Prelingual Profound Deafness and Psychology
What is deafness ?

Deafness, partial or complete loss of hearing, may be described in a number of ways including severity, time of onset, and aetiology. The British Society of Audiology (BSA, 1988) provide audiometric descriptions of the severity of deafness as follows:

Descriptor... Hearing loss:
Mild deafness... 20 - 40dB
Moderate deafness... 41 - 70dB
Severe deafness... 71 - 95dB
Profound deafness... 96+dB

*dB loss in the better ear on pure tone audiometry, average across 250, 500, 1000, 2000, and 4000 Hz. The intensity of conversational speech lies within the range 60 - 70 dB.

Hearing loss may result from a number of different causes such as prenatal rubella, meningitis, prematurity, complications of Rh factor, ototoxic drugs, syphilis, mumps, Ménière’s Disease, and exposure to noise (Vernon & Andrews, 1990). Although, as shall be discussed, it is important to consider the aetiology of presenting deafness, the many causes may be divided into four categories as follows (O’Rourke, 1990): a) Conductive losses, which are those which result from a mechanical problem such as malformation of the ear. Because intensity at all frequencies is reduced, amplification can be beneficial. b) Sensori-neural losses which involve the cochlea and/or the auditory nerve and so affect fidelity as well as intensity, resulting in distortion. c) Mixed losses, which are those with both conductive and sensori-neural elements, and d) Progressive loss, which is a rare type that worsens over time (Freeman et al, 1981).

Finally, and perhaps most importantly, time of onset has a significant effect on the degree to which the hearing impairment becomes a disability, in that severe or profound deafness occurring before one year of age can significantly affect the acquisition of spoken language (Hindley, 1993). Kitson and Fry (1990) state both the incidence and prevalence of prelingual profound deafness to be 1 per 1000. Following from Basilier’s (1972) definition of ‘social deafness’ - ‘deafness which with the best hearing aids available (that the person will use) does not allow understanding of speech through the ears well enough to take part in a brisk conversation’ - Kitson & Fry (1990) describe a more practical system of categorisation:

1. Prelingual (congenital or acquired before language development)
a) Profound (no speech reception through the ears)
b) Partial (some difficulty in speech reception)
2. Postlingual (acquired after language development)
a) Profound
b) Partial.

It is this classification which will be adopted below. However, when discussing the psychological implications of the impairment, it is important also to consider the cultural aspects of deafness, including the use of sign language, lip-reading or cued-speech, and membership of organisations for deaf people (Hindley, 1993). As has recently become standard practice, the essay will refer as far as possible to deaf people, who identify themselves as members of the deaf culture, as Deaf with a capital D, leaving deaf with a lower-case d for those people who may or may not identify with Deaf culture but do have a hearing impairment. It will be assumed that Deaf people communicate in a sign-language, while deaf people may or may not. Except where indicated, ‘deaf’ or ‘deafness’ will refer to prelingual profound deafness.

In this study of prelingual profound deafness, the question of whether there is a psychology of deafness, and what that means, will be addressed. The different ways in which deafness impacts on psychopathology will be discussed, and various responses or solutions to this considered.

The Impact of Deafness:

“Deafness before the acquisition of language [is] a greater affliction than blindness.”
Helen Keller (1929)

A brief look at the literature pertaining to this field quickly gives the impression of deafness as a uniform condition, and of deaf people as an unvarying population. This is clearly not a true picture. However, as a result, it can be inferred that there is a psychology of deafness, distinct from that of hearing people, which either compares deaf with hearing populations, assuming hearing norms, or adopts norms of ‘deafness’ thus homogenising a demonstrably diverse group. Neither of these conclusions are particularly satisfactory. There are specific difficulties of cross-cultural study which will be outlined later, however, Cole (1991) provides a practical perspective in that

“What makes it possible to talk about a psychology of deafness is that for many Deaf people their experiences have a lot of important factors in common and we can study the psychological effect of these factors.”

Cole proposes a model that assumes a normal development throughout childhood and adolescence, which is encroached upon by a variety of experiences associated with deafness. These experiences include the deafness itself, and so the model becomes, to the pedant, somewhat tautologous, however the above model, as a rule of thumb, is a useful maxim to adopt when thinking about the impact of deafness on psychology and psychopathology. This impact may reasonably be expected to take any of three forms: i) The aetiology of the deafness may bring with it further concomitant disorders or experiences, ii) the deafness per se may give rise to a describable psychological effect, and iii) the deafness may itself lead to an intermediate factor which results in a psychological effect. This essay will consist of an exploration of these three forms. It will become apparent that the distinction between ii) and iii) is impractical, and so will be discussed together (Aspects of Deafness.)

Concomitant effects of certain aetiologies of deafness:

It is estimated that 50% of deaf people are deaf as a result of trauma, and many of those are likely to have suffered some degree of brain damage (Kitson & Fry, 1990). Hindley (1993) describes how powerful the effect of brain damage is in the aetiology of psychiatric disorder, citing among others Seidel et al (1975), Shaffer et al (1975) and Brown et al (1981), and the means by which this effect may occur are described as:

“...impairment of intellectual function, specific learning disabilities, associated social disadvantage, social stigma associated with handicap, the effects of brain damage on temperament, and the effects of anticonvulsant drugs.”
Hindley (1993)

Of these mechanisms, it can be seen that some involve the direct effects of brain damage, such as specific learning disabilities, while others are concerned with secondary results, such as the effects of social stigma or drugs. However, be they direct or otherwise, they are all means by which concomitant brain injury may impact on a person’s psychological functioning. Vernon & Andrews (1990) describe how trauma which results in profound deafness can occur as a result of a number of conditions (described above) and these conditions may give rise to further problems not necessarily directly related to the deafness. Outlined below are two examples of such conditions:

