Deaf culture, tactile and visual methods
of gaining a person’s attention such as touching someone on the shoulder or arm,
waving hands, stomping on the floor, banging on surfaces such as a table, and/or
flicking lights on and off (Metro South, 2016, p. 7) are common behavioral strate-
gies to get a Deaf person’s attention. These are not signs of aggression or rudeness,
but rather behaviors and customs of those who depend on their vision for communi-
cation both with hearing and non-hearing people.
4  Deaf Mental Health: Enhancing Linguistically and Culturally Appropriate Clinical… 69

Challenges in Mental Health Care Access for Deaf People

It is difficult to assess the actual depth of the issue in the Deaf population. Glickman
and Pollard (2013, p. 360) reported that study within the area of Deaf mental health
(DMH) is some 40 years behind that based on the general population. One of the
reasons for this is because deafness was historically pathologized and the focus was
on strategies to eliminate deafness. It wasn’t until the 1960s, when Stokoe, a lin-
guistic professor, recognized that American Sign Language is a formal language,
that attention to and within the Deaf community shifted. Notwithstanding this
acknowledgement that sign language is a formal language, few professionals have
had exposure to this language or Deaf culture, creating challenges in establishing
effective two-way communication between hearing health professionals and Deaf
service users.
Discrimination and practical obstacles related to lack of understanding of Deaf
language and culture creates unique barriers for Deaf people to access services,
which then leads to clinical ramifications for this population (Cabral et al., 2013;
Cornes & Napier, 2005; Fellinger et  al., 2012; Mathos et  al., 2011; McDonnall,
Crudden, LeJeune, & Stevenson, 2017).
Research suggests there is a high prevalence of mental health problems in the
minority Deaf community (Barnett, McKee, et al., 2011; Critchfield, 2002; Kvam,
Loeb, & Tambs, 2007; Vernon & Leigh, 2007). Queensland Health, Australia
(2008), suggested that, at a minimum, the incidence of mental illness in the Deaf
community is approximately similar to that in the hearing population. Austen (2006)
suggested a higher prevalence of serious mental disturbances in Deaf adults and
children when compared to the hearing populous, and Hill and Nelson (2000) sug-
gested that the prevalence of mental illness might be as much as four times higher
in the Deaf population than in the hearing population.
As the literature reports, few clinical staff have worked with a Deaf person, and
so may not fully understand the barriers Deaf people experience in accessing mental
health care (Landsberger & Diaz, 2010; Mathos et  al., 2011; McDonnall et  al.,
2017; Woodcock & Pole, 2007).
The challenges experienced by Deaf people accessing a mental health assess-
ment, intervention, or follow-up may include the following:
• Difficulties booking an appointment because of over reliance on telephone
bookings
• Patients’ difficulties explaining their health problem to a clinician or allied men-
tal health professional in the absence of a shared language
• Professionals’ assumption that Deaf people are literate in written English, and
use of written English to conduct an assessment and communicate diagnosis,
medication dosage, medication side effects, a treatment plan, and/or follow-up
• The use of mental health assessment tools not validated for Deaf Sign Language
users and applied through the Deaf person’s second language of written or spo-
ken English
• Difficulties booking interpreters due to a lack of interpreter availability
70 T. A. Bone

• Lack of accessible information—most mental health prevention or promotion

materials are presented in a written format, rendering much of the content inac-
cessible to Deaf consumers
• Too few crisis hotlines that are ASL based
• Stigma of mental illness in the Deaf community, preventing people from seeking
assessment and services
• Reluctance of some mental health intervention or support services to provide
ASL interpreters due to cost
• While having an interpreter in the room may facilitate communication, the pres-
ence of a third party in the room may inhibit the discussion of private health
issues by the Deaf person.

 trategies for Facilitating Effective Two-Way Access

S
to Communication

McKee et al. (2011) found that concordant patient–provider communication resulted

in higher use of appropriate preventative medical services by the Deaf ASL users in
their study (see Barnett, 2002). Active participation of mental health consumers in
the treatment planning process is consistent with the recovery philosophy (Smith,
2000; Walsh, 2013).
The Canadian Association of the Deaf (CAD) reports that the most effective way
to ensure accurate two-way communication between a non-deaf person and a Deaf
person is through a qualified or certified ASL English interpreter (2015c). To
enhance the effectiveness of the interpretation, it is recommended that any written
materials to be used in the meeting, including an overall agenda, be shared with the
interpreter in advance of the meeting, so the interpreter can familiarize themselves
with the concepts to be discussed. The seating layout is also important, with the
interpreter seated alongside the speaker (see Fig. 4.2—seating arrangement). This
allows the Deaf person to easily visually move between watching the speaker and

