Prevalence and patterns of mental illness among deaf people attending counselling services in the UK

Abstract

Background: Deaf people may be systematically excluded from life in a society ‘designed’ for the hearing and those deaf people with mental health problems face even greater isolation. Social workers potentially play huge roles in bridging the divide between the world of the deaf and the hearing world. However, not much is known about the patterns and prevalence of mental health problems in deaf accessing counselling, clinical and other social services.
Aim: This study sets out to explore the prevalence and patterns of mental illnesses in deaf and hard of hearing people.
Methods: Relevant primary studies were identified through a search of databases of indexed journals like Psychinfo. Relevant reports from the Department of Health and Mental Health Foundation were also accessed. Using a narrative review of relevant documentary evidence, issues around prevalence of mental illness, patterns and determinants are explored and analysed.
Results: Three primary studies and three reports were identified and provided the core of the documentary evidence used in this review. It emerged that (1) there is a paucity of UK-based studies on the mental health issues of deaf people in the context of counseling or clinical centres; (2) methodological and communication difficulties plague attempts to study the mental health issues of deaf people; (3) Deaf and hard of hearing people are more likely to suffer common mental health problems but are no more likely to have psychotic or more severe mental health issues than the hearing population; (4) factors like ‘communication congruence’ in early life modify the relationship between deafness and mental illness.
Conclusion: Social workers can demonstrate greater awareness of the dynamics of mental ill-health in their deaf clients and can reduce the likelihood of mental illness by serving as important bridges between these people and their hearing world.

INTRODUCTION

About nine million people in the UK are either deaf or partially hearing and twenty-three thousand persons are known to be deafblind (RNID, 2006). Deafness may be mild, moderate, severe or profound. Although levels of deafness are strictly defined according to the quietest sound (measured in decibels) an individual can hear, generally, people who have mild deafness may have difficulty following speech especially in noisy settings. Those with moderate deafness have difficulty following speech without a hearing aid. Severely and profoundly deaf people, for whom the British Sign Language (BSL) may be a first or preferred language, depend to a significant level on lip reading (Macnair and Hicks, 2006). It is important to distinguish the group of deaf, mainly older people, whose deafness developed in later life and who thus still communicate mainly with speech, from the group of deaf people of all ages (the ‘deaf community’), for whom sign language is their first language (Grant, 2000).
A deaf person is almost twice as likely as a hearing person to suffer mental health problems. In keeping with the ethical concept of equity, the distribution of and access to health services should be a function of need. Consequently, the expectation is that since deaf and hard-of-hearing people may be worse off with respect to their social and mental health, the availability of mental health services for them should be greater in quantitative, if not qualitative terms, than that for the general population. Experience may however suggest that the inverse care law (Hart, 1971) does hold true with respect to their mental health burden and associated care they receive. For this population of people, attendance at counselling clinics and hospital facilities may be used as an indicator of how they access mental health services.
While there seem to be a handful of literature exploring the association between deafness and mental ill-health, studies on the patterns and prevalence of mental health problems in deaf people attending counselling clinics or hospital settings are much less comprehensive. Deaf people are more likely to suffer from social exclusion and reduced educational opportunities (DoH, 2005) and it could be that these factors determine how they access much-needed mental and other mainstream health and social services. Discussions of mental health care for deaf people should thus distinguish issues of service provision from those of service access. This study will examine mental health problems and related issues in deaf people in the context of counselling centres or clinics/hospitals. It will also seek to identify and highlight the nature of other social issues like unemployment in deaf people.
Terminologies in this work will be used in accordance with Hauser’s (2006) suggestion that hearing “loss” refers to a reduction in the functional aspects of audition, “deaf” (with the lower case ‘d’) refers to hearing loss sufficient to prevent access to and/or reliance upon auditory channels for understanding speech, “hard-of-hearing” refers to a more modest hearing loss that allows for auditory input, and “Deaf” (with the upper case ‘D’)refers to a cultural identification of oneself with the Deaf Community, a recognized linguistic minority that shares a culture. This work will refer mainly to all categories but mainly the Deaf.