During pregnancy, the otherwise fairly harmless rubella virus can have pervasive and traumatic effects. It quickly assaults the layers of embryonic tissue and reduces cell division in the developing body parts such as the ear, brain, eye, and heart. Vernon (1969) describes the prevalence of deafness due to rubella in his sample of 1,468 as 139, that is, 9.5%. In examining the IQ distribution of post-rubella deaf children, he identified a mean IQ of 95.3 with a standard deviation of 16.8, significantly less than the general population, and it is suggested that post-rubella deaf children do not succeed educationally as well as their deaf peers (Vernon et al 1980). Feldman et al (1971) distinguished an increase in aphasia among rubella-deafened children, which would also compound communication problems resulting from the deafness, and Chess (1977) identified an increased incidence of autism. Also implicated in rubella are psychosis and behaviour disorders such as poor impulse control, excitability, rigidity, distractability, instability, and emotional shallowness (Trapp & Himelstein, 1972; Chess & Fernandez, 1980; Vernon, 1969). Although these effects should be borne in mind, Vernon and Andrews (1990) stress the importance of realizing that the majority of prenatally rubella-deafened persons are, however, behaviourally within the normal range.

Meningitis is an infection of the membranes surrounding the brain. It deafens between 3 and 10% of its survivors and is the leading cause of postnatal profound hearing loss (Raivio & Koskiniemi, 1978; Vernon, 1967a&b). Also, as a result of the introduction of antibiotic treatment, the proportion of those deafened by meningitis being so before the acquisition of language is increasing. This is because once the early symptoms may be verbalised, antibiotic treatment may be quickly instituted, whereas the prelingual infant may only be recognised as meningitic once the disease is somewhat advanced. Vernon & Andrews point out that at this stage, even if treatment enables survival, the chance of sequelae such as deafness is greater, especially as, unfortunately, some of the drugs used for treatment have ototoxic effects (Hindley, 1993.)

Vernon (1969) has found the mean IQ of post-meningitic deaf children to be 95, and that 34% had an IQ of less than 90. (He also states that from a study of 26 meningitic deaf children aged between 7 and 12 months, the mean IQ was 91.50 and the percentage of those ‘mentally retarded’ [sic], 34.6%.) It was also identified that 38% of the post-meningitic deaf sample had additional major disabilities including, in order of prevalence, aphasia, learning disability, emotional disturbance and cerebral palsy, and that these were more likely following an early onset. Of the 8.3% that were dropped from school for ‘emotional disturbance’, 29.3% had problems such as aggression, hyperactivity, poor impulse-control and distractibility, psychosis, or anxiety as a reaction to aphasia.


Other aetiologies which may have concomitant effects include prematurity and complications of Rh factor, which both appear to correlate with lower IQ, aphasia, and emotional disturbance, prematurity also being implicated in schizophrenia.

It can be seen from the above studies how the aetiology of a hearing impairment may itself increase the probability of further, psychological, problems, which may be considered in isolation from the deafness. That is, certain sequelae of a particular disorder may manifest in a person whether or not deafness is also indicated, and should not be interpreted as alleged ‘symptoms of deafness.’ However accompanying deafness must be acknowledged as it may influence the effect of that symptom, as well as the processes of assessment and treatment (see Implications for Services, below).

Aspects of Deafness:

Deafness per se:
A number of different authors have suggested that, among other things, concrete thinking, impulsivity, rigidity, and lack of insight, are the direct results of deaf enculturation (Altshuler, 1971; Misiaszek et al, 1985; Kitson & Fry, 1990.) The term coined by Basilier (1964) for describing these behaviours - surdophrenia - which literally translates as ‘deaf mind’ - suggests that such behaviours are characteristic of deaf people in general, but there are a number of reasons why the term is unhelpful (BC Swaans Joha, 1991):

• It implies that surdophrenia is a mental illness, and is therefore confusing.
• The criteria and characteristics are inadequate.
• The literal translation implies that all deaf people necessarily suffer from mental health problems.
• The deaf community find it offensive.

The surdophrenic condition was simultaneously described by Rainer et al (1963) as ‘Primitive Personality’ although Vernon (1978) uses this term to describe deaf people who have been inappropriately provided for, such as those who live dependently and overprotected with their parents and who, when those parents die, have to face the double trauma of bereavement and independent living for which they are not prepared. Although the label suggests a particular personality type, as well as being pejorative, Vernon’s use of it implies a problem not of a personality type unique to deaf people, but of a failure to adequately provide for the specialised needs of the deaf person. Perhaps as a result of the over-representation of deaf people in mental illness hospitals (that is by a factor of about 10 - Denmark, 1966) or by the assumption that no speech indicates no language which indicates no thought (Cole, 1991), it seems as if there has been an assumption of a problem or personality type peculiar to deaf people. The literature seems to imply that this assumption is unfounded, for example Vernon’s (1978) use of Primitive Personality above being read as service deficiency, or John Denmark’s (1985) description of problems related to deafness: Denmark describes 250 patients referred to a specialist psychiatry department for deaf people, underlining the need for such specialised services. The problems of these patients are categorised into three types - those suffering from mental illness, those with problems related directly to deafness, and those with communication disorders (which will be discussed later.) Of the prelingually deaf people studied, all of the problems related directly to deafness were behavioural and adjustment problems resulting from the communication difficulties of being deaf in a predominantly hearing world and/or family. It would not be valid to infer from this that such adjustment problems were necessary sequelae of deafness as there are certain other conditions the fulfilment of which effect the presence or extent of the problem; for example being raised in a predominantly oralist milieu, as Higgins (1987) demonstrates how deaf people from an oralist background are more likely to have a negative-self image, while those from Signing backgrounds are more likely to have a positive self-image.

Rather than supposing that deafness results in its own unique set of psychological problems, it may therefore be more constructive to look at how the experiences of deaf people differ from those of the hearing, and then it may be possible to deduce reasons for those differences.