Fig. 4.2 Seating Deaf service user

arrangements including
ASL interpreter

Clinician/allied Interpreter
professional
4  Deaf Mental Health: Enhancing Linguistically and Culturally Appropriate Clinical… 71

the signing interpreter. This also allows the speaker to maintain eye contact with the
Deaf person, thereby enhancing the therapeutic relationship. In the case of a larger
group, a round table should be used to ensure that all attendees remain in the field
of vision of the Deaf person (Michigan works, 2011).
Sign language interpreters must have specialized training in how language in
general can be impaired by mental health symptoms such as psychosis, and the
types of questions commonly asked in mental health diagnostic interviews. They
should also receive education specific to the norms and dynamics of different men-
tal health service settings, such as emergency rooms, psychiatric centers, inpatient-
and outpatient-based services, and other community-based resources. Training on
different types of mental health screeners and assessment tools (i.e., Beck Depression
Inventory-II revised for Deaf consumers), as well as common and general medical
evaluation questions, will better prepare the interpreter to engage with the patient,
and the Deaf patient in their health and mental health care process. The literature
warns that mental health services provided through a third party, even if a certified
American Sign Language (ASL) English interpreter is involved, may not provide
equal access to services (Leigh, Corbett, Gutman, & Morere, 1996). While ASL
English interpreters are intended to be “impartial conduits” in the therapeutic pro-
cess, neither subtracting from or adding to the therapeutic relationship, Brunson and
Lawrence (2002) found that the interpreter’s mood negatively impacted the Deaf
service recipient’s mood, even when the therapist’s mood was “neutral/cheerful”
(p. 1). Also, errors can occur in the interpretation process from English to ASL, and
vice versa (Napier, 2004). These factors will influence the quality of services that
members of the Deaf community receive when compared to the dominant hearing
community.
Deaf clients requesting an ASL English interpreter should be offered the oppor-
tunity to select their interpreter whenever possible (Bone, 2013), given the hetero-
geneity in the Deaf community by language preference, skill, and prior relationship.
In cases where the Deaf person has limited communication skills or uses a non-­
standard sign language, it may be necessary to engage the services of a Deaf inter-
preter (DI) as part of the interpreting team. A Deaf interpreter translates what the
hearing interpreter is saying, through the communication strategy most understood
by the deaf person. It may include an appropriate level of ASL, a series of informal
signs, gestures, or other communication strategies the deaf person understands
(Canadian Hearing Society, 2018).

 ractical Strategies When Working with an ASL English

P
Interpreter

Factors such as the layout of the room, lighting, and inclusion of a Deaf interpreter
(DI) will enhance service access for Deaf participants.
–– Layout of room: See Fig. 4.2: Seating arrangements including ASL interpreter.
72 T. A. Bone

–– Lighting: There must be sufficient light in the room for the Deaf person to see the
ASL interpreter clearly. To avoid distraction, neither the interpreter nor the Deaf
person should be seated directly in front of a bright light or window with bright
light outside. This makes viewing the signed communication difficult. Blinds
may need to be drawn or seating repositioned to avoid light distractions.
–– See the checklist (pre and post) for interpreter engagement below (Appendix A).
A dedicated amount of time should be allocated prior to, or at the start of, the
meeting for the Deaf person and the interpreter to communicate so as to establish
their form of communication.
Effective two-way communication between the hearing professional and Deaf
consumer may occur through either a voice message or video relay services. Voice
Message Relay Services (MRS) do exist, through are considered outdated technol-
ogy and used less often by many Deaf people who prefer wireless phones for the
communication through texting services. Video Relay Services (VRS) involve a
voice sign language interpreter/operator interpreting between spoken and signed
communication (Canadian Radio-Television and Telecommunication Commission,
2014). VRS allows deaf people, or those whose first language is a sign language, to
communicate in their first language with the same “fluency, range of expression,
ease, and speed” they otherwise communicate in using their first language (CRTC,
2014). VRS is viewed as superior to non-specialized or generic video chat applica-
tions such as Skype, as the latter does not provide access to a qualified sign language
interpreter.

