Mental Health Care of Deaf People

A Culturally Affirmative Approach

Neil S. Glickman, Sanjay Gulati, Neil S. Glickman, Sanjay Gulati

• Publisher: Routledge
• Year: 2003
• Print ISBN: 9781138980945
• eBook ISBN: 9781135626860
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

Deaf adults and children, like their hearing counterparts, experience a full range of mental health problems. They develop psychoses, sink into deep depressions, abuse alcohol and drugs, commit sexual offenses, or simply have trouble adjusting to new life situations. But when a deaf client appears on the doorstep of an ordinary hospital, residential facility, clinic, or office, panic often ensues.

Mental Health Care of Deaf People: A Culturally Affirmative Approach, offers much-needed help to clinical and counseling psychologists, psychiatrists, social workers, nurses, and other mental health professionals--and to their program administrators. The editors, a psychologist and a psychiatrist, and the authors, leading authorities with a variety of expertises, systematically review the special needs of deaf patients, particularly those who regard themselves as "culturally Deaf," and provide professionals with the tools they need to meet those needs.

Among these tools is an extensive "library" of pictorial questionnaires and information sheets developed by one of the very few psychiatric units in the country devoted to the deaf. These handouts greatly simplify the processes involved in the diagnosis and treatment of people who in many cases are not good readers--for example, explaining medication and inquiring about side-effects. The handouts are reproduced on downloadable resources, to enable purchasers to print out and use copies in their work.

This comprehensive clinical guide and its accompanying downloadable resources constitute vital resources for all those who seek to provide sensitive, effective mental health care to deaf people.

1
Culturally Affirmative Mental Health
Treatment for Deaf People: What it Looks
Like and Why it is Essential

Neil Glickman
Westborough State Hospital
Assumption College

PERSONAL INTRODUCTION: CROSS-CULTURAL LEGITIMACY

I am a psychologist who administers an inpatient psychiatric unit for deaf people. I’ve made a career of touting culturally affirmative mental health treatment for deaf people. I am constantly thinking about the cross-cultural dynamics between deaf and hearing people, and I have done everything in my power to shape my program so that it lives up to the ideals I advocate. But I face an obstacle in talking about this issue, at least with a deaf audience: I am hearing. Over the years, deaf people have challenged me with questions like these:

What makes you an expert on deaf people, or even on psychotherapy with deaf people? You’ve written some articles and edited a book? Hearing people have been writing about deaf people for years, usually presenting us as incompetent and inadequate. You run a mental health program for deaf people? Almost all mental health programs for deaf people are run by hearing people. Most of them are grossly insensitive to our viewpoints. If your program is so ‘culturally affirmative,’ why isn’t it run by a deaf person? If you are so pro-deaf, why do you sign in Pidgin Sign English? Why are most of your staff hearing? Who are you, as a hearing person, to even suggest what ‘culturally affirmative’ mental health treatment is? You can’t see your hearing biases. You are still a hearing person exercising authority over deaf people.

These questions challenge my “cross-cultural legitimacy” (Pollard, 1996), the degree to which a culturally different community accepts one as a helper. For example, if you don’t sign at all, promote oral education of deaf children, and encourage hearing parents to seek cochlear implants for their deaf children, you will not have cross-cultural legitimacy with the Deaf community. They will not accept you as a helper. Indeed, they may even see you as an enemy.

You can’t give yourself legitimacy to work with a community to which you do not belong. All the academic credentials in the world mean nothing. The community decides whether you are trustworthy and whether you understand them. Establishing cross-cultural legitimacy is the greatest challenge any hearing clinician faces in working with deaf people. Consider the challenge for me as a hearing program administrator: I must hire, promote, discipline, and terminate staff as well as establish policies that are clinically sound, fiscally prudent, responsive to constraints on available resources, and acceptable to the Deaf community. Yet if a mental health program seeks to serve a minority community, it must achieve cross-cultural legitimacy or the intended clientele will reject it.

In addition to the notion of legitimacy, cross-cultural theory gives us the concept of “ally.” German Christians who hid Jews during the Nazi era were their allies. White abolitionists who fought to end slavery, and the White civil rights workers who fought to end segregation were allies of African American people. Members of PFLAG (Parents and Friends of Lesbians and Gays) are allies of gay men and lesbian women.