Comparative rates of prevalence:
In order that one may examine such differences, to explore the possible effects of being born deaf on psychopathology, and to identify any clinical evidence for a psychology of deafness, it will first be necessary to examine rates of prevalence. Vernon & Andrews (1990) provide perhaps the most comprehensive analysis of the comparative prevalence rates of non-psychotic and psychotic behaviours between deaf and hearing people. The following is a brief summary. Where observation is based on research, this will be indicated, otherwise it may be assumed that it is based on Vernon’s 1969 paper, or his clinical experience:

Learning disability: There is a similar distribution of IQ scores for both deaf and hearing populations, although Brill (1963) has shown genetically deaf people to have higher mean IQs than the general population. The main problem is one of poor assessment measures, as described later.

Attention Deficit Disorders: There is a higher prevalence of attention deficit disorders among deaf people, as a result of the brain damage or endocrine disorders associated with the aetiologies of deafness (Vernon, 1969).

Substance Misuse: Patterns of the misuse of drugs and alcohol are said to be similar for deaf and hearing populations. Hooten (1978) suggests isolation, unemployment and stress could lead to increased levels of alcoholism in deaf people as they are more prone to these, while Altshuler and Rainer (1970) propose that lack of depression (see below) would reduce the prevalence of drinking problems. Overall, the rates of substance misuse are no different from the general population.

Anxiety Disorders: Obsessive-compulsive disorder, anxiety, post-traumatic stress and phobias occur as frequently among deaf as hearing people.

Somatoform Disorders: According to clinical experience, these are no more prevalent in deaf than hearing populations.

Paraphilias: No research data exists on prevalence rates, but Vernon’s clinical experience suggests no difference between deaf and hearing people.

Disorders of Impulse Control: Impulsiveness seems to be found more often in those people who are deaf as a result of organic factors. Harris (1976) and Levine and Wagner (1974) showed that there is no more impulsiveness in deaf people who have early exposure to sign language, deaf parents, or high levels of academic achievement, so, a lack of these factors may raise the likelihood of problems with impulse control.

Paranoid, Schizoid, and Schizotypal Personality Disorders: There appears to be no increased risk of schizoid and schizotypal personality disorders among deaf people. Neither is there an increased risk of paranoid personality disorder despite there being significant mention of connections between deafness and paranoia in the literature, such as DSM III (Spitzer, 1980) and Cooper (1976). Cooper goes on to distinguish between pre- and post-lingual deafness, describing a clearer relationship between post-lingual deafness and paranoia - perhaps as a result of increased (possibly reality based) suspiciousness, or of misunderstanding (Kitson & Fry, 1990.)

Histrionic, Narcissistic, and Borderline Personality Disorders: Vernon and Andrews describe Histrionic Personality Disorder as being no different in deaf than hearing people, although they admit a lack of research data. Narcissism may have an increased prevalence among deaf people, but there is no explanation other than its possibly being caused by naivety. This naivety could reflect a number of the common experiences of deaf people outlined by Cole (1991) - lack of experience, lack of knowledge, and lack of incidental information being picked up which is critical to the development of what many would refer to as ‘common sense.’ The presence of Borderline Personality Disorder in deaf people does not appear to be mentioned in any literature, while its significant absence is described by Grinker (1969). It is stressed that this absence may be due more to diagnostic difficulty than nonoccurrence.

Avoidant, Dependent, Compulsive and Passive-Aggressive Personality Disorders: The social dynamics of deafness (which are not described) are said to result in a higher prevalence of both Avoidant and Dependent Personality Disorders among deaf people. Compulsive Personality Disorder is no more common, while Passive-Aggressive Personality Disorder is implied to be more prevalent as a result of failures of communication with authority figures, leading to direct, impulsive ways of acting out (which leads to more trouble), which becomes a passive compliance with an underlying resistance. This seems a rational hypothesis, but, reasonably, the increased prevalence is only implied.

Schizophrenia: Kitson and Fry (1990) suggest that schizophrenic psychoses are found equally among deaf as hearing people, quoting Altshuler & Sarlin (1963), although they point out that there are no reliable figures - possibly as a result of problems in diagnosis. Similarly, Vernon and Andrews describe how the proportion of hospital admissions for deaf people for schizophrenia is about the same as for hearing (presumably meaning the proportion of deaf to hearing schizophrenic admissions is the same as the proportion of deaf to hearing people in the general population; the description is ambiguous.) However there are more deaf schizophrenic people in hospitals than hearing (Basilier, 1964) probably as a result of communication problems impeding the monitoring of treatment, and the concurrent misdiagnosis of paranoia or learning disability resulting in admission to more long-stay chronic wards. As an illustration of this, Timmermans’ (1989) study found the average stay in hospital to be 148 days, while deaf inpatients remained for 19.5 years (Kitson & Fry, 1990).

Depression: Altshuler (1971) suggests that depression is rare in deaf people, possibly as a result of deaf children not being so exposed to parental and societal pronouncements, leading to a less developed super-ego and so less depression; that is, it is “suggested that hearing is required for normal development of object relations and conscience.” (Kitson & Fry, 1990.) Kitson and Fry go on to suggest that Deaf people with normal language development (in sign) do not appear to suffer delayed personality development, but that this population is too small to effectively study. Evans and Elliot (1987) suggest, also, that “contrary to a commonly held belief about deafness, depression is fairly common in our prelingually deaf patients, particularly in the self-referrals seen in our satellite clinics” - suggesting that referral and presentation patterns may mask depression in this population.

Autism: Autism has not been shown to be any more or less prevalent among deaf than hearing people unless the cause of the deafness was prenatal rubella, in which case the prevalence is 7.4%, compared to 0.7% for the general population (Chess, 1977; Chess & Fernandez, 1980.)

