Peripheral Brain

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Autistic Spectrum Disorder

noreply@blogger.com (Jim Cromwell) — Mon, 23 Mar 2009 10:19:00 +0000

People keep asking me about autism and deafness. I don't consider this to be an area of expertise for me, but here are the few common responses I give:

Many children are deaf from an interesting biological cause, and that cause can give rise to a whole panoply of interesting psychological sequelae like dyspraxia, semantic pragmatic language disorder, learning disability, low emotional literacy, hyperactivity, attentional problems, etc, all of which mean making a pure diagnosis of autism rather interesting. For these kids the correct “diagnosis” is “a whole bunch of unhelpful neurological problems” and the question then is “do any of this individual’s array of difficulties overlap with the list of symptoms of ASD in such a way that ASD treatment approaches would be helpful?”

There’s more to it than this of course. As well as these aetiological considerations, there are considerations of the consequences of the deafness, such as, do the child’s parents share a language with that child? As a result of the deafness and, probably, hearing parents, is attachment compromised during important early years? Is the child literally deaf to the incidentally learned social mores that define social competence? These cloud the symptom picture even further.

Contact details for specialist mental health services for Deaf people

noreply@blogger.com (Jim Cromwell) — Thu, 20 Sep 2007 10:42:00 +0000

Click here for a PDF factsheet from Sign and the Mental Health Foundation.

Exploring the perceptual characteristics of voice-hallucinations in deaf people

noreply@blogger.com (Jim Cromwell) — Wed, 06 Jun 2007 20:21:00 +0000

Click here to download the paper.

Thoughts on Intellectual Assessment

noreply@blogger.com (Jim Cromwell) — Thu, 31 May 2007 08:20:00 +0000

I was asked for my thoughts on intellectual assessment. Here they are:

Primarily, intellectual assessment is not as uninvasive as people imagine. I think there is an assumption that if it doesn't literally get under your skin then it can't be bad. However, physical trauma is self-healing whereas a psychological impact is not. It is not just the case that a below average result would be hard to cope with either; people find it hard to discover that they are "average" as well - and those discovering their IQs are in the 'superior' range can begin questioning their own perceived social standing, successes or failures in the light of this apparent observation of one's ability, leading to doubt and depression. So the first thought is that intellectual testing is not just something that can be done without thought for how the person would cope. Whatever the result might be.

Secondly, 95% of referrals to me are wholly inappropriate, and I imagine that is representative of intellectual function referrals to other psychologists in other services as well. These ill-informed referrals fall into three categories:

1) Those wishing to estimate someone's function in a particular area from an estimate of global intellectual function (ie IQ.) For example, "we think X is unable to manage her money and an IQ value would help us decide that" - No it wouldn't. Test her financial acumen. "We want to know if Y is able to validly consent to sexual relationships and an IQ value would help us decide that" - No it wouldn't. Conduct an assessment of sexual knowledge, assertiveness, and social skills. IQ rarely if ever correlates with these or similar specific concerns, and even if they did at a sample level, that is not to say that it is a valid estimate of THIS person's ability in THIS area. The correct assessment tests the domain in question and does not attempt to extrapolate from IQ data (this is even before we bring into play the question of the validity of hearing tests with deaf people. See elsewhere on this blog for more on that.)

2) Those wishing to diagnose learning disability. To be fair, this is partly fine as IQ forms part of the LD diagnostic criteria. However, it must always be considered alongside a comprehensive assessment of daily living skills. If the living skills are unremarkable, then the IQ is purely academic. Unfortunately people always want IQ first, possibly because it appears to be less time consuming but also because they intend dodging the skills assessment and extrapolating purely from IQ. This is invalid. The question of learning disability is nearly always about how the person manages day-to-day so daily living skills assessments are the bedrock of the assessment. There is one domain in which learning disability is not about function, and that is number three:

3) Learning Disability Teams wishing to know if this or that person meets criteria for their service. For me this is the most inexcusable IQ request there is. Firstly, if a service provider wishes to establish acceptance criteria, then that service is responsible to assessing to see if their customers meet that criteria - nobody else is. Secondly, IQ cutoffs are meaningless and arbitrary as cutoffs for service provision. Nobody, not one person, needs a learning disability team to foster and enhance their intellectual function. What they do often require is support and development of their daily living - so acceptance criteria should reflect that need. I have lost count of the number of times I have been asked to do these assessments. One lady had sensory integration difficulties, physical difficulties, and an IQ of about 120. She clearly needed local LD services to help with housing, support, and DLS - but her IQ forbade it. My position on these things is to firstly say "No." Then sometimes I give in and test anyway because it is worse to leave the person in limbo than to move things forward in an albeit invalid way. When I feel brave enough I sometimes insist the local team do the assessment, knowing that they will invalidly underestimate this deaf person's IQ and so appear to meet their equally invalid criteria. I am happy with the ethics of this, but wary of it because, well, it just feels wrong.

