Working with Deaf and Hard-of-Hearing
Clients in Therapy
Someone has suggested that I write this article. At the outset, I’d like to say that I’m always reluctant to take on this kind of thing. We have so many competent deaf professionals who could speak to this more eloquently, and from inside the experience. After 35 years as part of this community, I am not part of the core community because I am “hearing” and that’s my disability.
...So, this only speaks to my personal experience as an interpreter, group and foster home operator, administrator, and psychotherapist, working in and around the deaf community, since 1972. I owe a great debt of gratitude to the many deaf adults who took one more chance on another ignorant hearing person, many who come and go, and spent time teaching me and welcoming me into their hearts.
Many deaf, Deaf people and hard-of-hearing people find the terminology “hearing-impaired” pejorative. For some, deaf and hard-of-hearing refers to a difference in hearing, not necessarily viewed as a deficit. People that identify themselves as part of the cultural/linguistic minority(1) that primarily communicate in the indigenous sign language(2), self-identify as ‘D’eaf. This does not address people who are deafened, having lost their hearing somewhat later in life, after having full access to a hearing community for some period of time.
There is significant diversity within the deaf community, much like in the hearing community. They have differing values, underlying cultural backgrounds, and communication styles. They identify in different ways. There are people who have attended residential school, which in many instances has been a better experience for them than those who have been mainstreamed into hearing schools. There are the usual issues around residential schools, and those who have had that historical issue, and tend to be older, often are struggling with coming to terms with growing up in an oppressive, possibly abusive, paternalistic educational and living environment. Others, who have been mainstreamed have also had this experience, but tend to be socially isolated because they don’t have deaf friends, teachers, or role models. Deaf culture runs against the western normative culture in that it is more collective and less individualistic. Contribution to the whole is valued. History and identity are very important. Although 90% of deaf children are born to hearing parents, very few of those parents are fluent in ASL/LSQ.(3) People who speak a “sign language” value their visual language and their visual cultures. They often encounter oppression in hospital settings, with ignorant professionals, in educational settings, and in their own homes.(4) Decisions are made about them without any consultation, and doctors make decisions with parents about how they are going to fit into this hearing world without any consultation with the broader deaf community, or with the child themselves.(5) In the past, hearing aids were forced on all deaf children, even those with little or no residual hearing, who did not benefit at all. At the present time, the medical trend is to cochlear implants, which have limited success rates, and do not restore “normal” hearing, but sometimes assist the client in functioning in hearing culture, but are usually not well-received by the deaf community at large. Younger deaf clients are a bit more receptive, but many take them off when they become adults and have more control over their own lives.
I have sometimes heard therapists tell deaf people that they should teach the therapist about deafness and culture and that will help them to build a rapport. I think the therapist thinks it also levels the power imbalance. On the surface, this sounds alright, but deaf people are part of a marginalized minority, and part of this experience is constantly educating everyone around them, so that they can access services in a helpful way. Some feel frustrated with this process. Others feel they should be paid for their expertise. Whatever perspective the person has, when they are in crisis, this is not a helpful time to take 3 or 4 sessions out, at the beginning, to do ‘education of the therapist’.
This does not mean that they should not be part of the creative process of how communication and collaboration evolves in therapy. It does mean they want the therapist to do the research to find about the cultural background information. Communication happens in many ways. I know people who have chosen to write or type with their therapist. Some have sufficient hearing and lip-reading/speech-reading skills to do sessions orally. English is a particularly difficult language to read on the lips because 80% of the sounds don’t show, and so the client is guessing about 80% of the information from context. You cannot expect that this is a good solution unless the client expresses a desire and shows an aptitude in this area, and the therapist is easy to lip-read. For most deaf people, English is at least a second language, sometimes a third or fourth, with a different grammatical structure and different inherent values than their native language, which makes communication challenging at best. For those of us with high school French, you might want to think of it in those terms. Many will want to have a qualified interpreter that they can trust. Credentialed sign language interpreters are rigorously trained, and follow a strict code of ethics. You can expect that this may be a difficult process for the client. Most of us would not choose to discuss our personal issues with a third party in the room.