Certain themes are evident in this summary. Perhaps most striking is that, given appropriate assessment tools, there is no reason to suggest that prevalence rates for deaf people are any different than those for hearing people on at least a half of the above disorders, including schizophrenia, certain personality disorders, and anxiety disorders. Of those that are different, two show reduced rates - possibly due to presentation rates and referral pattern, problems of diagnosis, or maybe developmental issues, while six show increases in prevalence - some as a result of common organic aetiology, and others as a result of social factors such as being overprotected or isolated, and frustrating failures of communication. Certain issues of neuropathology have been discussed above, and so will not be dealt with again here, however, the main explanation for certain prevalence rates would therefore seem to be the many different experiences associated with deafness which may impact upon issues of psychopathology. Cole (1991) collates these as follows:

Deafness and background variables:
Age of onset
Degree of deafness
Speed of loss
Time of diagnosis
Deaf or hearing parents
Parental attitudes
Individual Character
General environment
Other problems (physical, intellectual etc.)

Type of education
Attitudes of professionals
Attitudes of parents
Information input
Deaf or hearing world
Lack of experience
Lack of knowledge
Limited role models
Over protection

Feeling rejected
Lack of identity
Identity confusion
Fear & anxiety
Lack of control / power
Hard work
Self image
Self esteem
Limited opportunities
Limited social roles

The categorisation of certain items in these lists is debatable, for example some may argue that parental attitudes and time of diagnosis are a resulting experience, and indeed the distinction between experiences and consequences could seem a little arbitrary. However, they provide an excellent aide memoire for items which the professional should consider, and Cole describes how they relate as follows: “Background variables to do with deafness, the individual’s characteristics, particular family circumstances and the wider social environment interact to dictate the individual’s experiences, some of which can be influential in determining their psychological functioning.” She points out that many of these experiences emphasise disability and goes on to describe in detail how development may progress differently for a deaf person, which demonstrates quite clearly how it is the combination of deafness and the environment which impacts on psychological functioning, rather than the deafness per se. There are probably three main aspects from these lists which psychological services should consider: professionals and their attitudes, issues of communication, and deaf or hearing world (culture), for these may have serious implications for assessment and the process of intervention.
Implications for services:

Issues of communication:

“Language influences the assessment process more than almost any other variable...”
Orr et al (1987)

Alice Thacker (1990), a specialist speech therapist in hearing impairment and psychiatry, provides two explanations for the over-representation of deaf people in mental health services described above: the first is a failure to detect the hearing loss at all, such that certain limitations resulting from the deafness such as impoverished vocabulary, rigid structure and little linking of themes are interpreted, for example, as poverty of content, poor insight and withdrawal. The second is a failure to adapt diagnostic procedures and management appropriately. This is pointed out well by Monteiro (1989) who describes how “it is extremely difficult to diagnose even physical illnesses without effective communication between patient and doctor.” Clearly, a psychological assessment can be rendered almost impossible without effective communication between therapist and client, which, as Monteiro describes, can render the assessor feeling deskilled and helpless and so, under pressure to offer an opinion, often makes an assessment which has little established basis.

One answer to this problem could be the use of an interpreter. However, this also affects the assessment or therapy session in a number of ways (Orr et al, 1987). For example, the presence of an interpreter turns a dyadic process into a triadic one which Hoyt et al (1981) point out may dilute and distort the relationship, complicating transference issues, and make the interpreter become a centre of authority. Also the interpretation is never a literal word-for-sign conversion as most sign languages, like spoken ones, have different grammatical structures and inferences attached to the concepts. Therefore, the interpreter’s job is also to try to capture the hints and flavours of the conversation, which necessarily introduces that person’s history, expectations, and understanding of psychological concepts into the situation - to accommodate this, Orr et al emphasise the necessity of using an interpreter with expertise in the mental health situation. There is also a question of confidentiality.

If the psychologist chooses to use sign language, it is clearly important that that language can be used fluently. Orr et al point out that it is easy to slip from ASL or BSL (American and British Sign Language) into signed English, which differs in syntax, thereby unintentionally changing the meaning. It is also necessary to recognise that deaf clients may have variable abilities in the chosen method of communication as a result of a changing educational and familial background. Thus, if for example BSL is the predominant language of choice for a particular client, it may not be the case that that person is fluent in that language, and so may also slip into other signed systems, or indeed other means of communication altogether. Even the most fluent professional would have to be extraordinarily skilled to effectively follow such a conversation. Similarly, though, as a result of a varying background many deaf people are able to adapt their language to the situation. Orr et al, however, describe how this can lead to tension, stress, frustration, misunderstanding, and constriction. Schlesinger and Meadow (1972) point out, also, that communication difficulties can be used as a resistance by clients, for example by signing too rapidly, looking away, or selectively misunderstanding troubling material.

Issues of Assessment:

“Misdiagnosis of deaf patients is common. Many are labelled mentally retarded or schizophrenic as a result of their language disability due to deafness, not the actual presence of retardation or psychopathology.”
RR Grinker (1969)

As described by Monteiro (1989), there are a number of ways in which communication issues can affect assessment and diagnosis. One is that psychopathology is inferred when in fact there is none, as proposed by Thacker (1990), above, while another is that presenting psychopathology may be missed. The former is further described by Hoyt et al (1981) who demonstrate that “what may appear to be unusual or distorted thinking may actually be a normal and appropriate locution in ASL” and by Evans and Elliott (1981) who report “the tendency to overdiagnose schizophrenia as a wastebasket classification when confronted by a gesticulating, excited patient who cannot be understood.” Denmark (1966) has also written that “the inability in the deaf to express dissatisfaction or anger in the normal way, or quickly enough, by emotionally tonal verbalisation, often leads to the physical display of such feelings. To those without a knowledge of the psychology of the deaf person these reactions, at times explosive in nature, are incomprehensible and may be mistaken for the manifestation of mental illness.”

Neither positive nor negative misdiagnosis is helped by the standard classification systems such as DSM-IV which often unavoidably have to use symptoms based on a mostly hearing population. As illustration, Evans and Elliott (1981) demonstrated how of the fifteen signs and symptoms of schizophrenia they identified from three separate classification systems, six were present in non-psychotic as well as psychotic deaf people. (This paper therefore provides a good working system for identifying schizophrenia in deaf people.) Thus, even without overriding communication difficulties, strict diagnosis, for those who demand it, becomes problematic in and of itself.