Legal and policy context

When in 1998, a profoundly deaf young man by the name of Daniel Joseph was found guilty of the manslaughter of his landlady on the grounds of diminished responsibility, an independent inquiry into the incident called for a national strategy addressing the mental health needs of Deaf people. The Department of Health consultation document ‘A sign of the Times’ was published in 2002, addressing mental health concerns for this community of people who are thought to number about 50,000 to 75,000 in England (DoH, 2002). While policy documents like the National Service Framework (NSF) for Mental Health, the NSF for Older people and the NSF for Children all had elements expecting health and social services to ensure uniform mental health care standards for everyone including deaf people, there was no explicit strategy focusing on the peculiar mental health needs of the Deaf and deafblind. The consultation document highlighted the greater burden of mental ill-health in Deaf and deafblind children and adults compared to the general population and examined the potential challenges associated with providing equitable care for the Deaf that is in accordance with the standards set out in the NSF for Mental Health. Within the responses to the consultation was the widespread view that the level and organisation of mental health services for Deaf people was far from adequate (DoH, 2005). The Department of Health Best Practice Guidance titled ‘Mental Health and Deafness: Towards Equity and Access’, which was published in 2005, built on ideas generated from the consultation and made important recommendations regarding the organisation and delivery of mental health services for the Deaf.
One of the earlier recommendations of the guidance was the need for consideration to be given to conducting local needs assessments of the mental health of Deaf people. Such needs assessments should also have embedded within them an explicit attention to the implications of cultural and ethnic diversity. The prevalence and characteristics of mental health disorders in Deaf people who are in contact with the criminal justice system have been reviewed previously, with consideration given to the paucity of linguistically appropriate disposals that may account for a twelve times greater representation of these people in the high-security population than in the general population (Young et al, 2000). However, not much is known about the prevalence and characteristics of mentally ill Deaf people who access counselling services or other acute or secondary care services in England. This piece of work sets out to assess the mental health needs of the Deaf in such settings.
In addition to the above policy drivers of innovations in the care of Deaf people with mental health difficulties, other legal drivers include the important Disability Equality Duty (DED) which came into force in England and Wales in December 2006 (Disability Rights Commission, 2006). The Disability Discrimination Act (DDA) of 1995 had laid out the explicit requirement that the disabled be treated fairly but the DDA (2005) carried this further by statutorily requiring all public authorities to build disability equality into the way they carry out their functions. This requirement for mainstreaming of disability equality in public function is expressed in the DED which clearly considers Deaf and deafblind people among the disabled seldom-heard-from population groups, according to the DDA (2005).

Significance for social work practice

Important and evolving changes in the way Deaf people with mental health problems are cared for means that the role of social work practice will assume increasing importance. Allusion has already been made to the fact that Deaf and deafblind people detained under the Mental Health Act (1983) may be disadvantaged with regard to their legal rights for information. However, the Mental Health Act (1983) ‘Code of Practice’ now duly takes into account the needs of Deaf people and makes recommendations concerning the use of BSL interpreters and the training of Approved Social Workers in Deaf Awareness (DoH, 2002).
With the advent of national legislative Acts like the DDA, public authorities and social services organisations will need to become more aware of the needs (including mental health, if applicable) of their deafand hard-of- hearing clients. In their capacity as service providers, socialworkers will increasingly need to see to it that their own services and practices adequately meet their legal and ethical obligations to Deaf people. This may include social worker training in BSL and in Deaf Awareness, but more importantly, it may involve whole system changes in the way services are planned and dispensed. In the capacity of social work professionals as advocates, they will need to increasingly advocate for other agencies and public bodies to do the same.
The policy drive to make services increasingly and equitably accessible to Deaf people may also have implications for the working relationships of social care workers. For example, although some counsellors may be trained in the BSL, counselling services may sometimes need to have social workers work with BSL interpreters, a context with potential to impact the therapeutic process (de-Bruin et al, 2006).
In summary, social care workers are and will increasingly be pivotal to the success of any efforts to deliver equitable mental health care to Deaf.