There's probably more than that.

Do Profoundly Prelingually Deaf Psychotic Patients Really Hear Voices?

noreply@blogger.com (Jim Cromwell) — Wed, 27 Sep 2006 15:34:00 +0000

Robin Paijmans, Clinical Psychologist, Denmark House, Birmingham
Jim Cromwell, Clinical Psychologist, National Deaf Services, London
Sally Austen, Consultant Clinical Psychologist, Denmark House, Birmingham

Abstract

The psychiatric literature has described profoundly prelingually deaf people with psychosis reporting hearing voices. We propose that such reports reflect the beliefs of professionals in mental health and deafness and not a hallucinatory experience of psychotic deaf people.

We demonstrate that it is functionally meaningless to assert that a prelingually profoundly deaf psychotic patient “hears voices”, and provide a theoretical structure from which to more appropriately consider the internal experiences of deaf psychotics, and to encourage the clinically relevant articulation of them. We also suggest that the “true” phenomenological experience is of secondary clinical interest to the meaning imposed upon it by the client and the distress caused by it.

Introduction.

The psychiatric literature has frequently made mention of the counter-intuitive finding that profoundly prelingually deaf people with psychosis report hearing voices. For instance Critchley et al. (1981) studied twelve apparently prelingually profoundly deaf psychotic patients and reported that ten patients reported visual hallucinations, and that ten patients also described experiences “analogous to auditory hallucinations” although the authors concluded that “voices may not have been heard”. Schonauer et al. (1998) interviewed 67 prelingually deaf schizophrenic patients, in sign language, about their hallucinatory experiences over the entire course of their illness and also reviewed clinical records of their previous admissions. Deaf psychotic patients reported much more visual and tactile hallucinations compared to hearing psychotic patients. Although some deaf patients reported visual hallucinations of sign language messages, the hallucinatory reception of meaningful information appeared associated with the 'auditory' modality. The authors considered that deaf patients might be imagining in their own way what “hearing” might be, even though they had never experienced it. Du Feu and McKenna (1999) translated the structured Present State Examination psychiatric interview into sign language and interviewed 17 schizophrenic and schizoaffective patients, with onset of profound deafness prior to the age of 2 years (as far as could be ascertained), and attempted to evaluate whether these patients might in reality be describing other symptoms. Ten patients gave accounts of verbal auditory hallucinations with description of content and spatial localisation (although not voice quality). These did not appear to be attributable to other psychotic experiences and showed typical characteristics of schizophrenic hallucinations. The symptom was present in six patients who had been deaf from birth or early infancy. Interestingly when asked how they could hear voices if they were deaf, patients typically were unable to give an explanation, or would (incorrectly) claim that they had acquired hearing. One patient believed that his hearing had been restored by God. The authors concluded that auditory hallucinations may be a common phenomenon in profoundly prelingually deaf psychotic patients.

Although some phenomenological analysis has been attempted of these experiences, so far no clear explanation has been offered to account for them. How can profoundly prelingually deaf people, who have never heard a voice, know when they experience the hallucination of one?

Issues of methodology.

Degree of deafness:

As the above authors have noted, research into this topic is fraught with methodological problems. The first difficulty is to obtain a sample of research participants who are truly profoundly prelingually deaf. Deafness is not a uniform phenomenon but exists to varying degrees, ranging from profound prelingual deafness, in which the person has had no experience of hearing sound at all, to restricted hearing only in those frequencies required for verbal communication, to central auditory processing deficits in which a person has the full frequency range of hearing but cannot meaningfully process these sounds. Without thorough audiological testing it is not always clear what the actual residual hearing capability of a deaf psychotic patient is. Therefore whether this patient does have some experience of hearing to form the basis for experiencing or making sense of auditory hallucinations, remains unclear.