Recommendations for Creating Accessible Environments

Enhanced technology in mental health-related waiting rooms would support access

for Deaf users. Technology such as electronic check-in monitors (computer screens
to allow independent check-in) would reduce dependence on receptionists calling a
Deaf patient. Receptionist staff could physically signal to the Deaf person when
being called to their appointment (rather than simply calling out the name). With the
patient’s permission, a note could also be put on their file (i.e., Patient Deaf or
Patient Hard of hearing—Interpreter required) with details on how to contact an
identified interpreter. The inclusion of ASL-based educational and informational
videos, as found in the Deaf Wellbeing Program website (Vancouver Coastal Health,
2019), in clinician’s waiting rooms would also enhance access for Deaf people to
mental health content and resources. Linguistically accessible mental health materi-
als would enhance the mental health literacy of this population overall (McKee
et al., 2015), and begin to address the issue of mental health stigma in this minority
community.
4  Deaf Mental Health: Enhancing Linguistically and Culturally Appropriate Clinical… 73

Conclusion

The United Nations Convention on the Rights of Persons with Disabilities (CRPD)
clearly states that all disabled people should experience “equal enjoyment of all
human rights and fundamental freedoms by all persons with disabilities, and to
promote respect for their inherent dignity” (2006, Article 1). This includes the elim-
ination of “obstacles and barriers to accessibility” (2006, Article 9, Accessibility).
As evidenced in the literature, members of the Deaf community experience unequal
access to mental health assessment, intervention, and follow-up when compared to
the dominant community.
The Deaf community experiences many challenges preventing their equal access
to mental health services, including too few professionals familiar with the Deaf
community, culture, and language; inaccessible mental health materials; and resis-
tance of community-based programs to accommodate the costs associated with sign
language interpreters. A number of strategies have been proposed to reduce these
barriers. Increased support for Deaf people to receive the training necessary to
become mental health professionals would enhance access for this minority culture,
and reduce the prevalence of mental health challenges in this population.

Definition of Terms

Audism  Term first coined by T. Humphries, a deaf researcher, in his 1977 doctoral
dissertation “Communicating across cultures (deaf/hearing) and language learn-
ing.” He defined the word Audism (o-diz-m) as the notion that one is superior
based on one’s ability to hear or behave in the manner of one who hears. Eckert
and Rowley (2013) further defined audism as a “stratifying system of oppres-
sion” that can be experienced through the practice of overt, covert, and aversive
practices of discrimination (p. 101). (See also Bauman, 2004).
Closed-captioning Closed captioning makes TV programming and other video
content accessible to deaf and hard of hearing individuals by translating audio
into text captions that are displayed on the screen Canadian Radio-Television
and Telecommunication Commission (CRTC), (2014).
Deaf (lower case d) The word deaf is a medical/audiological term referring to
those people who have little or no functional hearing. It may also be used as a
collective noun (“the deaf”) to refer to people who are medically deaf but who do
not necessarily identify with the Deaf community (CAD, 2015a).
Deaf (upper case D) A sociological term referring to those individuals who are
medically deaf or hard of hearing, who identify with and participate in the cul-
ture, society, and language of Deaf people, and whose primary or preferred lan-
guage is sign language (CAD, 2015c).
74 T. A. Bone

Deafened (Also known as late-deafened)  The term is both a medical and socio-
logical term that generally refers to those individuals who lost their hearing after
the acquisition of speech and language. Individuals who are late-deafened gener-
ally share the cultural experience of being “hearing.” A number of psychologi-
cal consequences are associated with being late-deafened, with some “viewing
themselves as having a disability” (De Graf & Bijl, 2002), reporting sense of
“loss or social isolation,” and having lower levels of psychological adjustment
(Polat, 2003).
Deaf interpreter (DI) Deaf interpreters are Deaf individuals who are fluent in
ASL and have interpreting experience. They provide interpreting services to deaf
immigrants with limited ASL, deaf people with learning or language challenges,
or those whose illness or injury limits or prevents the deaf person signing. The
hearing interpreter translates from spoken English to ASL; the DI translates what
was signed in ASL to the deaf person via ASL, sign, gestures, or other commu-
nication strategies the deaf person requires (Canadian Hearing Society, 2018).
Hard of hearing  A person is hard of hearing when their hearing loss ranges from
mild to profound, regardless of the cause of loss, whose primary mode of com-
munication is speech. Hard of hearing is regarded as both a sociological and
medical term.
Oral deaf  “A deaf person whose preferred mode of communication is verbal and
auditory and/or lipreading. An oral deaf person who can both Sign and speak can
be considered ‘Deaf’ if he/she is accepted as such by other Deaf persons and uses
Sign within the Deaf community” (CAD, 2015c).
Sign Language The official language of Deaf communities around the world.
There is no universal sign language, with more than 137 sign languages docu-
mented around the world (Lewis et al. 2013). Many of the worlds’ sign languages
have developed independently from one another, and as such are linguistically
diverse.
Telehealth Defined as “live video conferencing technology” (Wilson & Schild,
2014, p. 324). Wilson and Schild reviewed the extent to which service providers
are using this technology to provide services to Deaf ASL users where face-to-
face services do not exist. Further research is required to explore the full capac-
ity of this technology for this client population.
Video relay service (VRS)  A video service that connects a deaf signer with a hear-
ing person directly through an ASL interpreter. The service was launched in
Canada on September 28, 2016. Canadians with a sufficient internet connection
can access VRS at no cost through their computer (Mac and PC), tablet (iOS or
Android), and smartphone.
4  Deaf Mental Health: Enhancing Linguistically and Culturally Appropriate Clinical… 75

