Deaf Mental Health – What is Unique and What are the Challenges
What are the Implications of Deafness?
One of the most common misconceptions about deafness is that its impacts are minimal, limited to not being able to enjoy music or hear birds twittering.
In a nutshell, the reality of deafness is that it can create immense communication barriers that can result in high levels of frustration for all parties wishing to communicate as well as a sense of deprivation, inequality and isolation for the person living with the deafness.
Deafness isolates the individual from an ease of communication and access to information that people who can hear take for granted.
Helen Keller, who lived her life as a deafblind person, was asked if she could have one of those two senses returned, which would it be? Her reply, her hearing. When asked why, her response was that her blindness isolated her from things whereas her deafness isolated her from people.
Deafness can range from relatively mild – for example, where hearing speech in noisy environments is difficult, but not overly problematic in quiet, controlled environments – to profound deafness, when speech cannot be clearly heard or cannot be heard at all. When speech cannot be heard, then, depending on a range of factors, communication needs to occur using sign language, written language or the individual may lip read. However, it is important to recognise that lip-reading English is extremely difficult with only about 30% of English speech sounds occurring on the lips themselves.
Broadly speaking, deafness can divided into separated into two categories. That is, in very early life (from birth or the first three years of life) prior to language acquisition (pre-lingual deafness) or acquired deafness (post-lingual deafness). It is important to acknowledge that acquired deafness can be further categorised by when it occurred (i.e. later in childhood, as an adolescent, as an adult or in the latter stages of life).
Early Life Deafness and it Implications for Mental Health
Significant deafness from birth or early life (pre-lingual deafness) has broad reaching implications on not only language acquisition and learning, but – ultimately – on mental health.
It is important to recognise that all children learn a great deal about their inner world and about the wider-world as a result of parent-child interaction as well as through unconscious learning that occurs by overhearing the communicative interactions of others in their families and, as they grow, the communicative interactions of others at childcare, school, the community and so forth.
For a child who is born deaf or becomes deaf very early in life, there is, at best, reduced access to these communications. However, the reality is that for most of this population, there is little to no access to this type of early learning. The only exception to this is a deaf child who is born to deaf parents; however, this is a very small percentage (estimated as 10%) of children with early life deafness.
Think about what you know about how our understanding of what are feelings are and how our self-awareness and insight are developed. In our early lives, this is exclusively the result of parent-child interaction. A crying baby is spoken to by its parent, words of reassurance as well as discourse around the expression of emotion – “are you tired?” “you’re not happy today” “do we need to change your nappy?” and so on. All of this interaction not only teaches language to a child, it also teaches self-awareness, the ability to name ones emotions and, hopefully, provides the distressed child with input that relieves its suffering. As a mental health professional, you would be well-aware of the importance of these early-life interactions as the original building blocks of the tools and resources that will continue to grow over time, supporting our mental health. Most deaf children have little to no access to these interactions.
People with significant deafness from early life usually use Australian Sign Language (Auslan) as their primary language. Auslan is a visual, gestural and spatial language that is not a visual representation of English. Therefore, even though a person can be born and educated in Australia, their first language will not be English; it will be Auslan. Auslan is a rich language with a capacity to express all aspects of human communication, including the abstract, metaphor, humour, sarcasm and so forth equally as well as English or any other spoken language. Like all languages, Auslan is culturally bound so that some things or concepts which hold cultural relevance are more extensively encoded into the language whereas other concepts which do not hold much cultural relevance have a paucity of lexical items (signs) to express them.
People with significant, early-life deafness may also use some lip-reading and may use some speech, but usually only family members and friends will understand their speech. As technology has evolved, many deaf babies are now implanted with cochlear implants. This provides the wearer with some access to speech and can assist in understanding spoken speech. Similarly, hearing aids can provide some access to speech sounds or they may only provide the wearer with an awareness of environmental sounds.
People who have less significant deafness from early life will usually get more useful information from technology and often will communicate using solely lip-reading and speech. However, it is important to be mindful that they do not hear as a hearing person does and that often there are still significant gaps in what they can hear. This can make their communication appear stilted, incomplete and, possibly, even inappropriate or peculiar.
As noted, much depends upon when the deafness occurred. However, people with post-lingual deafness rarely use Auslan. They will communicate using lip-reading and their speech, which was developed prior to the deafness. They may also use technology – cochlear implants or hearing aids – to augment their lip reading.
Cochlear implants and hearing aids work in quite different ways. Before explaining how they work, it is quite important to understand neither correct the sound that is heard; they do not give the wearer “normal” hearing. Neither are like glasses; they provide no correction to what is heard. As well, noisy environments can make it difficult to decipher and filter sound and meaning. And so, even when using technology, communication barriers can and do occur.
A cochlear implant – which has both an internal component that has been surgically implanted into the cochlea where the auditory nerve is and an external processing component that can be seen – uses a small number of electrodes to stimulate the auditory nerve. The sound heard has been described as a series of electronic beeps. With rehabilitation, the wearer’s brain re-learns how to identify the meaning of the sounds and the wearer grows accustomed to how speech sounds through the implant.
Hearing aids amplify sounds at the varying frequencies which are required to satisfy the aim of making all the speech sounds of English accessible. However, the sound being “accessible” does not mean that it can be understood as the nerve cells may be damaged and so what is heard is distorted or incomplete. Some people describe the sound as similar to the scratchy sound of a radio that isn’t quite on the station (less common now in a digital world!) or trying to make sense of a mobile call that drops in and out.