LITERATURE REVIEW

Prevalence and patterns

This literature review of mental health in the Deaf, deaf and hard-of-hearing people will explore the relationship between deafness and mental health, examining the more detailed patterns of mental health or ill-health in categories of the Deaf and deaf people. The determinants, mechanisms and pathways of deafness will be highlighted from diverse literature sources and issues around the development of services for the Deaf and deaf population will be visited.
Mental disorders may be more common among all categories of deaf people. It is useful, in discussing the association of mental disorders with deafness, to bear in mind the variety of specific diagnostic categories under the umbrella of the term. Having taken into account this wide range of sub-disorders, Hindley (1993) suggests a prevalence of 40% in Deaf children and 25% in hearing children. Using an interactive computerised package including special versions of the World Health Organisation’s Brief Quality of Life Questionnaire (WHOQOL-BREF), the 12-item General Health Questionnaire (GHQ), and five subscales of the Brief Symptom Inventory in a sample of 236 Deaf people, Fellinger and colleagues (2005) found higher levels of emotional distress and poorer psychological wellbeing in the Deaf compared to the general population. Despite these findings of higher rates of mental illness in this population, some authors suggest caution in relating mental illness to deafness. Such putative links could represent a basic misunderstanding of the language and culture of Deaf populations. Although de-Graaf and Bijl (2002) suggest the link is not as strong as would often be assumed, Thewissen and colleagues (2005) used a prospective approach to investigate the link and found deaf and hearing-impaired (DHI) people to have a 3.8 greater likelihood of developing psychotic symptoms as non-DHI people.
Although the Deaf identify with a community held together by a common language and culture, they are by no means a homogenous group with regard to the kinds of mental health issues associated to a greater extent with them than with the general population. There appears to be reasonable agreement among experts that psychotic illness is not any commoner in Deaf people than in the general population. According to Fellinger and colleagues (2005), somatoform and psychosomatic symptoms (such as nervousness, anxiety and stress) are more common in the Deaf while selected psychiatric disorders (ICD-10 F1, F2, F3, F4 and F6) are as common in the Deaf as in the hearing population. Indeed, Deaf adults have the same prevalence of psychotic disorders as the general population but are more likely to be diagnosed as having personality disorders or behavioural or adjustment problems, probably as a consequence of being Deaf in a hearing world, rather than an innate predisposition (BSMHD, 1998).
Apart from Deaf people, other people who suffer loss of hearing or are hearing impaired may also have a greater risk of mental ill-health than the general population. Indeed, among those who suffer hearing loss, the degree of loss of hearing, later age at onset of hearing loss and poorer acceptance of hearing loss are all positively associated with poor psychosocial adjustment in deaf students (Polat, 2003).
Generally, existing literature would seem to support the view that the Diagnostic and Statistical Manual (DSM)-IV (American Psychiatric Association, 1994) Axis I disorders (specific disease syndromes like depression, anxiety, schizophrenia and phobias) are as common in the general population as they are in Deaf people, while the Axis II disorders (developmental and personality disorders) may be significantly more common in the Deaf, although as alluded to above, the greater difference may reflect a lack of understanding of the social dynamics of Deafness than any innate biological predisposition to mental ill-health.