I am fluent in ASL, and have been interpreting since 1975. I find that I use visual and tactile devices to reinforce concepts. I’m finding that it’s very useful with hearing people who are more visual or kinetic as well. I find that ritual is helpful and that showing respect for deaf culture is essential.(6)
Deaf culture is collective, rather than individualistic. Deaf people value what they and others do for the deaf community. They work toward everyone’s good, when they can. As a rule, I am more available to my deaf clients than I usually am to hearing clients. They will ask me to edit emails for work, or for family; will ask about the meaning of correspondence they receive; will contact me to ask for clarification about letters they’ve received or other English that they’ve encountered. I occasionally would make calls for them as well. I look at this as normative.(7) With some clients with special needs, who have difficulty self-regulating, or knowing appropriate boundaries, I have very strict limits with them about when they can call, how they would call/email, and how long they would wait for me to contact them back before calling again. With most of my clients, that’s not an issue. I’ve just received an email from a client with a minor crisis, who is taking care of themself, and wanted me to know. I’m in another part of the country, and will arrange to see them on my return. They know that it’s okay. I also take my computer with me when I travel, and, if necessary, could contact them online to talk. I offer that to some of my hearing clients as well. I do distance therapy with people in other towns, and provinces by videophone on a weekly basis. I also am a bit more flexible about time with clients in general, and that’s the influence of the deaf community on my life. Deaf culture usually includes some physical touching around issues like attention getting (tapping on the shoulder), and they have a difficult time understanding the constraints of a hearing society that requires so much distance. I often find that my deaf clients who are in crisis expect a hug, and it’s culturally appropriate for them, but I would let them initiate, or check with them first. Sometimes it’s an expression of relief.(8) Some deaf clients with other disabilities will depend on other deaf members of the family to “interpret” for them. I encourage them to work with me directly, but sometimes the additional resource is helpful, while I’m figuring it out.
There are great resources in print and on-line for doing work with deaf clients who are struggling with mental health, addiction and abuse issues. Some agencies have done some wonderful work in this field as well. Please feel free to contact me for a list. I’m discovering more all the time.
The greatest outcome of systemic discrimination in the deaf community in Canada, at present, is lack of employment. Locally, many who are employable, are subsisting on Ontario Disability Support Program (ODSP). Because of this, many deaf people have difficulty affording therapy, and there is still a lag in the community, so there is a lack of understanding about what is involved in psychotherapy, and why one would go. Most would not be able to pay full price for therapy on an ongoing basis. There are some funded services, but there are problems inherent in this, because there is a lack of resources, so positions go unfilled for long periods of time, and many people find themselves in the position of receiving services from their former classmates.
Hard-of-hearing clients differ radically across the spectrum. This will depend on the amount of hearing difference, and where the residual hearing is in their audiogram, how well they communicate orally, who their community is, and how they self-identify, to name a few. Many hard-of-hearing people have been encouraged to believe that they are better than deaf people, but the hearing community doesn’t really accept them, so they don’t really fit in anywhere. It’s a lonely place to be, and sometimes they are the hardest people to communicate with. They have been left out at home, at school and in society at large. They pretend to understand, so as not to offend or upset people who are trying to communicate with them. It is a very difficult place to live.
In the end, creativity is essential. Having an open mind to seeing deafness as difference and not less than, makes a huge difference. Not imposing your cultural or communication biases on the client is very important as well. You might think that is self-evident, but it is surprising what goes out the window when we’re at a loss in a new situation. I used to work with a psychologist who said that he always tried to think, “What would I think this was if a hearing client was doing this?” I have had some of the stupidest comments from psychiatrists over the years, which just underlines their ignorance, and yet we need them to be learning. There are very few who have been helpful, or motivated to stay engaged and to participate in the community. It’s an ongoing issue, along with many others. There is no easy solution. It takes time and commitment to do this well.
Working with Interpreters
Contrary to popular opinion, one interpreter is not as good as another. Often deaf people have preferred interpreters, and the reason usually is that the interpreter is able to adapt to their personal communication style, and there is synergy, which will significantly impact the communication process.
