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Deaf Mental Health
The prevalence of deaf mental health problems in deaf people is around twice those of hearing people Deaf4Deaf are working to remedy this.
40-50% of Deaf people experience mental illness over a lifetime (compared with 25% hearing people) – Hindley & Kitson, 2000 – Hindley, P. & Kitson, N (Eds) (2000) Mental Health and Deafness. London: Whurr. This higher rate of mental illness is linked to various factors including aetiology of deafness; higher rates of abuse; delayed language acquisition and associated psychosocial factors; social exclusion.
Best practice guidance is that culturally deaf mental health is assessed and treated wherever possible by clinicians who understand deaf community and culture and British Sign Language, due to the complex presentation of mental distress in this community and the consequent is the need for specialised services. Currently, inpatient services are commissioned by the National Commissioning Board. Community services are not included in this funding and at the current time are commissioned on a case by case basis.
Accessing Appropriate Care
Many deaf people avoid their GP because of communication difficulties. UK-based research has consistently demonstrated that deaf people access GP services more infrequently and much later in the progression of a problem than the general population.
Issues include barriers to appointments, doubt over communication support (such as whether a qualified interpreter would be provided), lack of health-related information in sign language.
Access to psychological therapy for a deaf people requires a referral from their GP, however, this is not necessarily the case for hearing patients.
General Health Issues
NHS mental health care is delivered in a stepped care model. This aims to provide care in the least restrictive manner and by the service best placed to meet an individual’s needs.
For hearing people this means that the lower levels of intervention are easiest to access, with self-referral at the lowest level.
Deaf people do not have the same access to the stepped care model.
A deaf person cannot self-refer, for example.
Deaf people are therefore not being offered the least restrictive nor more preventative option.
Deaf people are a hard-to-reach minority group and as such, it is unlikely that there will be enough sign language population to make it cost effective for the NHS to set up a local primary care service contract with a specialist provider for deaf mental health.
Provision of Accessible Information
Deaf people face several challenges obtaining accessible information about their health. This results in a low level of knowledge about health among the deaf population leading to lower levels of self-identification of problems and self-care.
When Deaf people do attempt to obtain the help they often face the challenge of using a telephone ‘single point of access’ service to arrange an appointment. The low level of English literacy in the deaf population means that appointment letters may be misunderstood, and self-directed learning and homework resources may be incomprehensible. This means that even if a deaf person is referred to a service, they may not be able to access it or benefit from the intervention.
Deaf people are not uniform in their communication needs and preferences. There is a wide range of different forms of communication and cultural attitudes that are indicative of the deaf community, including combinations of spoken and signed language. Therefore, it cannot be assumed that a way of meeting one deaf person’s needs will be the same as another and, as such, an initial assessment by a practitioner who is able to quickly define the linguistic and cultural needs of that individual should be sought and funded.
What is the standard care pathway for your patient’s condition?
Interpreted counselling is most commonly used in parts of the country that do not support deaf mental health patients using a deaf counsellor.
When deaf patients have been offered interpreted counselling, the conversation becomes a 3-way triangle of communication.
In most cases, the deaf patient does not feel understood or understand what the counsellor is saying to the interpreter or if the feeling is being relayed accurately as intended back into the interpreter and then relayed back to the deaf patient.
Sign language interpreters in mental health settings face extreme linguistic and cultural difficulties in interpreting basic, everyday language used in these settings. In most cases, the interpreters are qualified to level 4 sign language competency, D4D offer level 6.
Deaf patients, in general, have limited English proficiency which often requires interpreters to use expansion techniques to render messages successfully.
The question must always remain that an interpreter should not be a reasonable adjustment as there are services such as ours that are competitive by price and more importantly match the person’s communication and cultural needs. Deaf counsellors understand the culture within the deaf community and the problems faced by most individuals.
National Deaf Survey using Interpreters within Deaf Mental Health Settings
Deaf people who are offered and take up interpreted counselling in most cases re-enter counselling time and time again, Why?
It is reported there are 50,000 profoundly deaf people in the UK. A commissioned nationwide survey of the deaf community explored their own personal experiences of interpreted counselling.
Over 20,000 deaf people responded to this survey, representative of approximately 40% of the community.
Questions and Answers asked:
Why did you seek help?
Was your application declined or approved?
If counselling was awarded, did you complete all the sessions?
If accepted why did you not complete the sessions?
How was your counselling experience?
Summary of the Questionnaire
21% of the people who responded stated they had been abused, 15% have addictions, 11% Anger and Depression at 39%. It could be said that as a community deaf mental health is complex and cannot be duplicated in any other cultural group.
Key points to take from the survey is that 76% of the deaf population that used interpreted counselling did not complete the sessions, the chances are they will re-apply which adds additional cost to the national health service.
24% of people could not understand the counsellor and interpreter communication and 47% felt that the counsellor did not understand deaf culture.
Only 20% of people who used interpreted services were satisfied with the mental health counselling they received.
72% of people who ask D4D for help have already tried the hearing counsellor experience more than once.
Why should deaf mental health patient’s be treated as exceptional over and above other patients with similar conditions for whom this treatment is not currently available?
