Ordinary Muggles in the mystical world of Harry Potter are oblivious to the magical wizards who live in their midst. Roger C. Williams, LMSW, the director of Services for the Deaf and Hard of Hearing in the South Carolina Department of Mental Health, used this metaphor to describe one of the barriers that deaf individuals encounter when trying to access mental healthcare services.
“The hearing community lives with deaf people but is blissfully unaware,” he explained. Health planners and mental healthcare professionals as a result often fail to consider the deaf population's special needs. “It's not that they're excluding deaf people, but they're not including deaf people,” Mr. Williams added.
That is just one of the obstacles deaf people encounter when trying to access mental healthcare services. Recent literature highlighted a glaring gap between the need for mental healthcare services among members of the international deaf community and access to those services. (Lancet 2012;379:1037; see FastLinks.) The review focused on severely to profoundly deaf individuals whose hearing loss occurred early in life before acquiring a language. It is estimated that seven of every 10,000 people worldwide are members of this vulnerable population.
Johannes Fellinger, MD, and colleagues at the Health Centre for the Deaf at the Hospital of St. John of God in Linz, Austria, noted that “there is ample evidence for higher rates of mental health problems in people who are deaf than in hearing individuals.” Emotional and behavioral problems in deaf children are approximately two times higher than in hearing children. Children who cannot make themselves understood within their own families are four times more likely to be affected by mental health disorders than hearing children, studies have shown. (Lancet 2012;379:1037.)
It is not that being deaf in itself leads to a greater mental health burden; it is that some parents, schools, and communities fail to provide the support that prelingually deaf children require, explained Robert Q Pollard, Jr., PhD, a professor of psychiatry, the director of the Deaf Wellness Center at the University of Rochester School of Medicine, and an author of the review. “As you can imagine,” Dr. Pollard observed, “lack of communication when you're growing up leads to all sorts of barriers to normal psychological development, like your ability to talk about emotions, for example, or learn what they are.”
The Lancet article did not examine hearing loss that occurs in adolescence or adulthood, but “we certainly know that adult onset hearing loss can be associated with depression,” Dr. Pollard said.
NEED FOR ASL-FLUENT PRACTITIONERS
Deaf culture and mental healthcare experts report that deaf individuals often face frustrating barriers to care despite the need for mental healthcare services. That is because providing care to deaf people differs in important ways from serving the hearing population. One main difference: Most hearing-impaired individuals prefer dealing directly with a healthcare practitioner fluent in American Sign Language (ASL), but more often than not the exchange involves a third party.
“Interpreters are not good enough,” said Steve Hamerdinger, the director of the Office of Deaf Services in the Alabama Department of Mental Health in Montgomery. He was born with a genetic hearing loss that progressed to deafness by the time he started school. Mr. Hamerdinger noted that hearing clinicians do not think about and are not trained to consider factors such as how the interpretation process changes the clinical work or how language deprivation affects the ability to engage clinically with the therapy process, among other factors.
It is also important for mental healthcare practitioners to understand the cultural issues of living with hearing loss, and how isolating, confusing, and exhausting it can be, said Annie Steinberg, MD, a clinical associate professor of psychiatry at the University of Pennsylvania School of Medicine in Philadelphia who has studied deaf people's healthcare access problems.
The National Association of the Deaf insists that deaf people in America have a “fundamental right” to receive “culturally affirmative and linguistically accessible mental health services.” It also said states must implement coordinated mental health services that take into account the cultural and linguistic needs of deaf individuals. (See FastLinks.) Culturally competent and linguistically appropriate services can reduce inappropriate diagnoses, increase utilization, and can change the way deaf people perceive negative encounters while seeking treatment, according to the National Association of State Mental Health Program Directors. (See FastLinks.)
A shortage of mental healthcare clinicians fluent in ASL, particularly in rural areas, and insufficient numbers of interpreters trained to work in mental healthcare settings make accessing appropriate services all the more difficult, Mr. Hamerdinger observed. Even in places where these professionals are available, insurance rules or limited provider networks may pose barriers to care, he added.
The Americans with Disabilities Act of 1990 is supposed to ensure access to public services for people with disabilities. (See FastLinks.) It is illegal to turn away a deaf patient, even when providing an interpreter costs more than what the clinician would be reimbursed for services. Dr. Steinberg said, however, that denials are not uncommon. A practice might say, for instance, that it is not accepting new patients.
Simply providing an interpreter does not necessarily solve the problem. The whole system of care needs to change, experts said, and in many cases, that change is occurring as a result of lawsuits or the threat of litigation. Some states are taking steps to improve access to care. State mental healthcare employees in South Carolina sign directly with their deaf clients, and Alabama and Georgia are training interpreters to work better in mental healthcare settings.
Video technology also promises to play an increasing role. “It has great potential,” said Patrick J. Brice, PhD, a professor of psychology and the director of the doctorate program in clinical psychology at Gallaudet University in Washington, DC. A few things need to be worked out, though, such as where the clinician providing services to a client in another state should be licensed, he added.
THE ROLE OF HEARING HEALTHCARE PROVIDERS
Audiologists have a role to play as the front-line caregivers to those with hearing loss. Adults who lose their hearing definitely should be screened for depression, said Dr. Pollard, and prelingually deaf children should be offered a full array of communication choices, including sign language. “Auditory-only interventions should not be so be so doggedly pursued that it puts children and families at risk for the types of cognitive and psychological negative consequences that can readily occur when communication is delayed or minimized in families,” Dr. Pollard said.
A proper assessment and fitting with amplification is not necessarily a solution for a family whose child is having tantrums, added A. Barry Critchfield, PhD, the director of Deaf Services in the Georgia Department of Behavioral Health and Developmental Disabilities in Atlanta and the president of the American Deafness and Rehabilitation Association. He recommends that hearing healthcare professionals establish collaborative relationships with behavioral healthcare providers to whom they can refer such patients.
- Read the abstract from The Lancet's review article at http://1.usa.gov/LancetMentalHealth.
- Learn more about NAD's position statement on mental healthcare services at http://bit.ly/NADstatement.
- Read NASMHPD's position statement on mental healthcare at http://bit.ly/NASMHPDstatement
- Check out the Americans with Disabilities Act of 1990 at http://www.ada.gov/statute.html.
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- Check out HJ's R&D Blog at http://bit.ly/RDBlog.
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