Mechanisms

The pathways from Deafness to mental ill-health have been elucidated by several authors. Grant (2000) makes a case for the link between Deafness and social exclusion, the latter affecting both the mental health of the Deaf and their access to mental health services. Social exclusion, on the other hand has a relationship with self-esteem in that low self-esteem inhibits social integration and social exclusion itself reduces positive self-esteem (Stanley et al 1998). Thus Deaf people who are socially excluded are likely to have less positive self-esteem. Considering that positive self-esteem is necessary for maintaining good mental health, it could be said that Deafness leads to poor mental health through the pathway of social exclusion and lowered self-esteem. This putative relationship has important implications for social integration efforts for the Deaf.
Deaf children can also be disadvantaged at critical stages in their development due to the language and communication difficulties they face in early life (SIGN, 1998). Modifying their environmental and social circumstances to limit these difficulties is key to healthy mental development.
Long term unemployment is known to negatively impact mental health (Acheson, 1998). In a UK national survey of unemployment conducted by the Royal National Institute for the Deaf, it was found that the rate of unemployment in severely and profoundly deaf people of working age was four times more than in the general population (Bradshaw, 2002). The greater amount of unemployment in the deaf population and the connection of unemployment to mental ill-health make a strong case for the social and economic integration of the Deaf.
Ninety percent of deaf children are born to hearing parents and studies suggest that the cognitive dissonance faced by these children, especially if the hearing parents are unable to communicate in BSL, can significantly impair their psychological adjustment and development (BSMHD, 1998).

Mental health services for the Deaf in the UK

There has been interest and expansion in mental health services for hearing-impaired persons over the past 35 years, but the availability and accessibility of clinical services still seems to be lagging behind developments in research (Steinberg, 1991). The best practice guidance and the department of health document issued by ministers in UK contain the recommendations and also set out how the government plans to improve mental health services for the deaf people. It also includes the recommendation that frontline NHS staff need to undergo specialized deafness awareness training (NIMHE, 2005). The different methods for improving health services for the deaf and hard-of-hearing people have been mentioned in the local authority services letter (LASSL, 1999) which is mainly intended to assist social services and other agencies to consider the problems of deafness and hearing disability with respect to their prevention, partnership and the promotion of the independence agenda.

METHODOLOGY

Conceptual issues underpinning the methodology

Certain ontological, epistemological and ethical considerations relate to the methodology used in this study. From the ontological perspective, it is worth noting that researchers may occupy a position of power relative to the Deaf whom they research, and the Deaf may thus be excluded from a definition of the research question and other methodological aspects of the research process.
The basic questions posed by epistemology translate into issues of scientific methodology. A lot has been demanded of service-providing organisations with respect to client empowerment through client-centred care. However, researchers will increasingly need to demonstrate similar competence in recognising and respecting the diverse cultures of people whom they study, even though they do not necessarily provide services to them. The discourse within which a study of Deaf people is conceptualised and operationalised should not rest primarily in the domain of the hearing. With respect to research on the Deaf community, the data collection approach that would produce the most reliable information and subsequently, knowledge, would be that in which the people who conduct the interviews and observations speak the language of the Deaf (BSL) and are properly oriented to the cultural context in which the research activity is conducted (NCDDR, 1999).
Sampling and data collection methods also need to be sensitive to Deaf culture. Demonstrating how important this issue is, a needs survey of disabled people in Hawaii using a mail survey approach was unable to obtain an adequate return rate, prompting the authors to conclude that the return rate “may have been affected by the values and traditions within Asian cultures that emphasize the importance of keeping information about the family within its unit” (Anderson et al, 1993). The method of sampling and data collection in this study will take due account of any conflicting cultural issues in the way Deaf people perceive and respond to research.
With respect to the analysis and interpretation of data deriving from research on unique populations like the Deaf, it is not uncommon that researchers misinterpret data due to a lack of cultural understanding. In addition, there is all too often the tendency to emphasize between-group differences (for example, the difference between Deaf and hearing populations), while ignoring or minimising within-group differences (for example, the differences between Deaf people of different socio-economic groups) which are equally, if not more, important (Anderson et al, 1993).
Other practical issues to bear in mind include the fact that the use of written English language questionnaires between Deaf and hearing individuals may be potentially unreliable and when lower grade reading level questions are used in questionnaires, they may fail to reflect the cognitive sophistication and depth of experience of Deaf respondents. When sign language translators are used, the translation of the questions may differ across them. Finally, English language constructs may be unknown or may not be interpretable in sign language (Kroll, 2006).
From the ethical standpoint, it is important to be guided by Beauchamp and Childress’s ethical principles of autonomy, non-maleficence, beneficence and justice (Beauchamp and Childress, 1994). The independence of the potential participants must be respected at all times especially in regards to their right to decline participation. The entire research procedure must ensure that there is no harm that accrues to participants either directly or indirectly in connection with any activity in the research process. The ultimate good of the participants specifically, and Deaf people generally, must be the goal of the research.

