Applied Psychology OPUS

Misdiagnosis of Deaf Individuals: Toward a Culturally Sensitive Approach

by Brit Lizabeth Lippman

         Two summers ago, I stood as an intern in the hallway of a hospital’s psychiatric unit and silently observed a memorable interaction unfold among a psychiatrist, an American Sign Language (ASL) interpreter, and Joseph*—the first deaf patient I ever met. Joseph sat in a chair as the two hearing individuals stood around him in an attempt to have a meeting that was spontaneously scheduled to accommodate the interpreter’s packed agenda. Other patients received daily visits from their doctors and social workers, but our resident deaf patient was dependent on an ASL interpreter who was nearly impossible to locate and seldom available to visit the unit. Joseph was frequently dismissed or met with hostility in his attempts to communicate via written notes; I often watched the nurses on duty scowl at the pieces of paper he left by the nurses’ station. I found this reaction curious considering how often the nurses tolerated questions and complaints from their hearing patients. During the meeting that I witnessed—conducted publicly rather than in the privacy of the conference room— Joseph tried to describe his recent hallucinatory experiences to the psychiatrist. He grew frustrated by the doctor’s failure to fully understand his descriptions as he stated, “Deaf culture is different than hearing culture.” Again a few moments later, he repeated, “Deaf culture is different.”

        As aspiring psychologists and scientists, we are encouraged to approach our work with an open mind and a willingness to learn. We are taught we cannot work as clinicians or as researchers until we are aware of our cultural biases and address the areas in which we lack knowledge. Despite this fact, not once have I ever been exposed to the term Deaf culture in a formal educational setting. It was only through my own personal experience and interest that I began to learn about the unique experience of deafness. As I began to learn, I also began to wonder—how much do mental health professionals know about caring for deaf individuals?

        With the limited understanding that many Americans have about deafness, it is no wonder that the literature on psychiatric diagnosis of deaf individuals expresses concern about inaccurate diagnoses. In fact, psychotic disorders, developmental disorders, and mental retardation are over-diagnosed among deaf psychiatric patients, (Pollard, 1994; Shapira, DelBello, Goldsmith, Rosenberger, & Keck 1999; Black & Glickman, 2006; Landsberger & Diaz, 2010) while other illnesses such as mood or personality disorders are less frequently recorded. Some studies indicate that the usual signs of Bipolar Disorder and mood disorders are sometimes misunderstood and consequently mistreated as psychotic illnesses when they appear in deaf people (Shapira et al., 1999; Black & Glickman, 2006). Most of the literature points to the clinician’s lack of cultural sensitivity as the major factor in misdiagnosis of deaf patients, especially considering that these patients are usually Volume II Fall 2011 assessed and treated in places dominated by hearing professionals (Misiaszek, Dooling, Geiseke, Melman, Misaszek, & Jorgensen 1985; Steinberg, 1991; Pollard, 1994; Black & Glickman, 2006; Glickman, 2007; Landsberger & Diaz, 2010).

        One factor contributing to miscommunication between deaf patients and hearing clinicians is language. Language dysfluency, or poor delivery of language, presents a challenge for deaf patients that are assessed for psychiatric disorders. Often, hearing clinicians unfamiliar with Deaf culture mistakenly assume that their deaf patients are able to communicate in written English and consequently pathologize poor writing skills as symptoms of disordered thinking or low intelligence (Misiaszek et al., 1985; Pollard, 1994; Glickman, 2007). This issue is especially pertinent among individuals who became deaf before mastering a spoken language, a phenomenon known as prelingual deafness (Steinberg, 1991). Prelingually deaf people very often lack the ability to write fluently in English. When a person with prelingual deafness uses written English, his or her sentences are likely to appear different from those produced by a hearing person. To a hearing clinician who expects writing will solve the language barrier, a deaf person’s sentences may come across as disjointed or bizarre (Glickman, 2007). For this reason, a clinician must never rely on written text when assessing a deaf client, for a language discrepancy may be wrongly interpreted as a sign of psychotic thought processes. In addition to possible misdiagnosis, the clinician also runs the risk of causing shame or embarrassment for a deaf client who might be uncomfortable with writing (Steinberg, 1991). During an assessment that may already be nerve-racking or frightening, conjuring up such negative feelings is likely detrimental to the treatment process.

         To further complicate the issue, some prelingually deaf people were not raised in homes that use conventional sign language, and instead use gestures or specialized signs that are distinct from the unique grammatical structure of ASL (Glickman, 2007). Since these individuals are marginalized from both the Deaf and hearing worlds, they are more likely to exhibit poor self-care or lack of social skills typically associated with developmental disorders (Landsberger and Diaz, 2010). In such cases, what appears to be inappropriate behavior is actually understandable considering the client’s isolated upbringing (Landsberger and Diaz, 2010). With these clients, detecting thought disorder is tremendously difficult and communication issues must be considered very cautiously so as not to assign an inaccurate diagnosis.