Similarly, of course, assessment tools and psychometric tests are more often than not equally bound up in a hearing milieu. F.R. Zieziula (1982) describes four critical questions to be addressed when selecting a test for use with a deaf person:

1. Does the test consist of verbal test items or performance items ? Prelingually deaf people will usually have difficulty with English syntax and vocabulary, indeed, the mean reading level for this population is estimated to be at a third- or fourth-grade level. Performance on verbally loaded test items will therefore be clearly impeded.

2. Do instructions for the test require verbal communication ? Even if the test items are performance-based, the instructions often are strictly verbal. Sometimes, the test developer will allow alternative instruction procedures, which may make translation into sign language a viable option, but even then, the validity of the results must be questioned (see issues of culture, below).

3. Do any test items discriminate against people with an auditory impairment ? Some test items relate to an individual’s ability to hear and function in a hearing world. For example behaviour items in the Vineland Social Maturity Scale include “makes telephone calls” and “talks in short sentences” while the Minnesota Multiphasic Personality Inventory includes statements such as “my hearing is apparently as good as that of most people.”

4. Are hearing impaired people included in the normative sample provided by the test developer ? This can include a separate normative sample of hearing-impaired people, or even whether deaf people are included in the general normative sample. (Which sample is more appropriate is a matter for debate, and would probably depend on the purpose of testing.) When a test does not satisfy this criterion, interpretation of results should be made very cautiously. Indeed, most tests do not - of those that do, Zieziula identifies the WISC-R Adaptation by Ray (Ray 1979), the Stanford Achievement Test (Hearing Impaired Edition), the Geist Picture Interest Inventory: Deaf: Male Form (Geist, 1962), and the Hiskey-Nebraska Test of Learning Aptitude (Hiskey, 1955), to which Orr et al (1987) add the Leiter International Performance Scale (Leiter, 1948).

Issues of Culture:

It is the shared experience of being deaf, described by Cole above, which, partially, determines members of the Deaf community (Higgins 1987), and, while the above criteria relate to the communication issues surrounding deafness, there are also factors of cultural validity to take into account when testing Deaf people. A useful analysis of cross-cultural testing is provided by Flaherty et al (1988) who identify five sorts of validity which should be achieved: The first is Content Validity in which each item of the test is examined to ensure relevance to the culture. The second is Semantic Validity where items in the translated, or otherwise adapted, version of the test continue to mean the same thing after translation (a useful test of this being back-translation where the item is translated back into the original language and examined for equivalence.) Technical Validity is that in which the method of data collection affects the results in different ways, depending on the culture.(Hindley (1993) points out that the interpreter in his research considered a face to face interview to be foreign to deaf children.) Criterion Validity is concerned with whether the test items refer to the same concepts in each culture, and Conceptual Validity considers whether the test items relate to concepts that are not alien to the culture.

While Flaherty et al’s study is concerned with research tools, the issues therein are still as pertinent for the hearing professional working at any level with Deaf people. No attempt has been made here to define Deaf culture, as attempts to define any culture must necessarily be so precise as to be lacking depth, or so general as to be uninformative. Higgins (1987) provides a clearer picture, but for the purposes of service provision, recognition that a client may identify with the Deaf culture should render the professional receptive to whatever that may mean for that client.


Deafness has been described above in a number of ways, for example in terms of time of onset, severity and aetiology. The question of whether there is a ‘psychology of deafness’ has been discussed and the various means by which a hearing impairment has been said to influence psychopathology identified - common aetiology, aspects of deafness per se and experiences of deaf people. Many different authors have described this in as many different ways, including the assertion that deafness leads in and of itself to a particular type of person - which seems to be both unfounded and unnecessary. The most practical explanation seems to be one in which deafness can result in different experiences from those of hearing people, and it is this combination of experiences which impacts upon psychopathology. This is not to say that deaf people all share a unique homogenising set of life events, but that there is a set of experiences resulting from being deaf, a subset of which may apply to a particular person. It is also clearly important to consider the cause of the hearing impairment, as this may play a critical role in presenting psychopathology.

Three considerations to observe as a hearing professional when working with a deaf person have been discussed. Communication issues, once identified, may be addressed in a number of different ways, though none of these is without its drawbacks; formal assessment is plagued with pitfalls which cause the assessor to rely almost entirely on qualitative rather than quantitative measures; and Deafness as a culture also has pervasive effects on both formal tools and informal understanding.

To conclude, the question of whether there is a psychology of deafness, of whether prelingual profound deafness affects psychopathology, becomes less meaningful once one acknowledges a culture of deafness. Indeed, when one attempts to delineate a psychology of deafness, recognition of culture becomes unavoidable.

In the absence of comprehensive psychology services, of deaf psychologists, and of appropriately standardised assessment tools, other than by developing as thorough an understanding of deafness as possible the main answer when working with a deaf client must be to be truly client-led.


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Jim CromwellComment
What are the effects of using interpreters in therapy with British Sign Language users?
“Figure of room, occupancy in a field of general space occurs.”
Verbatim translation of a sentence meaning “it has plenty of room” in Shawnee (an American Indian language). Kyle & Woll (1985).