My response to questions about my legitimacy is that, while I do have a position of authority with regard to some deaf people, I strive to live, not as an expert, but as an ally. I accept that the final judges of my cross-cultural legitimacy will be deaf people. I present a model of culturally affirmative inpatient treatment of deaf persons in that spirit. I hope that both deaf and hearing people use it, critique it, and improve on it.

WHY IS CULTURALLY AFFIRMATIVE MENTAL HEALTH
TREATMENT NECESSARY?

If you are hearing and if you are awake, if you seriously attend to what deaf people say, then you know that the mental health problems that some deaf people develop can not be separated from the abusive ways they have been treated by hearing people. Some of these abusive responses to deaf people include:

• Controlling deaf schools and other programs that serve deaf people.
• Forbidding sign language in deaf schools and programs, and corrupting sign language into unnatural imitations of English.
• Focusing obsessively on speech and speech reading to the exclusion of academic subjects.
• Imposing hearing aids on students who do not want them.
• Forcing surgical procedures on deaf children who cannot consent.
• Mainstreaming deaf children, resulting in isolation from peers and deaf adults.
• Delaying 20 years from the recognition of sign languages as true languages to accepting them broadly for instructing deaf children (1960–1980).
• Drawing erroneous and damning conclusions from inappropriate psychological testing.
• Diagnosing deaf people as mentally retarded, autistic, or schizophrenic, and allowing them to languish in institutions.
• Holding a medical conception of what it means to be deaf—deafness as a pathology, a handicap, and a tragedy—and therefore believing that deaf people need to be “fixed.”
• Believing that deaf people are disabled not just in being unable to hear, but intellectually, emotionally, and morally.
• Promoting the idea of the psychology of deafness, that deaf people are unintelligent, egocentric, concrete, irresponsible, impulsive, immature, paranoid, and so on.
• Actively discriminating against deaf people in hiring and promotions.
• Showing paternalism, pity, and contempt toward deaf people.
• Excluding of the Deaf community from decision making on key matters, such as educational policies and medical procedures that pertain to deaf people.

But the absolute core of oppression of deaf people, as I have come to understand from their stories, is:

• Disempowering them around communication, resulting in communication isolation.

Hearing mental health professionals who do not have full knowledge of the deaf experience, self-awareness, and an appropriate set of skills may actually repeat these forms of oppression in their treatment. This is well illustrated in the story of Janet DeVinney, whose experience opened this book. Ms. DeVinney was working toward a graduate degree in psychosocial rehabilitation, and needed a brief inpatient treatment for depression. As a mental health professional herself, she knew the mental health system and her rights as a deaf person under the Americans with Disability Act (ADA) and other laws. She had strong signing skills. As a late-deafened person, she also had fluent English and comprehensible speech. She was in a strong position to advocate for herself. Some middle-class or well-educated deaf people like Ms. DeVinney would not want to be treated in a specialized deaf program such as ours, however much they want and need sign language for treatment. Some might have concerns about confidentiality. Ms. DeVinney, for example, might have worried about being hospitalized with her own clients. Others might worry about finding peers at their level of functioning. Ms. DeVinney, however, was not offered a choice. She was hospitalized in a hearing facility that was completely unprepared to help her.

Ms. DeVinney’s depression, as she saw it, was largely due to the pain of struggling with hearing people, including her own family, around communication. Her communication isolation was repeated in the treatment setting. How could she articulate her experience to people who were repeating the same mistreatment that brought her to that point? To add insult to injury, her providers saw her depression and anger as something purely internal, and denied their part in it. Rather than responsibly attempting to make their treatment environment more accessible, they did things like referring her to an anger management group without an interpreter. They encouraged her to assert herself, but treated her as unreasonable when she asserted her need for an interpreter. In the end, she got qualified interpreting for exactly three therapy sessions. The treatment environment retraumatized her; she was later diagnosed with Posttraumatic Stress Disorder caused by her hospital experiences.