Onset of deafness:

Similarly even with early onset profound deafness it is often difficult to establish at which point exactly a person became deaf. Traditionally, a baby is seven to eight months old before the health visitor carries out a ‘distraction test’: the baby sits on her parent’s lap and is encouraged to play with a toy, while the health visitor makes sounds out of sight to both the left and right of the child to see whether they will notice and turn to localise the sound. This distraction method fails to detect three quarters of the children born deaf each year in the UK, which means that many children with hearing problems are not identified until they start school. However conversely, unless a clear congenital cause can be identified in hindsight, it is impossible to say for certain whether a child was profoundly deaf before it started school or whether progressive hearing loss only reached that stage just prior to the time of diagnosis. With modern advances in technology, more recently babies can be given the minute-long Oto-Acoustic Emission test, within two days of birth. The test involves sending sound into the baby’s ear and measuring the level of sound returned, enabling hearing function to be calculated. A similar test is the Auditory Brainstem Response test, which registers neurological responses to auditory stimulation. Furthermore reliable genetic screening of congenital deafness through a simple blood test is now becoming available (Preciado et al. 2004). Nowadays, therefore, the onset of deafness can be much more reliably determined. However with older generations, time of diagnosis may have been as late as four to five years of age, at which point their previous hearing experience may remain shrouded in mystery.

This is critical because the first four to five years of a child’s life appear to be the most vital in terms of acquiring spoken language. At the age of six to eight months the infant is already acquiring the first fundamentals of its native language, its brain dynamically “tuning” the cochlear to be sensitive to the phonemes and frequencies relevant to that language (in illustration the Chinese and Japanese language does not discriminate between “L” and “R” sounds, and typically native Chinese and Japanese speakers cannot distinguish between these sounds either). As such the decoding of speech is an active central auditory process based on prior exposure and learning of what are meaningful sounds during the early life stages critical to language development (e.g. Kuhl et al. 1992). This means that a person’s hearing experience in the first four to five years of their life makes a considerable impact on their ability to decode speech. The existence of these critical early language development stages may explain why, for instance, profoundly prelingually deaf children receiving a cochlear implant after age 7 show little central auditory development even years following implantation (Sharma et al., 2002). It also suggests that someone who has been profoundly deaf from birth should not be able to decode (or perhaps even recognise as such) speech “heard” in auditory hallucinations. However, as stated before, in cases where profound deafness was diagnosed quite late it is very difficult to establish whether a person is indeed profoundly “prelingually” deaf and has no hearing experience whatsoever.

Issues of communication:

Communicating with mentally distressed patients.

Bridging the communication gap between hearing researchers and deaf psychotic participants is not merely a straightforward matter of translating spoken language into sign language and vice-versa. In asking people about their experiences, the implicit general assumptions are that they understood the question correctly, are able to reflect on their internal states and recall their recent experiences accurately, and are able to express them in an understandable way. However this is rarely the case with someone who is experiencing a mental health crisis. Problems in communication, reasoning and suggestibility are a major issue with people who are distressed, confused, cognitively impaired or, as with psychosis, combinations of the above. So when a person suffering from psychosis is asked “Do you hear voices?” (a question only meaningfully understood in the context of Mental Health culture anyway), and they say “yes”, it cannot be taken for granted that they understood and considered the question in the correct context, and upon introspecting, recollecting and carefully weighing up their experiences, decided that, in all likelihood yes, they probably do.

Interpreting across modalities

Communication and suggestibility take on a deeper dimension where Deaf patients are concerned. How to translate “do you hear voices” or “do you have auditory hallucinations” into Sign Language correctly? As Vernon and Miller (2001) point out, when interpreting occurs not just between two languages, but between languages with different modalities - spoken and signed - the relationship between source and target texts can be even more complex. Sign language interpreters in mental health settings face extreme linguistic and cultural difficulties in interpreting the everyday language used in these settings. This is particularly true when deaf clients have limited English proficiency, which often requires interpreters to use expansion techniques in order to render messages successfully.

Written discussions about interpreting issues, or any issue of an exchange of concepts between users of different languages are notoriously difficult to present, being inevitably presented in at most one of those languages. Vernon and Miller admirably attempt to illustrate the difficulties, but they also demonstrate the real issue of presenting issues of sign language or sign language users’ conceptual lives in a different language (i.e. any written language). When they talk about “a sign or combination of signs, such as NERVOUS, SCARED, CRABBY, IRRITATED, or UPSET” they give the impression that, for example, the English word “NERVOUS” equates to a specific ASL sign. It does not. Just as “S’il vous plait” translates literally as “If it pleases you”, but is more accurately translated as simply “Please”, so signs and words only loosely correspond. As a result those two languages will not correspond in a comfortable word-for-word or word-for-sign relationship. Naïve second-language learners nevertheless assume such a relationship in order to assist learning, although fluency can only naturally arise as the conceptual world of that learner adjusts to accommodate the new language. Importantly sign language interpreters, as Vernon and Miller suggest, also retreat to this safer, though risky, strategy when assisting the clinical interview of psychotic deaf patients.