         For those deaf clients who use ASL, it may seem as if the language problem is easily solved by the presence of an interpreter. However, the use of an interpreter has both advantages and pitfalls. In order to ensure clarity between a hearing clinician and a deaf client, the clinician must communicate openly and effectively with the ASL interpreter. Effective communication requires interpreter’s input on how the client is expressing himself or herself (Glickman, 2007). For example, through verbal communication, a psychiatrist may notice that a hearing client has rapid, pressured speech that may be attributed to a manic episode. An interpreter can often detect similar communication styles in the signing patterns of a deaf client that might otherwise go unnoticed by the clinician. In this way, an interpreter contributes a valuable perspective to the assessment process.

         Despite the helpfulness and necessity of an interpreter during mental health assessments, the mere presence of a third party in the room presents its own challenges. Reliance on an interpreter interrupts the therapeutic alliance and may hinder the level of comfort and trust between client and clinician. Furthermore, the deaf community tends to be small and tight-knit, which may be problematic if the interpreter turns out to be someone the client knows personally. When friends, family members, or familiar individuals serve as interpreters, the potential for a secure and confidential atmosphere becomes fragile and potentially ruptured (Steinberg, 1991). It is impossible to tell how this potential discomfort may affect the honesty of the client during an interview, or how a client’s uncomfortable or superficial behavior may ultimately impact the given diagnosis.

         Beyond basic language and communication issues, there is a more complex cultural barrier between the hearing and Deaf worlds that may very well jeopardize the accuracy of psychiatric diagnosis. Specifically, Glickman (2007) emphasizes the complexity of recognizing delusional thoughts among deaf clients. He asserts that the problem with identifying delusions in Deaf patients is that culturally Deaf views are at risk of being misunderstood as a distortion of reality rather than a common cultural belief that hearing people may not be aware of. For instance, many deaf individuals that are well assimilated into Deaf culture embrace the experience of deafness and do not see it as a hearing “impairment” or a physical disability. A clinician who lacks exposure to this idea may wrongly classify this positivity toward being deaf as a delusional thought (Glickman, 2007). In the same vein, a deaf client preoccupied with his or her safety on a psychiatric unit or is suspicious of mental health providers is not necessarily exhibiting diagnosable paranoia. Clinicians must consider that perhaps reluctance and distrust of hospital staff is logical or even warranted for deaf patients who are put into treatment settings where no one can understand them—in such a case, Glickman proposes, feeling unsafe should not be pathologized.

           The cultural issues associated with diagnosing deaf individuals speak volumes about the challenges of cross-cultural diagnosis in all clinical contexts. Although clinicians seek to better the lives of their patients, they can just as easily do harm if they are insensitive to the unique background and culture of the person whom they are treating. According to personal interviews, deaf individuals often mistrust mental health providers and feel they are at a disadvantage compared to hearing patients (Steinberg, Sullivan, & Loew, 1995). The literature on misdiagnosis suggests that perhaps their concerns are valid. Even more importantly, it reveals a pressing need for mental health providers to reevaluate the ways in which they approach deaf clients and, more broadly, the amount of caution they assume when constructing guidelines for what is “normal” and what is not. The complexity of diagnosing deaf people is by no means an isolated subject; in fact, it demonstrates the greater importance of cultural awareness in psychology. Further cross-cultural research involving deaf populations would be highly beneficial for clinicians to better understand how to best treat patients.

References

Black, P.A. and Glickman, N.S. (2006). Demographics, psychiatric diagnoses, and other characteristics of North American deaf and hard-of-hearing inpatients. Journal of Deaf Studies and Deaf Education, 11(3), 303-321.

Glickman, N. (2007). Do you hear voices? Problems in assessment of mental status in deaf persons with severe language deprivation. Journal of Deaf Studies and Deaf Education, 12(2), 127-147.

Landsberger, S.A. and Diaz, D.R. (2010). Inpatient psychiatric treatment of deaf adults: demographic and diagnostic comparisons with hearing inpatients. Psychiatric Services, 61(2), 196-199.

Misiaszek, J., Dooling, J., Geiseke, M., Melman, H., Misaszek, J.G., & Jorgensen, K. (1985). Diagnostic considerations in deaf patients. Comprehensive Psychiatry, 26(6), 513-521.

Pollard, R.Q. (1994). Public mental health services and diagnostic trends regarding individuals who are deaf or hard of hearing. Rehabilitation Psychology, 39(3), 147-160.

Shapira, N.A., DelBello, M.P., Goldsmith, T.D., Rosenberger, B.M., & Keck, P.E. (1999). Evaluation of bipolar disorder in inpatients with prelingual deafness. The American Journal of Psychiatry, 156, 1267-1269.

Steinberg, A.G., Sullivan, V.J., and Loew, R.C. (1998). Cultural and linguistic barriers to mental health service access: the deaf consumer’s perspective. The American Journal of Psychiatry, 155, 982-984.

Steinberg, A. (1991). Issues in providing mental health services to hearing-impaired persons. Hospital Community Psychiatry, 42, 380-389.

Author's Biography

Brit Lizabeth Lippman is a senior in the Applied Psychology Undergraduate Program. She is a research assistant for Dr. Niobe Way on the Indian Adolescent Study. She is also part of the PhotoCLUB project under the supervision of Drs. Alisha Ali and Randy Mowry. Her research interests include mental illness, bias in diagnoses, mental health of people with disabilities, and trauma. Upon graduation, she hopes to pursue her interests in graduate study and attain a PhD in clinical psychology.