Ms. DeVinney’s experience of psychiatric inpatient treatment is typical for deaf people admitted to hearing units. I know this because I take referrals from them. Many deaf people have a more difficult time than Ms. DeVinney because they lack the education and intellectual sophistication to advocate for themselves or because they are more seriously mentally ill. Ms. DeVinney was not linguistically impaired or psychotic. She was not given psychological testing that drew incorrect conclusions drawn about her mental capacity and diagnosis. She had strong “premorbid” functioning, and no history of the developmental and behavioral difficulties common in most of our patients. For a deaf person presenting for help in a hearing psychiatric facility, she presented a “best case scenario.”

Consider, for instance, the case of a 30-year-old man I call Ed, who was transferred to our unit from a hearing psychiatric unit. Ed had grown up in a third world country. Because no one in his life had used a formal sign language, he had no language system of any sort. He communicated entirely through gesture and “home signs.” (Fortunately, this situation is now rarely seen in the United States.) Ed had enormous deficits in developmental skills. His ability to manage his emotions in almost any social situation was poor. He was a large man. To get what he wanted, he would gesture dramatically, vocalize loudly, and raise his fists.

Sometime in Ed’s past (no records are available, and he certainly couldn’t tell us), a doctor prescribed Haldol, presumably believing him to be psychotic. His family dutifully continued it for years. When he arrived in this country, the prescription was renewed. Ed experienced painful muscle cramps as a side effect of Haldol, and often refused it. His family began crushing it and hiding it in his food. He became “paranoid,” refusing to eat unless he saw the food being prepared. He became angry with his parents and sometimes threatened them. Finally, they called the police who, with a force of some six men, subdued him and brought him to a hearing hospital, a facility renowned for medical excellence. There he was strapped in restraints for days because he was big and scary and nobody could communicate him. While in restraints, he was given an injection of—Haldol.

We were apprehensive about Ed being transferred to our unit, but our fears were unjustified. We were not put off by his lack of formal language skills, as we were used to finding creative ways to communicate with our clients. Our deaf staff members in particular were remarkable in their ability to communicate with Ed through gesture and drawing. Simply being on our unit, where people seriously attempted to communicate with him, Ed’s behavior improved dramatically. It quickly became clear that he was not psychotic but did have Obsessive-Compulsive Disorder (OCD). He spent 3 or 4 hours a day in the bathroom washing his hands and face. We stopped the Haldol, started teaching him sign, started him at the sheltered workshop, and eventually got through his “paranoia” and convinced him to try an appropriate medication for his OCD.

The experiences of most deaf people in hearing psychiatric facilities lie somewhere between those of Ms. DeVinney and Ed. Most facilities will attempt to provide some interpreting services, perhaps for meetings with the psychiatrist or social worker, but the larger treatment milieu, including group therapy and interactions with nursing staff, will remain inaccessible. They will own one TTY (teletypewriter) and may even be able to locate it when needed. One or two of their staff may know some sign (although this becomes more a curse than a blessing if these staff are elevated into “deafness experts”). Their clinicians will likely have no knowledge of the biological, developmental, social, and cultural implications of deafness, no sense of what is normal for deaf people, and no appreciation of their biases as hearing people. Misdiagnosis will be common. The deaf patient will have no deaf peers, and staff may have no sense of the difficulty in integrating deaf persons in hearing groups, even when an interpreter is present. The resulting experience for the deaf person is isolation and frustration at best, misdiagnosis, mistreatment, and retraumatization at worst.

Oppression can occur in our facility too. An example is illustrative: When regular staff are out sick at Westborough State Hospital, staff from other units may be assigned to “float,” or cover for them. Many of the nurses and mental health workers who float to our unit would rather not be there. They are uncomfortable working with deaf patients, and often even more uncomfortable working with deaf staff. The nurse is always in charge of the milieu, even when she is supervising regular staff who know the patients better than she does, and who can communicate with them. One day a nurse I’ll call Julie floated down to our unit. Our staff know how she feels about being assigned to us: She grumbles that she hates it. Julie only looks at our deaf staff when ordering them to do something. She refuses interpreters, saying that “deaf people understand me fine.”