Thus:

when A puts into words what is intended.
an interpreter then puts into sign what was said and
B extracts meaning and supposed intention from the presented translated statement

and B then

considers a response, puts it into sign, and
that response is translated into words/speech and
A comes to some understanding of what was presented,

there are six points of potential misrepresentation and misunderstanding between A’s original intention and what he understands to be the response.

Interpreting and suggestibility

Some mentally healthy deaf people of normal ability may have difficulties with formal questions such as “how” and “why” even in BSL. Thacker (1991) suggests this may be because they are used to being told rather than asked. Also questions may have to be phrased in multiple-choice form, taking care not to lead or limit the subject too far and by presenting concrete examples. Recent research in a forensic setting (O’Rourke, 2004) suggests that in conversation with non-signing hearing people, the use of BSL interpreters could make deaf sign users more prone to suggestibility. In this respect we have observed that a sign often interpreted as “voice”, involving a mouth-like hand shape located near the ear, often appears after contact with Mental Health services, whereas before then signs used to describe hallucinatory experiences differ considerably.

Concepts of “hearing”:

When profoundly prelingually deaf people with psychosis report hearing voices, it is unlikely that they are referring to the same experience that hearing people with psychosis have, simply because they do not have the same framework for “hearing” as hearing people. Indeed in examining deaf psychotic patients’ reports of auditory hallucinations, Critchley et al. 1981 found that “exact subjective experiences were difficult to determine”. Some Deaf people with psychosis describe “voices” more as “ideas coming into one’s head” or as “the feeling of air brushing past the ears, like when someone speaks” while Thacker and Kinlocke (1997) as well as Fraunhofer and Kitson (reported in Kitson & Thacker, 2000) found that deaf people could describe their experience of auditory hallucinations in great detail, but whether this was akin to “hearing” in the conventional sense was impossible to say. One patient, who reported definitely hearing a voice through the ears, could identify that a person was “talking”, but not that person’s gender. The authors suggest that this may indicate that the experience is not a true auditory experience, in that properties like voice pitch and sound could not be described. However their conclusion may be too broad; what it appears to indicate is that deaf people cannot meaningfully or reliably describe their experience of “hearing voices” to hearing people.

However, it would be a mistake to think that Deaf people have no framework for “hearing” at all. As mentioned above, many deaf people may have some residual hearing, even if not sufficient for oral communication, and not every deaf person has been deaf from birth. Profoundly deaf people can still perceive the vibrations of sound. In this regard Thacker (1994) reported on a patient who described how her sister was “talking” (sign) to her in her abdomen, which was where in reality she sensed the vibration of loud sounds.

Moreover, even profoundly prelingually deaf people naturally have their own ideas and imagination of what “hearing” is like, just like hearing people have their own imaginary (simplistic) construct of what it is like to be deaf. Research has shown that profoundly prelingually deaf children develop phonological representations of words while learning to read, through the experience of lip reading, kinaesthetic feedback from one’s own throat during speech, cued speech and finger spelling. Each may provide information about the sound structure of words (Sterne & Goswami, 2000; Hanson et al., 1991) although phonological representations formed in this way are bound to be different from the hearing experience.

It seems then that, deaf or hearing, the human brain is predisposed to try and conceptualise “sound” in some way. This was alluded to by David Wright (1969) in his autobiography “Deafness”, when he described how he would find himself experiencing “sound-images projected by his mind onto his visually perceived environment as a function of visual cues”. Observing lip-reading or the wind moving leaves on a tree prompted the imagining of accompanying sound, which he referred to as “phantasmal voices” or “eye-music”. However, as Sachs (1989) points out, Wright was not deaf at birth and therefore had the experience of sound and speech as a basis for such mental associations, whereas a profoundly prelingually deaf person of course would not. Freimuth (2002) however points out that profoundly prelingually deaf people generally do not mention or complain about total silence in the same way that people blind from birth do not mention or complain about living in total darkness.

“I cannot speak for all deaf people, but I do not live in a silent world. All movement registers as sound in my mind, that is how I lip-read. The movement of the lips makes a sound, which I "hear". Seeing the trees moving in the wind or the waves lapping the shore make sounds to me.

