Mental Illness in the Deaf Community:
Increasing Awareness and Identifying Needs
By Sandra Mueller, LCSW
Various pieces of literature highlight the inadequacy of Mental
Health services for deaf and hard of hearing people in the United States. Tragically, many mental health providers
mistake normal adjustment, cultural, language and communication issues for developmental delays, mental illness or
mental retardation. Therefore, in order for clinicians to decrease the risk of misdiagnosing or worse not detecting
mental illness in deaf persons some key factors will be addressed. These factors will further highlight an
understanding into the realities faced by deaf persons living with mental illness.
To understand the prevalence of mental illness in the deaf community,
several common statistics were found. The prevalence of mental illness among deaf people is at least as high as in
the population at large (UCSF, 2004). Furthermore, findings reveal that the rate of Axis I mental health disorders
does not differ between hearing and deaf populations, but Axis II and childhood behavior problems are three to six
times more prevalent for deaf persons. Deaf children and adolescents exhibit higher levels of behavioral and
attention-deficit/hyperactivity disorders then the general population (Haskins 2000 & Chritchfield, 2002). The
prevalence of mental health issues in the deaf community is as significant as in the population at large, thus,
emphasizing the need to examine the some unique factors impacting deaf people living with mental illness.
Presentation of Mental Illness
Deaf people depend on gestures and body language to communicate.
Thus, behavior which may appear overly animated may reflect a style of communication rather than an agitated state.
English is often considered a second language for a culturally deaf person and when sign language is put into written
form it can appear fragmented, concrete or confusing to a mental health clinician who is not a part of the deaf
community. Therefore, distinguishing language limitations from confusion or thought disturbance is a complex clinical
A recent study conducted in a specialty deaf inpatient
psychiatric unit found that 75% of deaf individuals were non-fluent in American Sign Language (Black & Glickman,
2006). This finding may result from the fact that 90% of deaf children are born to hearing parents and these children
may not have received any usable language input during critical language acquisition periods of brain development.
Lacking language input during a child's earliest years and the underdevelopment of a formal language system can result
in an adult without fluency or competence in any language, including ASL (Sacks, 1989).
Possession of a language system is necessary to facilitate abstract
thinking. Without such a system some persons who are deaf may lack the ability to think abstractly or to generalize
concepts. To further compound the issue, the average deaf adult reads English at a fourth grade level (Haskins,
2000). Differentiating between a language system attributed to neurological or psychiatric illness rather than social
or experiential origins is extremely difficult for a diagnosing therapist. Misdiagnosing non-fluent (but otherwise
healthy) deaf individuals (as psychotic) is not a new phenomenon. But what may be equally common are deaf individuals
who are psychotic but whose illness is overlooked by clinicians who attribute symptoms to poor interpretation,
deafness, or minimal language skills (Pollard, 2005).
How then are abstract English concepts such as "delusion" or
"hallucination" to be explained or understood by a mentally ill deaf person? Standard psychiatric questions are very
abstract and for a deaf person with a limited language system, these questions may lead to poor assessment resulting
in barriers to treatment and ongoing appropriate intervention.
Deaf people who are psychotic can display disorders of thought form
and or thought content. Disorders of thought content can be diagnosed by asking concrete questions (i.e.: are people
following them, or is someone stealing their thoughts). Thought form disorders are more difficult to diagnose. Such
disorders can include loose associations, flight of ideas, incoherence, tangentially and fragmentation (Haskins,
2000). One must consider that the ability to determine a thought disturbance can be compounded when a deaf person may
have a limited language system.
Deaf people experiencing psychosis may have auditory hallucinations,
such as hearing voices. This is noted to be possible even if they have been deaf from birth. Research conducted in a
mental health setting revealed that 59% of deaf patients were able to give accounts of verbal auditory hallucinations
(Briffa, 1999). Additionally, deaf people may also experience visual hallucinations described as seeing signing; such
as Jesus signing or an image signing to them (Haskins, 2000). These scenarios highlight the importance of having a
diagnostic tool to effectively assess psychosis in deaf patients. This need was highlighted in a lawsuit stemming
from two murders that took place at Gallaudet University in 2000-2001. The case required accurate knowledge of the
deaf defendant's psychotic symptoms. The expert witness in the case was unable to explain the process for determining
psychosis in deaf vs. hearing people as there was no such tool for making this type of assessment. As a result, a
serious gap in mental health assessment was identified. Research and the development of a rating scale are currently
in process at the University Rochester Medical Center and are expected to be completed in 2010 (Pollard, 2005).
Standards of care for mental health services to deaf and hard of
hearing persons have been established (Myers, 1995). However, several studies continue to highlight problems with
misdiagnosis; denial of appropriate services; lack of sustainable resources for clients; lack of appropriate medical
care (assessment and treatment) and significant language and communication barriers. Several well documented ADA
lawsuits reveal that it is not uncommon for deaf persons to have experienced forced hospitalizations, medication, etc.