The areas of commonality between both groups – those with pre-lingual and post-lingual deafness – is that both rely heavily on their eyes to take in communication from another person; both encounter barriers to communication on a daily basis; and both can experience isolation because of their deafness. It is important to note in relation to this latter point, although both groups can find themselves feeling isolated because of their deafness, it can be experienced quite differently. The main reason for this is because people with acquired deafness mourn the loss of their hearing and how it impacts on their lives and relationships. People with early life deafness do not mourn the loss; indeed to them, it is the norm and most are actively involved with a vibrant community, the Deaf community. Their isolation relates more to their exclusion from opportunities within the mainstream community.
Communication Challenges and Barriers
People who are deaf face communication challenges and barriers on a daily basis. There are the many conversations – some small and incidental; some significant and highly complex – that we each engage in, every day. We may need to seek a consultation with a medical practitioner to discuss aspects of our health that are concerning us. There may be a public announcement about a change of platform at a large train station or about something more serious such as the need to evacuate a building. It can be something as seemingly insignificant as the idle chit chat of others at work that we listen to in the background and that we can “dip” in or out of, as we choose; however, it is an essential aspect of feeling a part of your workplace.
These are a few simple examples of how, in the main, our community is geared towards obtaining information by listening to it. This cannot be done by anyone with significant deafness, regardless of the reason for their deafness and how they communicate. They frequently face such barriers which they-alone are usually expected to resolve. And yet, as a community, we could do so much to remove the communication barriers.
Deaf people often need mediated communication. This may mean something as simple as ensuring the environment is as free of background noises as possible and making certain you continually face the person, making eye contact as you speak or it can mean that you need to employ an Auslan-English interpreter.
There are a range of strategies that you can employ to try to minimise barriers to communication. These can include:
• gain the deaf person’s attention before you begin to speak
• always face the deaf person when you speak, don’t turn away and keep talking
• minimise any background noise or distractions (including visual distractions)
• ask them how they prefer to communicate with you
• make certain that you speak clearly and distinctly
• don’t mumble but at the same time, don’t shout – both distort speech and lip patterns
• be as visual as possible, using natural gestures (e.g. if talking about a prescription, tap on it with your finger)
• if there is a computer on your desk, use it to do a Google™ search for images of what you are talking about
• be willing to write notes and/or draw pictures
• book an Auslan-English interpreter to facilitate communication
The most important thing to remember is that each deaf person will have their own, individual communication needs. This is why asking them how they prefer to communicate with you is so important.
Challenges for Deaf People in Accessing Mental Health Services
For a deaf person who is an inpatient – either voluntary or involuntary – on a hospital mental health ward, the experience can be profoundly isolating. This is especially true for a deaf person who communicates using Auslan. It is also an extraordinarily challenging time for the doctors and nursing staff who are caring for the deaf patient. Unlike overseas, Victoria does not have a particular mental health service or inpatient facility that has staff who can meet the needs of an Auslan user. Auslan-English interpreters can and are employed to attend the ward to interpret between the deaf patient and medical staff. At best, this is generally for a single hour, each day of the deaf person’s admission. Many times, it is for a single hour once or twice a week.
Highly trained medical staff – doctors and mental health nurses – are unable to monitor the deaf patient’s state-of-mind and symptomatology in the way that they do with other inpatients. For example, they are unable to ask questions or intervene if the deaf patient becomes distressed or agitated; they may be able to observe that a patient may be hallucinating and/or talking through Auslan to an entity not present, but they have no access to the content of the communication; most of the time, they cannot even form a very basic relationship that allows the deaf patient to begin to feel a level of trust that potentially allows them to actively participate in their own recovery.
From the deaf person’s perspective, they are an inpatient on a ward where no one knows their language or their culture – not just staff, but also the other patients. Ward activities often require the capacity to hear in order to engage; for example, relaxation groups where the group leader talks the group through various techniques. Expectations and “rules” are often quite different to when one is not in hospital and these can be difficult to negotiate and understand.
There are many more examples from both perspectives, but the simplest way to convey just how profound the isolation is would be to return to the notion of how frequently an Auslan user may have an interpreter available. To put it starkly, of the possible 168 hours in a given week, best case scenario finds a deaf inpatient with seven hours of communication access and in a worst case scenario, a mere two hours.
Interpreters and Mental Health
For deaf people who use Auslan as their primary language, the use of suitably qualified Auslan-English interpreters is essential. The mental health field is complex and it is important, especially if a deaf person is very unwell, to ensure that you are working with an interpreter who has appropriate experience and NAATI credential. Currently, this means someone holding NAATI Professional Interpreter level of accreditation. From 2018, this means that an interpreter who is minimally credentialed as a Certified Interpreter and after the new system is fully implemented, you should be seeking to engage a Certified Specialist Interpreter (Medical).
A part of why this is so important is because providing mental health services through any language interpreter is less than ideal. As a mental health professional, you have highly specialised skills that allow you to assess and work with your clients/patients. An important part of your work is the relationship that you establish with your client/patient.
When the work of the therapeutic relationship occurs through a third party (i.e. an interpreter) certain aspects of the work can become more complex and complicated. If the interpreter is inadequately skilled, this can further complicate and confound the therapeutic relationship, thus impacting on the effectiveness of treatment.
Where appropriate, we would recommend that you refer clients/patients who use Auslan to a mental health practitioner fluent in Auslan.