Fluorescent lights that are on the blink are very irritating to me and also several other deaf people I know, because it is like being in a noisy room. I also find someone tapping a table or constantly moving their hands irritating for the same reason.”

(--posted on a Deaf forum)

Profoundly prelingually deaf people sometimes report dreams in which they communicate with other people through speech. However transfer of information is described as an almost “telepathic” process of “knowing” what was said, rather than having “heard” it (although what is meant by “not hearing” is as unknowable as what is meant by “hearing”). This has a striking similarity with findings mentioned above, that psychotic deaf patients who reported hearing voices could not describe the voice quality, i.e. pitch, tone, accent, volume or even necessarily the exact words being spoken, even though they “knew” what the voices said. Kitson & Fry (1990) suggest that the reports of Deaf mentally ill people hearing voices may not be so surprising, when one considers that deaf people do possess the concept of oral communication. Although they have not been exposed to the sound of voices, they do experience accompanying quality (i.e. behaviour, gesture, facial expression and posture), function, meaning and effect of this vocal communication either in terms of responses in others or in themselves. Moreover, 9 out of 10 deaf people are born to hearing parents, many of which do not learn to sign, and in the wider community only 1 person in 1000 communicates in Sign. As such the most frequent socially meaningful (although perhaps not directly content-meaningful) communications are in an oral/auditory modality, albeit inadequate and incomplete.

The delusion of hearing voices.

Psychosis is a heterogenous phenomenon: patients present with various affective symptoms and modalities of hallucination, paranoid or non-paranoid delusions, negative or positive symptom complexes, thought disorder, cognitive disturbance and agitation or apathy. So when someone is psychotic and, with a confused and distressed mind, and muddled-up frameworks, tries to make sense of their confusing experiences, could they conclude they are “hearing”?. In the aforementioned research by Du Feu and McKenna, some psychotic patients were reported to have developed the delusion that they had acquired hearing. This raises the interesting question as to where hallucination ends and delusion begins.

Whereas hallucinations reflect a direct experience of the aberrant salience of internal representations, delusions are a cognitive effort by the patient to make sense of these aberrantly salient experiences

Chadwick, Birchwood and Trower’s (1996) ABC analysis of auditory voice hallucinations comprise:

A – Activating Event (a voice experience)
B – Belief regarding that experience, and
C – Consequent behaviours or affect

The model supposes that beliefs about the voice are secondary delusions, and for a cognitive approach to therapy for such experiences this is an appropriate model. However, for prelingually profoundly deaf psychotic patients reporting voices, it ought also to be considered that the delusional component may rather be as follows:

A – Complex, inexplicable experience involving apparent reception of meaningful information
B – Belief that that experience may be the hearing of a voice
C – Consequent behaviours and affect (including reporting the hearing of voices when asked)

As suggested above, even though they may never have experienced it, deaf psychotic patients may be able to imagine what “hearing” is like. A parallel can be drawn with hearing psychotic patients who report sensory “perceptions” which have no physical antecedents either, such as feeling that electric rays are penetrating the body, or that satellites are transmitting radio waves into to their brain, or that they are possessed by an alien or spirit. This model provides a more useful framework for the experiences of many psychotic deaf people than one that simply asserts that they “hear voices. It provides a potential strategy for therapy, which, incidentally, can equally apply to hearing psychotic patients: it invites the patient to re-examine and make sense of what seems at first a confusing and possibly frightening experience.

Secondary gains

Then there are all the issues of mental health and Deafness, sick-roles and secondary gains. Given that the experience of mental illness is generally private, it is not available to direct objective examination. Rather, symptom reports and illness behaviour are evaluated through a complex assessment of their impact and function in the patient’s life. As human social contexts have become more complex through history, so have the accommodations and allowances made for sick and disabled members of society. As such criteria for legitimate entry to the sick role have evolved, with modern society placing heavy emphasis on demonstrated tissue damage or organic malfunction, or severe mental distress as demonstrated through ratified psychiatric criteria. Due to the communication barrier, deaf people find it notoriously difficult to access services in times of distress and feel easily isolated. The powerful reassurance of a professional taking notice of, and making apparent sense of what seems a baffling and frightening experience is perhaps not to be underestimated.