(Haskins, 2004 & Steinberg, Sullivan & Loew, 1998).
The reality is that deaf persons suffering from mental illness are at
great risk of not receiving adequate treatment or may not be treated at all for milder, but still devastating mental
health problems such as depression and anxiety. A lack of knowledge and effective tools leads to poor assessment and
misdiagnosis of deaf persons with mental health needs. Valid detection and assessment of psychosis in deaf
individuals and effective tools to assess risk related factors is a serious inequity in mental health services.
Diagnosis & Treatment
Historically, there were a variety of psychiatric myths about deaf
people. One such myth was that deaf people could not suffer depression, as they didn't have enough of a superego to
rise to the level of obsessional defenses (Altshuler, 1971). Psychiatry and research have evolved over the years and
there are many recent case studies and research that dispute this way of thinking. Recent studies indicate a broader
range of diagnosis of mental illness than in the past. Posttraumatic stress disorder is noted as being the most
common diagnosis found in the deaf community. The study further revealed that deaf patients were less likely to be
diagnosed with a psychotic or substance abuse disorder and more likely to be diagnosed with a mood, anxiety,
personality, or developmental disorder. Furthermore, deaf patients presented at higher risks than hearing patients in
areas of self-harm and risk of sexual offending (Black & Glickman, 2006). Acknowledgement that the deaf community
struggles with significant mental health needs is noted. However, what remains is that professionals often have
limited knowledge of deafness or deaf culture which seriously impacts their ability to accurately assess and
Oftentimes a person who is deaf or hard of hearing may enter the
mental health system in the absence of severe mental illness. While the general population can be commonly treated
for many mental health issues through private therapy, deaf or hard of hearing individuals have limited access to such
services. This is due to that lack of communicative access. For example, mental health professionals are not skilled
to effectively communicate with the deaf and oftentimes times there is an unwillingness for the private sector to
provide a communicative resource (e.g. interpreters) (Myers, 1995).
Specialized psychiatric units which provide service to deaf people
are uncommon in the United States. Many States do not have specialized services for persons who are deaf or a
resource database available to deaf persons (Haskins, 2004). Offering services to psychiatric patients who are deaf,
especially to persons who lack full language competency, requires clinicians to know sign language as well as the deaf
culture. The ability to communicate is at the heart of good mental health. Deaf people face greater obstacles in
establishing good communication with the mental health community and with most mental health services available.
Without appropriate communication it will adversely affect the ability for deaf people to recover from mental health
It is well known that mental health is generally under funded and
socially marginalized across the country. Many specialized services have developed out of a critical incident that
may or may not have resulted in a lawsuit. There continues to be a need for a milieu that includes interpretation and
a strong understanding of deaf culture and language issues. Ongoing advocacy for mental health settings to become
skilled in the diagnostic, cultural and language needs of deaf people will increase accuracy in diagnosis and enable
better treatment planning for all deaf persons served.
Altshuler, K.Z. (1971),
Studies of the deaf: relevance to psychiatric theory. American Journal of
Psychiatry 127 (11): 1521-1526.
Black, P. & Glickman, N.S.
(2006). Journal of Deaf Studies and Deaf Education. 11(3): 303-321.
Briffa, D. (1999).
Hallucinations in Deaf People with mental illness: lessons from the Deaf Client. Retrieved 09, Sept. 2006. (www.qds.org.au/mentalhealth)
Chritchfield, A.B. (2002).
Cultural Diversity Series: Meeting the Mental Health Needs of Persons who are Deaf. National Technical Assistance
Center for State Mental Health Planning.
Haskins, B. M.D., Serving and
Assessing Deaf Patients: Implications for Psychiatry. Psychiatric Times.
December 2000, Vol. XVII, Issue 12).
Myers, R.R. (Ed.), (1995).
Standards of care for the delivery of mental health services to hard of hearing people. Silver Spring:
National Association of the Deaf.
Pollard, R. (2005).
Psychological testing studies: psychosis symptom rating scale. Deaf Health Task Force. University of Rochester
School of Medicine.
Sacks, O. (1989). Seeing
voices: A Journey into the World of the Deaf. Berkeley, California: University of California Press.
Steinberg, A.G., Sullivan,
V.J. & Loew, R.C. (1998). Cultural and Linguistic Barriers to Mental Health Service Access: The Deaf Consumer's
Perspective. American Journal of Psychiatry 155: 982-984.
UCSF Center on
Deafness: Preparing for Deaf Patients in a Mental Health Crisis Unit. (2004). Retrieved 24, Sept., 2006. (www.uccd.org).