An Interactional Handicap:

A paradox has been pointed out (Vernon and Brown, 1964) that deafness increases the probability of emotional problems by increasing tension and frustration, yet also gives rise to a barrier to communication that rules out the possibility of psychological assessment and treatment. Although many assessment techniques are inappropriate (Vernon & Andrews, 1990) and false-positive as well as false negative diagnoses are common (Monteiro, 1989) it appears probable, given appropriate assessment instruments and techniques, that deaf people show comparable rates of prevalence as hearing people for many psychological complaints such as anxiety disorders, depression, substance misuse, somatoform disorders, paranoid, schizoid, schizotypal, compulsive and histrionic personality disorders, and schizophrenia (Vernon & Andrews, 1990; Schein & Delk, 1974). Thus, Vernon and Brown’s (1964) initial premise is shown to be false and the paradoxical nature of the observation no longer applies - however, as a powerful means of indicating the central difficulty for a hearing therapist without facility in the appropriate sign-language it remains effective - it points towards communication as the main handicap resulting from deafness which influences access to psychology and other services. Following this, Elliott et al (1987) point out that communication is both expressive and receptive and as such the disability of the client (the deafness) gives rise to a handicap experienced by the client, the therapist or both. I would argue that communication is necessarily an interactional process, even in the presence of considerable time-delay between expression and reception, that it is the functional coincidence of expression and reception, and so that the above handicap is necessarily experienced by both parties.

This distinction may be further illustrated by considering an example of a hearing therapist and a hearing client, the difficulty in this example being that the therapist speaks only English and the client speaks only Japanese. The ‘disability’ if we may call it that, is clearly symmetrical - each is unable to communicate in the language of the other. A therapeutic situation involving an English-speaking therapist and a British Sign Language-using client may be compared in many important respects to this example, and enables us to move away from the idea of overcoming a disability to enabling communication between two parties who use different language-systems. Although BSL is the fourth major language of the United Kingdom (after English, Welsh and Gaelic) there are just three mental health services in this country providing their services in BSL, and very few psychologists, or other mental health professionals, who are able to communicate in BSL at any level, yet alone fluently. Also, the in-service components of most training courses for psychologists, psychiatrists, nurses and so on make access to such courses for potential deaf professionals particularly arduous, if impossible. How then may non-BSL-using professionals and BSL-using clients overcome this barrier to communication, and thus to services which are clearly needed ?

Breaking the Sound Barrier

It is sometimes assumed that a deaf person will be able to understand spoken English if the speaker were to speak slowly enough, speak louder and exaggerate lip movements (Roe & Roe, 1991). More enlightened people may stress the importance of speaking naturally, if a little clearer, in order to maximise the success of the lip-reader, and indeed in this situation many deaf people are able to understand spoken English with almost flawless accuracy. However, many other deaf people are not able to comprehend spoken English by this means - perhaps unsurprising in the absence of continued aural exposure to the grammar, syntax, vocabulary and idiom of the language. Jeffers and Barley (1975) have estimated that approximately 60% of English speech sounds are indiscriminable or invisible without the accompanying sound, consisting one half of the vowels and diphthongs and three-fifths of the consonants. Roe and Roe (1991) calculate from this that a fluent English speaker who loses his or her hearing could only be expected to distinguish 40% of spoken communication, although they do not elaborate whether this refers to spoken communication at a phonemic level, a word level, or a noun-phrase or sentence level. Equally, meaning derived from inflection and stresses is inaccessible to the lipreader. It can be assumed therefore that a prelingually profoundly deaf person without continued aural exposure to the language could not be expected to reach this level of understanding of spoken English. The utility of this approach in a therapeutic situation therefore is highly questionable for most clients. For a client unable to express spoken English, the question is also begged of how to confirm understanding, and of how this approach facilitates communication in the direction of client to therapist. Of course it does not.

In the absence of more appropriate means to bridge this gap in communication, some therapists have resorted to written communication, that is, passing written notes between therapist and client. The fact that this cumbersome method is generally inappropriate for psychological assessment and treatment requires no further elaboration, especially when one considers the reduced exposure to the syntax and so on of English alluded to above.

Other ways to bridge the gap include using a friend or member of the family to act as interpreter, or for the therapist with a basic understanding of BSL to attempt pidgin signed-English. The use of a friend or family member introduces issues of confidentiality, and the presence of that person is likely to have a detrimental effect on the process of therapy and the therapeutic relationship, while the attempt to engage in signed communication without a critical degree of fluency and confidence can only serve to frustrate the client as difficult material has to be discussed in terms simple enough for the therapist to understand. The therapist may also be perceived as being less skilled, in exactly the same way as deaf people have been misdiagnosed as learning disabled as a result of difficulties communicating with non-signing professionals. Hindley (1993), in his albeit small sample, found that using a qualified interpreter was preferable to attempting pidgin signed-English oneself. Indeed, apart from fluency in BSL oneself, it would be difficult to argue that any other alternative is preferable to using a qualified interpreter.

Use of an Interpreter:

The use of an interpreter in enabling a deaf person to access mental health services gives rise to a number of issues which should be considered when embarking upon such service provision. Roe and Roe (1991) divide these concerns into three groups: those centred on the client, those centred on the therapist, and those centred on the interpreter:

Client-centred issues:
Although the interpreter is usually seen as a facilitator rather than an encumbrance, it is possible that in psychological therapy, when the material discussed is often of a personal, highly charged nature, the client will begin to perceive the interpreter as an intrusion, albeit a necessary one (Stansfield, 1981). Also registered interpreters in this country are obliged not to “give advice or offer personal opinions in relation to topics discussed or people present...” and to interpret “without anything being added or omitted from the meaning” (C.A.C.D.P., 1996). This may be seen as indifference by a client who is unaware of this professional standard. It can be seen that from this position it would be less likely for the client to commit 100% to the process of therapy and to be more guarded. Ironically, as a result of this the interpreter therefore can to a degree become a hindrance to the therapy (although this process may of course be addressed within the therapy itself.) In this way the perceptions that the client has of the interpreter lead to issues within the sessions which would not otherwise have arisen. It is possible also that the interpreter may be seen as allied to the therapist, although further professional standards rule against this consciously occuring. The optimum seating arrangement when using an interpreter is for the client and therapist to sit opposite each other and for the interpreter to sit next to and slightly behind the therapist such that both therapist and interpreter may remain in the client’s field of vision simultaneously. From this arrangement one may imagine a client feeling somewhat outnumbered. Alternatively, the interpreter may be seen by the client as allied with him or her despite the seating arrangements, as it is the interpreter with whom the client appears to be communicating. It is of course necessary for the client to maintain eye-contact with the interpreter when the therapist is speaking, which may serve to compound this effect.