Identifying sources of documentary evidence

Apart from relevant reports from the Department of Health addressing mental health issues in Deaf people, a comprehensive search of specific databases that index several journals in the mental health discipline were systematically search in order to identify appropriate sources of documentary evidence for the research.
Specifically using the search terms ‘deaf’ and ‘mental health’ or ‘mental illness’ in the titles and abstracts, a search was conducted on Medline, Embase and Psychinfo. Duplicates were removed and all the studies identified were manually assessed for relevance to the subject. Further, a hand search of the British Journal of Psychiatry was conducted to identify relevant research reports.
In selecting studies that would provide the documentary evidence, it was acknowledged that an a priori statement of quality criteria would serve as an effective means of identifying rigorously planned and conducted studies with reliable findings. However, this was made difficult by the non-existence of any set of widely agreed quality criteria in research on the Deaf. However, it had been highlighted in earlier sections of this report that certain methodological qualities characterise a good research on the Deaf. These include the following: (1) the research question is generated from the viewpoint or perspective of the deaf and bears a clear relevance to their experiences and needs; (2) if research involves interviews, they are conducted by researchers who preferably communicate in the sign language, minimising the use of BSL interpreters; (3) researchers are aware of the cultural contexts of research on the Deaf community and deaf people generally; (4) research analysis and reporting recognises the heterogeneity of deaf people and thus emphasizes within-group as much as between-group differences; (5) data collection methods are clearly appropriate for the deaf; (6) research is guided by a strong ethical process and ethical issues are addressed at every stage of the process.
In addition, reports had to evaluate any dimension of mental health amongst the Deaf, deaf people and hard-of-hearing people who have access to clinical or counseling services. These dimensions could include prevalence, incidence, risk factors, epidemiological determinants, patterns, within-group differences, service and access issues relating to mental health in the deaf. Owing to the significant paucity of UK and international studies of mental health issues of the Deaf in purely hospital or counseling settings, community-based studies where participants had clear access to counselling or clinical care services were considered.
Bearing in mind these factors, identified studies were assessed qualitatively and appropriate ones were included as part of the documentary evidence at the foundation of this report.

Extracting evidence from documentary sources

Studies in mental health of the Deaf do not lend themselves to easy aggregation using rigorous objective approaches like systematic reviews. Multiple studies for each question may use different designs and inclusion criteria. In addition, there may be no simple guides on how to interpret conflicting and take account of outlying results. Therefore a decision had to be made about whether to use a systematic review process to identify and extract results or to use a traditional narrative review approach.
As a general guide, background knowledge, evolving concepts and controversy require the flexibility of anarrativereview with broad coverage and situational choices about the inclusion of evidence. In contrast, the rigour of asystematic review is needed for effectiveness of diagnostic and treatment interventions and for the outcomes of natural and therapeutic exposures, including adverse events and costs (Collins et al, 2005). In view of the nature of the topic, it was deemed realistic to use a narrative review approach to the synthesis of results in this study.