Deaf people are not uniform in their communication needs and preferences. There is a wide range of different forms of communication and cultural attitudes that are indicative of the deaf community, including combinations of spoken and signed language. Therefore, it cannot be assumed that a way of meeting one deaf person’s needs will be the same as another and, as such, an initial assessment by a practitioner who is able to quickly define the linguistic and cultural needs of that individual should be sought.
We know that health service providers have long-standing contracts with outsourced companies delivering all types of counselling. Our experience from the people we speak to tell us that contracted out service provider does not in most cases have a sign language counsellor.
So how do deaf people differ from other cultural groups that require interpreted services?
Asian & Ethnic Cultures – they have had full communication using their own language within a family unit, they have received culture and common values because they stay within their peer group. They do not have the same issues as a deaf person who in general is isolated into hearing society.
Foreign Nationals – They have grown up in their country of birth and have had a full language experience again within their own culture.
Deaf People– have not had the same experience They have had no English language in most cases, they are undereducated with little reading and writing skills, they have little employment opportunities (68% unemployed), abuse by able hearing people (sexually, emotionally and physically) is prevalent and could be said to be endemic. Therefore, communication as a reasonable adjustment is only a part of the challenge faced by counsellors who do not come from a deaf background or understand the culture within the deaf society.
Deaf people are exceptional. Communication should not be the first point of reference to their mental health needs. They require cultural understanding and empathy of their perceived feelings of discrimination.
Communication needs cannot be assumed to be the same for deaf people as it is for foreign nationals who do not speak English or ethnic individuals that have lived in a family-based same language cultural community.
“Deaf people are generally born to hearing parents within a hearing community”
It is widely accepted that the advice given by professionals to parents of deaf children in the 70s, 80s & 90s was to speak to their children using the spoken word. The children were expected to lip read with no or little signing. These children did not have access to mobile phones, Facetime or even subtitles on television.
A large % of these children became withdrawn or developed extreme anger issues. The majority (86%) of the applications we receive for counselling is from these age groups.
A hearing counsellor with no knowledge of the isolation deaf people felt could not reasonably help the mental health of the patient, therefore the health service does see deaf people re-enter counselling time and time again or the person simply suffered in silence.
Deaf people do have exceptional needs and cannot be the same as other patients who require counselling with language complications.
Why is this patient likely to benefit significantly more than other patients with a similar condition?
Deaf people have mental health problems that are unique to the deaf community.
Even when deaf people have the most supportive family and friends, they can find it difficult if not impossible to explain why they feel this way, through lack of communication, lack of external resources (money, access to education, and health care) and lack of self-awareness of feelings and emotions.
Deaf individuals are mainly born into a hearing family (92%) most parents do not understand the deaf culture or use sign language. Education and understanding of language are much better understood today than it was for thousands of children born in the ’40s, ’50s, ’60s, ’70s, ’80s and ’90s.
Deaf individuals have cultural mental health issues transcending the community. These individuals require counselling from counsellors who understand the inherent problems within society.
Using a deaf counsellor, the individual will feel:
Many deaf individuals re-enter counselling time and again. Using a deaf counsellor, the National Health Service will save valuable money and more importantly help deaf individuals re-enter society as a whole person.
What will be the impact of refusal on the patient?
D4D have received hundreds of self- assessments from within the deaf community each year. The self-assessment record the mental health of the individual. The self-assessments completed show Anxiety or Depression as the mental health issue faced by the deaf person.
On receipt of a self-assessment, we invite the patient into a 1.5-hour assessment session with a trained deaf counsellor.
This is where the self-assessment diagnoses change in most cases
Exclusion, abuse in all forms, isolation, deaf identity, education deficiencies, bullying & employment prospects all are common dominators but not recorded on the self-assessment using PHQ-9 and GAD-7 questionnaire.
BPD is one of the top 5 mental health problems for deaf people.
BPD is a long-term pattern of abnormal behaviour characterised by unstable relationships with other people, unstable sense of self and unstable emotions.
When counsellor and client communication can flow easily on a one to one cultural basis, the true mental health problems come to the service. A selection of mental health conditions is recorded below from the assessment sessions in comparison to the self-assessment.
On the left are the top five self-assessment issues recorded and then on the right the top five recorded after the assessment sessions by the counsellor.
1 – Depression 1 – Abuse, Physical and Mental
2 – Anxiety 2 – Trauma which includes a large % of Sexual Abuse
3 – Anger 3 – Suicidal Thoughts including suicide attempts
4 – Loneliness/Isolation 4 – Anger (BPD traits)
5 – Identity 5 – Self-Harm
Misdiagnosis of deaf individuals with complex mental health issues is a contributing factor why funding has been turned down in the past. We know this after we speak with doctors who do not have a full understanding of the individual’s mental health issues. This is commonly down to miscommunication or the individual no longer visits their GP regularly.
23% of applications made via the self – assessments find that individuals are no longer registered with a GP. This is common because letters sent to individuals asking them to attend the surgery are not read, they either cannot read or don’t understand the language within the letter as a result over time the individual is deregistered without their knowledge.
Refusal of funding could result in increased mental health issues which in turn could affect partners, children and wider communities that the individual may meet.