Conclusion: shifting the frames of reference

Church (1961) conceptualises the senses as “units of perception”. They are a composition of the sensory stimulus input and the interpretation/identification of that stimulus input. Interaction and communication with other people plays an important role in this, as it establishes a consensus of concepts and frameworks within which stimuli are interpreted and identified. Therefore perception units work in both directions; they form the basis for making sense of our impressions of the world, but also offer a shared framework by which we communicate these impressions to others in a meaningful way. Because their sensory experiences are different, profoundly deaf people and hearing people are unable to establish shared concepts and frameworks around the experience of hearing and sound. In that case, a hearing person cannot ask a deaf person any meaningful question about an aural sensory experience, such as “Do you hear voices”, and a deaf person cannot reply in a way that is meaningful to a hearing person.

In that case, why do we regard everything that a deaf psychotic patient reports with extreme scepticism, but not their counter-intuitive reports of hearing voices? Because we know that some hearing psychotic patients report hearing voices. It fits the hearing expectations despite its evidently paradoxical nature. Also, just as there still is a tendency for delusions to be dismissed as meaningless products of a confused mind (Berrios, 1991; Aschebrock 2003), rather than as experiences meaningful to the psychotic patient as attempts to make sense of their environment or of internal psychological conflict, so do we fail to appreciate the unique deaf psychotic experience as meaningful within their deaf frames of reference.

For instance, even in the aforementioned research by Du Feu & McKenna (1999), where one of the researchers had an acquired hearing impairment herself and had some experience in using sign language, a structured psychiatric interview standardised on hearing patients and devised according to symptom presentation and clustering of hearing subjects, was employed. Similarly researchers generally use psychiatric diagnostic criteria developed with hearing patients. However Evans & Elliott (1981) for instance expand on e.g. the misdiagnosis of psychotic thought disorder in deaf patients who have a fundamentally different way of communicating, and how the expression of emotions in gesture and action rather than spoken word or tone of voice can be misinterpreted as affect lability or impulsiveness.

This bias seems unavoidable. All scientific literature is written, and as such represents a philosophy of science, conjecture, hypothesis-testing, categorisation, deduction and induction from a hearing perspective (British and American Sign Languages, and possibly all others, have no written form). As a result it may quite reasonably be seen to be culturally hearing. Models of wellness and illness, symptom-clustering yielding diagnostic nosologies, treatment strategies and all aspects of mental health work may also therefore be meaningfully understood as culturally hearing. In addition, this cultural bias remains almost entirely unnoticed (though not unimportant) when those working within these models and on the basis of this literature are themselves hearing. Just as we think it is the others with the accent, so are we unable to perceive this hearing cultural bias. Just as our native language-development in the early years tunes our perceptions to the language in which we are embedded, and away from other languages’ phonetic forms, so it becomes extremely difficult for inevitably culturally hearing mental health workers (whether themselves audiologically hearing or deaf) to notice the biases and distortions inevitable in the culturally hearing fields of psychology and psychiatry.

When a (culturally) hearing professional converses with a deaf psychotic patient about auditory phenomena that are grounded in this complex statistical analysis of symptom presentation in hearing people and a culture of academic psychiatry, it is easy to imagine to what (a great) extent weak links in the chain of communication can detrimentally influence the discussion.

When deaf psychotic patients report “hearing voices”, they undoubtedly are experiencing something. Just what that is however, is not known. Moreover, hearing mental health professionals may have to come to terms with the fact that they most likely will never be able to know; that this experience is unknowable, because they do not share deaf phenomenological frames of reference. The only mental health professionals, who may be able to make sense of these experiences, are prelingually profoundly deaf mental health professionals –provided that they are able to extricate themselves from the cultural “hearingness” of the field.

However understanding the modality of the hallucination does not have to be essential in helping a deaf psychotic patient manage these hallucinatory experiences. Indeed it may be more clinically adaptive to actively acknowledge that this is not known. Many relatively healthy and undisturbed hearing people hear voices (e.g. Romme and Escher, 1992) but do not necessarily feel bothered by them, or impaired in their daily life functioning. In psychosis also, it is not the modality of the hallucinations that is a problem, or even the presence of hallucinations in itself; it is their perceived meaning and psychological impact that appear to matter (Chadwick & Birchwood, 1994). The distress they generate, and the delusional beliefs that are formed in an attempt to make sense of them may serve to maintain them (e.g. Beck & Rector, 2003). As such effective interventions aimed at managing hallucinations tend to concentrate on changing their perceived meaning and reducing their distressing impact.