One evening, a patient was feeling agitated. Julie told her, in spoken English, “go to your room or the quiet room.” Later this client assaulted someone and had to be physically restrained. Two deaf mental health workers (MHWs) were working that shift, including one of the most competent staff members on our unit, a leader who sits on our executive committee. Julie felt he was buckling the restraint belt too slowly, and motioned for him to leave the room. She wanted a hearing float to take over. There was an interpreter present, and the MHW signed that he knew what he was doing. He had performed this procedure many times. She motioned again for him to leave the room, telling the interpreter, “I know what he wants but he is too slow and is wasting my time.” Julie then had the other deaf mental health worker, a woman, leave the room too. Her rationale was that there were enough male staff there. So the two deaf staff members, the only people present who actually knew the person being restrained and could communicate directly with her, were ordered out while hearing floats took over.

The only person the deaf mental health workers could turn to that evening was the nursing supervisor. But the nursing supervisor that evening was also infamous among our deaf staff. She too complained about the hassles of dealing with deaf people. When she came down to “trip” the unit, she would ignore deaf staff and ask hearing staff how things were. She refused to write or to sign. The deaf staff rightly perceived that she valued input from the hearing people but not from them. Needless to say, the offended deaf mental health workers did not choose to complain to her.

Julie firmly believed that in an emergency hearing people should run the show. When we addressed this with her, she argued that her primary concern was safety. She felt that the situation had been unsafe because deaf staff could not communicate quickly with hearing nonsigners. (Notice how she blamed the deaf people for the communication problem.) We had heard this argument when we first hired deaf people. We heard it again when our deaf staff sought opportunities for overtime on the hearing units. Now we were hearing that they were not safe to manage a crisis on their own unit. We told her that 15 years of experience showed there was no truth to her claim. Deaf and hearing people can work together smoothly, even in emergencies. In fact it is more unsafe having no deaf people there. At the very least Julie was rude, insensitive, and unprofessional. The nursing supervisor supported Julie’s actions that evening. She could not fathom how Julie’s behavior reflected prejudice. She told me I was prejudiced against hearing people.

The deaf mental health workers involved in this incident were traumatized by it. Really, they were retraumatized. They had experienced hearing people discounting, undermining, rejecting, or ignoring them all their lives. Now it had happened even in a “safe” place. The psychological fallout of this incident was enormous. Our staff spent days processing it and recovering from it. Julie and her supervisor couldn’t even see the problem. How could a deaf person stay sane and healthy in an environment that was so ignorant and invalidating?

Sadly, all this occurred in an environment supposedly designed to be culturally affirmative. But at least on our unit, abuses could be named and challenged. The unit leadership were able to validate the deaf staff members’ perception of oppression, and we fought for them. Deaf staff could talk safely about their experience. Without this, the deaf staff would have sat with their rage. They might even have been written up for having objected to leaving the room, or fired for insubordination. This is normal, daily reality for deaf people. Unless the environment is specially attuned, new abuses will always occur. Deaf people will be enraged and silenced. They will not be as productive in their work and their patients will suffer.

Why are culturally affirmative mental health programs essential for deaf people? The answer goes well beyond the most obvious issue: the need for a signing environment. It goes beyond the need for deaf role models and for staff, deaf and hearing, who are sensitive to the deaf experience. It goes beyond the fact that working with deaf people requires special knowledge and skills as well as thinking about what it means, c...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• List of Contributors
• Preface
• Prologue: My Story
• 1 Culturally Affirmative Mental Health Treatment for Deaf People: What it Looks Like and Why it is Essential
• 2 Psychiatric Care of Culturally Deaf People
• 3 Psychological Evaluation of Deaf Children
• 4 Culturally Affirmative Inpatient Treatment With Psychologically Unsophisticated Deaf People
• 5 Sensory Strategies for Self-Regulation: Nonlinguistic Body-Based Treatment for Deaf Psychiatric Patients
• 6 Culturally Affirmative Residential Treatment Services for Deaf Children With Emotional and Behavioral Disorders
• 7 Culturally Affirmative Substance Abuse Treatment for Deaf People: Approaches, Materials, and Administrative Considerations
• 8 Toward Culturally Affirmative Assessment and Treatment of Deaf People With Sexual Offending Behaviors
• 9 Does God have a Cochlear Implant?
• Epilogue: When the Therapist Is Deaf
• Appendix: Contents of the Accompanying CD Skill Card Illustrator: Michael Krajnak