Sampling, data collection and analysis

In one of the primary studies included, auditorily deaf young people attending schools for the deaf and schools for the hard of hearing agreed to participate in a survey of mental health problems of their deaf wards. Another primary research study used diverse sampling criteria to recruit deaf and severely hard of hearing adults most of whom were invited to participate by interviewers within their cycle of acquaintance. A third study recruited 233 deaf adults who were members of deaf clubs and who had access to a specialised outpatient clinic of a General Hospital in Austria providing medical and social services through signing experts.
Data collection methods ranged from the use of the General Health Questionnaire and brief Symptom Checklist-8D adapted to the needs of deaf people and delivered in BSL to deaf-standardised editions of the Youth Self Report and computerised packages of these standardised symptom questionnaires. The instruments used to collect information were generally validated instruments adapted for deaf people. In addition, all studies obtained information from deaf people directly, rather than from proxies such as parents or carers. The importance of this in the light of “informant variation” will be highlighted in subsequent sections.
Data analyses generally addressed the quantitative and qualitative differences between deaf and hearing populations with respect to the prevalence of defined mental health problems.

RESULTS

There were three primary studies identified and used as documentary evidence in this report. Two of these studies were conducted in the Netherlands and one in Austria. The paucity of appropriate UK studies on this subject is notable. Although none of the studies was conducted in a strictly counselling centre, one study recruited from a population of deaf people normally accessing a specialised outpatient clinic for deaf people and another sampled respondents from an institute (incorporating counselling services) for young deaf people. The third study used a predominantly snowballing technique to sample from the spheres of contacts of deaf interviewers.
Three reports were also included as documentary evidence in this study. Two reports were from the UK Department of Health (“A sign of the Times” and “Mental Health and Deafness”) and one was from the Mental Health Foundation (“Mental health services for Deaf and hard of hearing people”).

Methodological difficulties in assessments

It emerged that there were important methodological difficulties in assessing deaf people’s mental health problems. Accurate evaluation may be hampered by a lack of communication skills on the part of evaluators. Of the primary studies, only de-Graaf et al (2002) conducted face-to-face interviews employing deaf and severely hard of hearing people as interviewers. Fellinger et al (2005) used a computerised package of standard questionnaires while van Eldik (2005) similarly used a paper-based questionnaire filled in directly by the deaf youths. The latter author however acknowledged the potential limitation of administering the questionnaire in the manner it was to young people growing up with the sign language. The mental health foundation report on mental health services for Deaf and hard of hearing people (2005) highlights the necessity of interviewers’ understanding of the Deaf culture to be able to reliably evaluate the mental health difficulties of the Deaf. Strengthening this position, the DoH report “A Sign of the Times” asserts that assessing the mental health of Deaf adults is a huge challenge for psychiatric services based primarily on a hearing population, citing another author’s argument that the scientific base of such assessments is still in its infancy. The report also makes reference to the likely inaccuracy of estimating the prevalence of mental health disorders in the Deaf using a psychiatric population as a source population.
In summary, while some studies and reports explicitly state the difficulties and limitations of assessing the mental health problems of the Deaf especially within a psychiatric population, a few others may not acknowledge these genuine limitations.