In deaf psychotic patients also, regardless of the question of modality, the meaning and function of their hallucinations appears to remain the same. They still have content and meaning, they still generate thoughts and feelings in the patient who may or may not be distressed by them, and who may or may not feel compelled to act on them. In terms of these dimensions, deaf and hearing people appear to share the same frames of reference. Therefore it is possible that deaf psychotic patients can be helped to manage their hallucinations in terms of the meanings they assign to them the level of control they experience over them and the distress that they generate. Whether the same strategies that have been developed for hearing psychotic patients are effective in managing the deaf hallucinatory experience however, like all aspects of deaf mental health, needs not to be assumed but to be explored.

References:

Aschebrock, Y., Gavey, N., McCreanor, T., and Tippett, L. (2003) Is the content of delusions and hallucinations important? Australasian Psychiatry 11(3):306-311

Beck, A.T. & Rector, N A. (2003) A Cognitive Model of Hallucinations. Cognitive Therapy & Research 27(1):19-52

Berrios G. (1991) Delusions as “wrong beliefs”: a conceptual history. British Journal of Psychiatry 159: 6-13

Chadwick P. and Birchwood M.J. (1994) The omnipotence of voices: a cognitive approach to auditory hallucinations. British Journal of Psychiatry 164: 190-201

Chadwick P., Birchwood M.J. and Trower P. (1996) Cognitive Therapy for delusions, voices and paranoia”. London: Wiley

Church, Joseph (1961) language and the Discovery of Reality: a Developmental Psychology of Cognition. New York: Random House

Critchley E.M., Denmark J.C., Warren F. and Wilson K.A. (1981) Hallucinatory experiences of prelingually profoundly deaf schizophrenics. British Journal of Psychiatry 138: 30-32

du Feu M & McKenna P.J. (1999) Prelingually profoundly deaf schizophrenic patients who hear voices: a phenomenological analysis. Acta Psychiatrica Scandinavia 99(6): 453-459

Evans J.W. & Eliot H. (1981) Screening criteria for the diagnosis of schizophrenia in deaf patients. Archives of General Psychiatry 38(7): 787-790

Kitson N. and Thacker A. (2000) Adult Psychiatry: Assessment in: Hindley P. and Kitson N. (eds). Mental Health and Deafness. London: Whurr.

Freimuth C. (2002) Was ‚hört‘ ein Mensch, der nicht hören kann? Das Zeichen‘, Zeitschrift für Sprache und Kultur Gehörloser 60(16): 1-16

Hanson Goodell & Perfetti (1991) Tongue-twister effects in the silent reading of hearing and deaf college students. Journal of Memory & Language 30: 319-330

Kitson N. & Fry R. (1990) Prelingual deafness and Psychiatry. British Journal of Hospital Medicine 44: 353-356

Kuhl, P., Williams, K. A., Lacerda, F., Stevens, K. N., & Lindblom, B. (1992) Linguistic experience alters phonetic perception in infants by six months of age. Science 255: 606-608

O’Rourke S. (2004) Access to the Criminal Justice System: Suggestibility and deafness. Presentation at the BSMHD 2004 Annual Conference, Cardiff.

Preciado D.A., Lim L.H.Y., Cohen A.P., Madden C, Myer D, Ngo C, Bradshaw J.K., Lawson L., Choo D.I., Greinwald Jr J.H. (2004) A diagnostic paradigm for childhood idiopathic sensorineural hearing loss. Otolaryngology -Head and Neck Surgery 131(6): 804-809

Romme M. and Escher S. (1992) Accepting Voices. London: MIND Publications.

Sachs O. (1989) Seeing Voices. London: Picador.

Schonauer K., Achtergarde D., Gotthardt U. and Folkerts H.W. (1998) Hallucinatory modalities in prelingually deaf schizophrenic patients: a retrospective analysis of 67 cases. Acta Psychiatrica Scandinavia 98(5): 377-383

Sharma A., Dorman M.F. and Spahr A.J. (2002) A sensitive period for the development of the central auditory system in children with cochlear implants: implications for age of implantation. Ear Hear 23(6):532-9

Sterne A. and Goswami U.C. (2000) Phonological awareness of syllables, onset-rime units and phonemes in deaf children. Journal of Child Psychology & Psychiatry & Allied Disciplines 41(5): 609-626

Thacker A. (1991) Communication: disorder, deprivation or discrimination? Proceedings of the Inaugural Conference of the British Society on Mental Health and Deafness. London.