Also American Sign Language is not a form of codified English, but has it’s own grammar and syntax, and consecutive interpreting is often more helpful than simultaneous, when dealing with complicated issues. There will be times when there needs to be an expansion of information to bridge the cultural gap both ways. In most situations, the interpreter should sit beside the hearing person who is speaking, facing the deaf person. You would maintain eye contact with the client (which is harder than it sounds when the voice is coming from beside you), and the client will shift back and forth between eye contact with you and the interpreter. In the best of circumstances, it’s seamless. Sometimes, the person who’s accessing therapy is from another country, or has mental health issues, or has something that interferes with their ability to understand and process complex concepts. In this situation, there would also need to be a deaf interpreter, who works with the ASL interpreter, and has special training in working with clients that have non-standard forms of communicating.
Interpreters are trained to make sense of things, and to self-correct for answers that seem to be non-responsive, assuming that there are errors in the interpretation when the response seems not to make sense. It is important that you discuss with the interpreter what your needs are. There are times when there truly has been an issue with the interpretation, and sometimes when the response from the client, whether it seems to answer the question or not, is instructive, and the therapist should be the person who clarifies the question, not the interpreter. It would be a good idea to pre-brief with the interpreter, and allow them a little latitude to explain an exchange that has taken place that seems interpreting-based.
Interpreters are not necessarily good at all venues. The most frustrating part of this is when someone truly has a mental illness or a disability that interferes with communication, but the interpreter is bent on making sense of their utterances. In my personal experience, people have been sent for 30 day assessments from court for fitness, and have come back “fit” because of the interpreter that has been employed, and the person is in no way “fit”, and cannot pass the test at the courthouse. Understanding the terminology used in therapy and the concepts behind them is very important for the interpreter to adequately facilitate communication.
Using family and friends should always be a last resort. Consider how much you would want to go to therapy with a relative interpreting for you, and being privy to your life. A person, who is involved in the therapy, should not be concurrently providing an interpreting function. That really interferes with their ability to be present during therapy. The community is small, and people will run into each other outside of your office. They need to be comfortable with who has access to the private arenas of their life. Confidentiality, while the general standard, is still a problem in this community and people need to feel confident that they have that kind of privacy in their lives. Some interpreters will ask many personal questions in the waiting room prior to the appointment, unaware that this is intrusive and could be an abuse of power. Finding the right interpreter can be a difficult process, and having consistency in interpreting is preferred, but not always possible.
1 Seeing Voices: A Journey into the World of the Deaf (1989), by Oliver Sacks is a good introduction to deaf culture and understanding.
2 In Canada, the languages are American Sign Language (ASL), and Langue des signes québécoise (LSQ).
3 I saw a family from another country, with one deaf adult child. Part way through one session, the mother started crying, when she realized that her adult son spoke 4 languages - two sign languages, and two spoken languages. She said, “I always thought my son was stupid, and now I know he is smart.”
4 The Mask of Benevolence: Disabling the Deaf Community (1993), by Harlan Lane does an excellent job of describing this. Harlan Lane has written extensively on deafness and culture, with the approval of the National Association of the Deaf in the United States. All are worth reading.
5 It should be noted that in countries like Sweden, when a child is born deaf, the national deaf association is involved in consulting on what is the most likely successful approach for this particular child.
6 I had a client, who was divorced, and their parents wanted them to have nothing to do with the estranged spouse, but they felt uncomfortable with this. The deaf community is small, and while they didn’t see their ex-partner often, they felt no particular animosity toward this person, and didn’t want to shun them in public. There had been no abuse, and there was no continuing risk. While I understand the parents’ feelings and concerns, culturally, this is inappropriate.
7 I had a client who was very traumatized by current events. Their partner had reached me earlier to explain the situation. I contacted their local interpreting services prior to their arrival, without divulging names. Then, with their permission, orchestrated an interpreter meeting them at the local hospital, and provided the interpreter with background information, and particular issues that might come up in the signing and would be relevant to the intake work she would be doing, then followed-up afterwards with all parties.
8 This sometimes happens to me when I’ve just finished interpreting at court, and I have to explain that this is an inappropriate venue for that to occur, but explain what venues would be acceptable, such as Mayfest, our local, annual deaf festival.