Prevalence and patterns of mental health problems

Common mental, emotional and behavioural disorders
Taking account of the whole range of mental health problems, the DoH report “A sign of the Times” cites Hindley (1993) estimating a prevalence of 40% in Deaf children compared to 25% in hearing children.
Although Deaf people may have poorer quality of life in the physical and psychological domains as well as more emotional distress, they are not any more likely to suffer difficulties in social relationships than members of the hearing population (Fellinger et al, 2005). This finding may reflect the fact that the Deaf community has a social culture distinct from and independent of that of the hearing world. Similarly, van Eldik (2005) found that about one in every two or three deaf and hard of hearing boys and one in every three deaf and hard of hearing girls had moderate to severe emotional or behavioural problems. These findings of greater emotional distress as measured by the General Health Questionnaire-12 were consistent despite the variations in the threshold values for mental distress used by the authors.
The Mental Health Foundation report noted that while depression had been found in community studies to be nearly twice as prevalent in Deaf people as in the hearing population, mental health services reported much lower rates although the rates of referral of Deaf people for depression by those services had recently been increasing owing to rising awareness and the advent of specialist Deaf mental health services. The report also cites some authors who found the prevalence of behavioural and personality disorders to be almost five times as common in Deaf as in hearing populations, linking this to the greater amount of educational and environmental deprivation that Deaf persons experience. The authors of “A Sign of the Times” however believe that the greater levels of diagnosed behavioural and adjustment problems in Deaf people are probably a consequence of being Deaf in a hearing world, rather than an innate biological predisposition of the deaf to these conditions.
The rates of impulsivity may be greater in Deaf children. In those children with hereditary deafness, it may not lead to greater Attention Deficit Hyperkinetic Disorder (ADHD) but in children with acquired deafness, there may be a greater degree of progression from impulsivity to ADHD (Bailly et al, 2003).
Severe mental illness
There is probably more agreement about the trends in the prevalence of severe and other mental health disorders in Deaf people than there is on the burden of these disorders in the Deaf relative to the levels in the hearing population. In “A Sign of the Times”, the authors make reference to a 1998 report by the NHS Health Advisory Service in which it is asserted that there is agreement over rising prevalence. Whether this rising prevalence represents a real increase or an increasing awareness among mental health service providers of the needs of their deaf populations is not very clear, although one would hope the latter was the case. Deaf adults are thought to share the prevalence rate for psychotic disorders as the general population. According to the authors of the Mental Health Foundation report, the incidence of conditions such as bipolar disorder were only a few years ago thought by mental health services to be less prevalent in the Deaf than in the hearing population but recent evidence does not support the position, attributing it to under-reporting rather than a genuine lower occurrence.
The Mental Health Foundation report also highlights another interesting dimension of the incidence of more severe mental illnesses in Deaf and hard of hearing people, which the evidence, albeit inconclusive, that paranoia and paranoid psychosis may be more common in people who acquire bilateral hearing loss in middle age, though not in old age or in the Deaf community.

Risk factors for mental illness in the Deaf

In their study, de-Graaf and Bijl assessed the relationship between certain demographic variables and deafness and found that in prelingually deaf people, no demographic characteristics were associated with mental distress; in postlingually deaf people however, women were more likely than men to report mental distress. In addition, prelingually and postlingually deaf people with more communication problems, lower self-esteem, and less acceptance of their hearing loss were more likely to report mental distress, among both categories.