Already it becomes apparent that the client may develop feelings towards the interpreter which may need to be addressed or considered during the therapy. Whether transferential or not, these feelings are especially likely to develop because the interpreter is professionally obliged to give away no personal information or opinions (Menninger, 1958) and it is possible for the therapist to be implicated in these feelings as well. For example, the client may resent the need for an interpreter in order to access appropriate services otherwise freely available to hearing people. Stansfield (1981) suggests that this resentment may lead to mistrust of the interactions between therapist and interpreter - the client would thus be less likely to feel safe or contained enough to explore emotionally charged material. Trust becomes compromised.

Padden and Humphreys (1988) point out that the deaf community is small and very tightly knit, and that interpreters and the members of that community often know each other very well. The deaf community is also characterised by the speed with which news travels within it. It is possible therefore that the client will know the interpreter already (calling into question the appropriateness of using that particular interpreter), but even if this is not the case the client may reasonably feel uncomfortable about disclosing difficult personal material to somebody who may have regular social contact with other members of the deaf community. The ethical position of confidentiality of the interpreter as well as the therapist, then, should be made clear in the initial session (”Interpreters shall treat as confidential any information which may come to them in the course of their work including the fact of their having undertaken a particular assignment” C.A.C.D.P., 1996).

It can be seen how, despite considerable ruling by the professional body for interpreters (the C.A.C.D.P. - Council for the Advancement of Communication with Deaf People), even the most conscientious interpreter cannot help but become more involved in the therapeutic milieu than the clearly defined role of faithfully translating between the two languages.

Therapist-centred issues:
Millie Stansfield (1987) emphasises this apparent dissolution of professional boundaries when she points out that one of the main vehicles for change is the therapeutic relationship itself. Simply by being present, the interpreter enters into that relationship and impacts heavily upon it, for example at the most basic level of changing a therapeutic dyad into a triad (Hoyt et al, 1981). Thus, any interaction between the therapist and the interpreter becomes a part of the process and dramatically affects the therapeutic relationship(s). The presence of the interpreter may also directly affect the therapist by giving rise to feelings which otherwise would have remained absent. Schlesinger and Meadow (1972) describe the “shock-withdrawal-paralysis” reaction experienced by therapists faced with a deaf client when otherwise established skills and techniques are suddenly unable to be used. Feelings of being deskilled and helpless occur which clearly have an effect on the nature of the relationship. I suggest that this reaction is not alleviated by the presence of an interpreter - indeed that it may be that the therapist fantasises that the interpreter will actually alleviate such feelings but when this is found not to be the case the reaction is only increased. Therapists used to individual therapy and to an environment in which, although they contain both parties, the boundaries and environment are largely controlled by the therapist, will find that the interpreter - with the aim of facilitating optimum communication - will suggest changes to otherwise comfortable and familiar aspects of the process and environment. For example, suggestions may be made regarding the seating arrangements (mentioned above) and the lighting, communication will inevitably be slower than usual as information is translated back and forth - interrupting the usual flow, and ideally the interpreter should take a break after approximately half an hour. The reason for this break is that after this time the error-rate of the interpretation increases to statistical significance (Brasel, 1976), but this can lead to a sense of intrusion felt by the therapist as the hour is broken. All of this may be perceived by the therapist as an ‘expert in deafness’ taking control away and drawing attention to his or her own shortcomings.

Similarly, the therapist’s own degree of understanding of BSL may be a double-edged sword. A therapist with no facility in Sign may wonder, as may the client, about the accuracy with which the interpreter is proceeding. Many English forms take longer than one would expect to portray in BSL, while others are suspiciously short. This and the seemingly constant eye-contact between client and interpreter can serve to isolate the therapist and increase the sense of paralysis. However, a therapist with some understanding of BSL who nonetheless is not fluent enough to competently conduct one-to-one therapy in that language without an interpreter may experience a quite separate difficulty. It is recommended (C.A.C.D.P., 1996) - and indeed polite - to look at the client at all times, even though that person may naturally turn to look at the interpreter. If the therapist is able to understand a proportion of the signed material this can be extremely distracting as attention is drawn away from the spoken interpretation to which attention should be directed. This effect is compounded by the facts that the interpreter should be seated slightly behind the therapist, and so seems a disembodied voice, and that the client will often vocalise variably clear words. It is not easy using an interpreter, and the fantasy of a rescuer from the shock-withdrawal-paralysis is soon shown to be false.

Interpreter-centred issues:
Many of the above concerns may equally be viewed as interpreter-centred, however, there are further issues which may reasonably be aired here. Mention has been made of seeming dissolution of professional boundaries and distortion of the therapeutic relationship. Elliott et al (1987) suggest, indeed assume, that the therapist will meet with the interpreter before meeting with the client to discuss issues such as these - clarifying the role of the interpreter, the expectations of the therapist and developing ways to deal with misunderstandings during the session for example. In particular they recommend such pre-session contact so that a system of covert signals may be set up. On occasion it is necessary for an interpreter to explore a number of translations of a particular concept and it would be up to the therapist to decide whether further exploration of an important concept was merited, or could be moved from. Evans et al suggest a signalling system for this, and during psychometric testing for the description by the interpreter of errors made by the client - and they argue that this leads to increased trust between the therapist and interpreter which serves to reduce a few of the concerns outlined above regarding alliance and isolation. It is recommended (Stansfield, 1987) that the client be informed of these meetings, but not of their content. The effect of this on the client’s perceptions of the role of the interpreter and the trust felt regarding both interpreter and therapist can only be guessed. Roe and Roe’s (1991) comments - that it would be better to address issues of communication and confidentiality, and for the interpreter to step out of role as communication facilitator (if necessary) in front of the client such that otherwise extant mistrust and suspicion may be alleviated - are relevant here. I would further add that it may be more productive, if not healthier, for roles to be collaborative rather than secretive, and to be honestly complex and variable rather than artificially and falsely straightforward. That is, if the interpreter is required to step out of role (for example to comment on non-verbal communication) it is better achieved within the session with an apparent crossing of boundaries, with corresponding increase in trust. I would argue that the boundary around the interpreter’s role is not being crossed in this instance, but being clarified as more complex than could be hoped for. If the interpreter is to be presented to the client as simply facilitator of communication, that person should only be used as such.