Resources to Facilitate Successful Engagement with Deaf

Service Users

Pre and Post Assessment Meeting with Interpreter

Checklist

When conducting any type of assessment with an interpreter, complete the follow-
ing checklist.

Pre-session

Item Check
The interpreter has explained his or her role.
I have explained the overarching purpose of the session to the interpreter.
I have explained the key principles and concepts of the meeting, treatment, or therapy to
the interpreter.
I have shared the relevant facts of the client’s case for the purpose of accurate
interpretation.
I have provided the interpreter with a copy of any assessment item(s) I plan to use.
The interpreter has highlighted areas of the assessment that they foresee may have
linguistic or cultural difficulty.
I have provided an opportunity for the interpreter to calibrate to the language that I will
use in the assessment or treatment.
Calibrating refers to the process of adjusting to the language level, patterns, and
idiosyncrasies of each individual in the communication exchange. Calibrating is an
important part of maintaining the integrity of the meaning intended in each
communication exchange

Post-session

Item Check
I clarified with the interpreter any linguistic or cultural concerns that were raised in the
meeting or session.
I asked the interpreter if they had any difficulties in translation or have any culturally
relevant information that may influence my assessment.
If the Deaf person and staff person myself are satisfied with the interpretation, I inquired
whether it is possible to book the interpreter for regular appointments.

Metro South Health, Queensland, Australia (2016, p. 60). Adapted and used with
permission
76 T. A. Bone

Service Accessibility Considerations

Checklist

To improve the accessibility for Deaf people, complete the checklist.

Item Check
Have I accommodated the communication needs of the Deaf person?
Have I ensured relevant staff knows how to book and engage an ASL English
interpreter?
Do I, and all necessary staff, understand the role of a Deaf interpreter (DI)?
If requested, do I know where and how to book a Deaf interpreter (DI)?
Have I planned for sufficient time to accommodate the purpose of the meeting (often
two to three times the length of time without an interpreter)?
Depending on the length of the meeting, have I confirmed with the interpreter service
whether I will require more than one interpreter?
Does the setting have sufficient lighting to accommodate visual language users?
Does the setting have sufficient space to accommodate a Deaf interpreter (if requested),
and ASL English interpreter in addition to the Deaf consumer and staff person(s)?
Does the institution have access to the necessary technology to facilitate communication
between the Deaf offender and community supports in a way hearing offenders have
access to telephone? This may include video conferencing, or video relay services for
interpretation purposes.
If the institution has appropriate communication technology, is it in good working
condition? Do all necessary staff know how to use the technology and facilitate access
for the Deaf offender?

Metro South Health (2016). Metro South Addiction and Mental Health Services:
Guidelines for working with people who are Deaf or hard of hearing, v. 3. (p. 61).
Adapted and used with permission

Educational videos for working with Deaf ASL first-language users

individuals

Deaf People in Medical Setting [Video file]. (2016). Retrieved from https://www.
youtube.com/watch?v=NpyvD6_uzZ0 Time: 2:26
The Holley Institute: In-Service Training for Deaf Patients [Video File]. (2017).
Retrieved from https://www.youtube.com/watch?v=hzzSZYbsRyM Time: 7:17
UC San Diego Health [Video File] (2015). Improving Health Communications
with Deaf Patients. Retrieved from https://www.youtube.com/watch?v=Cr0I41ZCb2o
Time: 4:46
4  Deaf Mental Health: Enhancing Linguistically and Culturally Appropriate Clinical… 77

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