DISCUSSION

The fact that the studies used in this report recruited participants from school or community settings (although participants had access to social or medical care) might be indicators of the paucity of research on the mental health of deaf people in the contexts of counselling clinics or hospitals. The methods of sampling used in these studies however come close to sampling from a counselling clinic to the extent that they sampled deaf people within ‘institutional’ settings such as deaf clubs and schools for the deaf. It would also appear that potential investigations in such contexts are plagued by the difficulty of comparing the mental health experiences of deaf people within a care-seeking population with those of deaf people in the general population.
Studies on deaf people in which the study population is sampled from a source psychiatric population can be produce unreliable results and the reason for this is that, depending on the setting, there are many factors that determine individuals’ access to mental health care. Those deaf people who for one reason or another, are systematically excluded from mental health services can be under-represented in such studies resulting in inability to generalise findings. This clearly presents a limitation for studies on deaf people conducted within institutional systems like hospitals or even counselling centres especially if access to such services is not universal. One would however expect that in health systems such as the UK’s, access should be universal. The paucity of UK studies however does leave the possibility that the results presented in many studies on Deaf people are not representative.
Methodological difficulties with studies on deaf populations centre on the difficulties in communication and the lack of communication skills on the part of some investigators. Investigators who understand the language and the culture of the Deaf may be more likely to ascertain information reliably from them. In one of the primary studies used in this project, de-Graaf and Bijl enlisted the communication skills of interviewers who were deaf or severely hard of hearing in assessing mental health issues in deaf people, providing an example of good practice. For counsellors who work with the deaf, understanding the culture and language of their clients will enable reflections on how their interventions meet the linguistic and cultural needs of the deaf.
Generally, there seems to relative agreement among researchers on the following: (1) that the prevalence of common mental health problems may be greater in Deaf people although some researchers feel it may have more to do with the general disadvantage of being deaf in a hearing world than any real innate predilection to mental ill-health; (2) that the more severe mental health problems are as prevalent in deaf as in hearing populations. It is notable however that although psychotic illnesses are no commoner in the deaf than in the hearing, the presentation of conditions like schizophrenia can markedly differ in the deaf because of the frequency of visual hallucinations observed in them (Hoffman et al, 2006). In view of the possible higher prevalence of common mental problems in the deaf, counsellors who work with these people can, through integration into the world of the deaf, understand the dynamics of these conditions in the Deaf and improve the general mental wellbeing of their clients.
The finding in van Eldik’s study that internalising mental health problems are more prevalent in deaf and hard of hearing young people is worrying. This, according to the author is because externalising problems, even though also more prevalent in the deaf, are more easily recognised by parents, carers, teachers and counsellors. Internalising problems, on the contrary, are more difficult to identify owing to factors like communication difficulty with hearing environment, lack of attention, semantic difficulties and masking by the young deaf person. Counsellors and social workers who work with deaf people need to be aware of this pattern of mental ill-health in deaf people. They can help deaf people communicate better with their environments and pay greater attention to these internalising reactions to emotional distresses in them.
Other explanations have been proffered for the higher prevalence of common mental health problems like emotional and behavioural difficulties in deaf people, one of them being the ‘Theory of Mind’. An individual is said to possess a ‘Theory of Mind’ if they recognise that other persons can hold beliefs and ideas distinct from theirs, even if those beliefs and ideas concern the same ‘reality’. Proponents of this theory assert that deaf children receive less social and emotional information than their hearing counterparts. In fact, deaf children who are native signers of a sign language display evidence of Theory of Mind development at a similar rate to typically developing hearing children, while children who are later signers display much difficulty in Theory of Mind development, even though they compare well with native signers in domains like nonverbal intelligence (Woolfe et al, 2007). The above analysis of the possible correlates and causes of higher mental health difficulty in deaf people must however not ignore the common associations of such findings, such as co-morbidities, social disadvantage, society, and social exclusion.
The associations of deafness with mental ill-health may be modified by factors such as degree of deafness, communication difficulties, developmental delays, self-esteem, parental adaptation and support as well as social deprivation. Counsellors who work with Deaf people and their families can demonstrate awareness of these vital links and thus support deaf people and their families appropriately.

CONCLUSION

The paucity of UK-based research on the mental health of deaf and hard of hearing people within the contexts of counselling centres or hospitals has direct implications for the direction of future research. The Department of Health recommends that assessments of the mental health needs of the deaf be embarked upon in order to more clearly define such needs but there is need to emphasize the necessity of widening the contexts of such assessments to include counselling centres and hospitals while bearing inn mind the limitations of studies in such settings.
People who are deaf appear to suffer common mental health problems like emotional and behavioural difficulties to a greater extent than the hearing population although they are no more likely than the general population to suffer the more severe mental health problems like psychosis. People with audiological impairments are also more likely to internalise mental health problems for a diversity of reasons than are those with normal hearing. The implications of these findings both for mental health service design and the professional practice of social workers and counsellors who work with the deaf are myriad.
First, mainstream mental health services need to make significant shifts in the way they work. They would either need to adapt their practice to accommodate audiologically impaired people, especially those who only communicate through the BSL. This may involve making specific efforts to bring on board deaf members of staff as well as training staff in the BSL and in Deaf awareness. Secondly, mental health service design needs to function at a more grassroots level, enhancing access to the deaf at community entry points. Finally, social workers need to increasingly demonstrate awareness of the specific details of mental health issues in deaf people and genuinely attempt to bridge the gap between these people and their hearing world.