In terms of psychometric testing, I feel an argument may be made at least for meeting with the interpreter beforehand - and likely for some time - in order to agree on appropriate translation of material and psychologist response. This should be carried out in some detail and may require an exchange of knowledge in that the interpreter will require a basic understanding of psychometric testing, and the psychologist will need to be somewhat versed in deaf issues, language and culture. The interpreter must understand the standardised administration (although it will inevitably be departed from as part of the stipulation is often that instructions are verbally presented), and the psychologist will need to understand if certain items are unhelpful by virtue of being culturally irrelevant, or because the very act of asking the question in BSL gives the answer away. For example the question “how are a ball and a wheel alike?” could not be used as the Signed administration would trace circular figures in the air, divulging the answer (Stansfield, 1981).

The cultural validity of standardised tests, or structured interviews, highlights another way in which the interpreter works apparently outside of straightforward linguistic translation. A good interpreter will communicate not just the spoken words of the therapist, but also the non-verbal and affective content as well. Many concepts do not translate smoothly from one culture to another, and the question is raised therefore of the degree to which the interpreter re-frames the spoken communication to fit most appropriately into the other culture. Gaviria et al (1984) - in a Peruvian study - outline four ways in which culture impacts on the validity of an instrument or technique standardised on a different cultural group and their observations and categorisations are relevant to Deaf and hearing cultures: Semantic validity demands that words in the original and translated versions carry the same meaning; technical validity requires that the very substance of the translated instrument carry the same meaning and familiarity, and yield similar expectations, as the original - the interpreter in Hindley’s (1993) study considered for example a face-to-face interview to be foreign to deaf children; criterion validity requires that items, questions or comments refer to similar normative concepts between the two cultures, and conceptual validity demands more directly that questions asked actually relate to concepts within that culture. If we (reasonably) assume a knowledge of, and familiarity with, Deaf culture from the interpreter, it is clear that all of these concerns are areas in which that person may be of help.

As alluded to above, it is equally desirable for the interpreter to be versed in mental health issues, the process of therapy and so on. Monteiro (1989) sees this as a requirement in that so much of therapy occurs outwith the spoken utterance, the interpreter needs to be aware not only of where the translation from therapist to client is going (ie translating culturally as well as literally) but also of where the translation is coming from - the therapeutic rationale behind the utterance. An interpreter I have worked with, for example, suggested ways in which she may interpret therapeutic silence. Monteiro suggests that an interpreter without such an understanding may even act to the detriment of the therapy.

Such a background is clearly advisable, but, although not arguments against this practice, certain considerations should be borne in mind. To refer back to comments made above, an interpreter with a grounding in mental health issues may be perceived by the therapist as even more threatening and intrusive. Also, an interpreter with such an understanding may find it quite difficult to work with a therapist who acts in a way which conflicts with the way in which the interpreter would act in the other role; and therapeutic approaches or techniques may be perceived erroneously by the interpreter and worked into the translation, conflicting with the approach then actually taken by the therapist.


A number of issues have been highlighted above, concerning potential reactions to the therapeutic triad of the client, the therapist and the interpreter. Certain of these issues can only be addressed with opinion, either from the literature or myself, while others remain simply highlighted. However, the aim here is not to provide answers to these concerns (since there are probably none which are irrefutable) - rather it is to provide a compendium of concerns which challenge the fantasy that using an interpreter will overcome all of the issues raised when a non-BSL-using therapist and a BSL-using deaf person work together in therapy. Some of these concerns are conspicuous in their absence in the verbatim translation of a Shawnee phrase at the head of this text.

Overall, however, it should be noted that apart from the therapist being fluent in BSL, the preferred means of conducting therapy with a signing deaf person is through an interpreter versed in issues of mental health.


Brasel B.B. (1976) “The effects of fatigue on the competence of interpreters for the deaf.” In H.J. Murphy “Selected readings in the integration of deaf students at C.S.U.N.” Centre on Deafness series (No.1). Northridge: California State University.

Council for the Advancement of Communication with Deaf People “C.A.C.D.P. Directory 1996/1997” C.A.C.D.P., Durham.

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Gaviria M., Pathak D., Flaherty J., Garcia-Pacheco C., Martinez H., Wintrob R. & Mitchell T. (1984) “Designing and adapting instruments for a cross-cultural study on immigration and mental health in Peru.” Paper presented at the American Psychiatric Association Meeting. In Hindley P. (1993) “Signs of Feeling. A prevalence study of psychiatric disorder in deaf and partially hearing children and adolescents.” RNID, London.

Harvey M.A. (1982) “The Influence and Utilization of an Interpreter for Deaf Persons in Family Therapy.” American Annals of the Deaf 7, 821-826.

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Menninger K. (1958) “The theory of psychoanalytic technique.” Harper and Row, New York.

Monteiro B.T. (1989) “Pitfalls in Diagnosis” Unpublished. Supra-regional Department of Psychiatry for the Deaf, Whittingham Hospital, Preston, Lancs.

Padden C. & Humphreys T. (1988) “Deaf in America: Voices from a culture.” Harvard University Press. Cambridge, MA.

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Stansfield M. (1987) “Therapist and Interpreter: A working relationship.” Paper presented at the Mental Health and Interpreting Conference, Annapolis, MD. In Roe D.L. & Roe C.E. (1991) “The Third Party: Using Interpreters for the Deaf in Counseling Situations.” Journal of Mental Health Counselling 13(1) 91-105.

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Jim CromwellComment
Jim Cromwell