Thacker, A. J. (1994) Formal communication disorder. Sign language in deaf people with schizophrenia. British Journal of Psychiatry 165: 818–823

Thacker and Kinlocke (1997)

Vernon M. and Miller K. (2001) Interpreting in Mental Health Settings: Issues and Concerns. American Annals of the Deaf 146(5): 420-434.

Wright D. (1969) Deafness. London, Allen lane.

Communication and Approximation

noreply@blogger.com (Jim Cromwell) — Thu, 13 Jul 2006 21:06:00 +0000

Any communication begins with an internal event - something in somebody's mind. It would be fairly simple to state that communication begins with an idea, though it is slightly complicated by the fact that ideas cannot occur without perceptions providing a fertile ground for their development, while equally our perceptions are influenced by our ideas about the things we perceive. (A perception is the internal representation of an external stimulus, and should not be confused with the stuff out there which, let us assume, we can all see, but which we perceive and understand in different ways.) Ideas and perceptions are clearly related, and this relationship is formed as we develop through childhood. This development takes place within an environment which is culturally mediated - the ways in which our parents and peers describe and explain to us the things we see influencing in turn the ways in which we ourselves categorise and label our world. Strictly speaking therefore, communication begins with a dynamic internal system comprising perceptions and ideas. To help us talk about this we could call it a "conceptualization" (and distinguish it from a "concept" - the latter being a single internal representation, whereas a "conceptualization" for our purposes describes an idea comprising a variety of concepts.)

A single to-and-fro communicative event therefore can be described as follows:

1. Person A forms a conceptualization
2. That conceptualization is put into words and articulated.
3. Person B perceives the words and understands them in terms of their own conceptual lexicon. That is, he conceptualizes meaning from the words observed...

4. He then conceptualizes a response.
5. That conceptualization is put into words and articulated.
6. Person A perceives the words and understands them in terms of his own conceptual lexicon. That is, he conceptualizes meaning from the words heard.

1-3 and 4-6 demonstrate the sharing of a conceptualization from one person's mind to another. It is important to note that communication is not the sharing of words - it is the sharing of concepts.

It is not uncommon for people to be described as more or less articulate, and this commonly refers to their ability to put their thoughts into words. An articulate communication may be described as a good fit between an idea / concept and its description, whereas an inarticulate communication is one in which the fit between idea and description is poor. A poor fit in this context entails loss of relevant concepts and gain of irrelevant concepts.

Loss of relevant concepts

Language always abstracts; if you look up "table" in the dictionary it does not describe your table, it describes tables generally. If you look up "Victorian oak occasional tables c.1885" in an encyclopaedia, it does not describe yours. Were we to set out to describe in minute detail this particular table, as well as being absurd, we would still fail to provide a complete picture because words abstract reality at any scale. Therefore, any statement will only partially reflect the intended conceptualization. Articulate statements will be more complete than inarticulate ones (by our definition), but either will lead to data loss.

Gain of irrelevant concepts

As a result of abstracting, words (or signs) offer more degrees of freedom to the receiver. When I describe my 1885 Victorian table as a “table”, what pops into the receiver’s head can be anything commonly described as a “table”. When I say “table” the receiver may well assume it has four legs, stands upright, and enables me to put things upon it, whereas in actuality (and in my head) it has three legs, is in pieces, and requires assembly. When the receiver’s assumptions of leg number, stability and utility are at odds with the conceptualization I intended to communicate, they bring noise to the communication. (Receiver assumption may of course alternatively reflect the speaker’s intention by happy accident.)

These losses and gains of data are both forms of error. This error arises at all points in the communication where a conceptualization is bundled into the vehicles of language, be they words or signs.

For the model above, assuming Persons A and B think clearly and form clear conceptualizations (and this is not always the case anyway), there are four points at which error creeps into the communication:

1) Where the conceptualization is put into words.
2) Where the words are perceived and “understood” by Person B.
3) Where B puts his conceptualized response into words, and
4) Where the words are perceived and “understood” by Person A.

When A and B come from similar cultures, at both macro (perhaps ethnic) and micro (such as family or locality) levels, then the introduced error will be low. When A and B are from different cultures, then error will be higher. This “cultural” background may equally be “professional”, for example when a mental health worker converses with a patient. When those cultural differences are also linguistic, inevitably error is increased still further.

With A and B from different linguistic backgrounds, we often predict that bringing an interpreter into the equation will reduce these errors. Indeed, many linguistic errors may well be avoided as the interpreter is fluent in both languages and will have a good idea about which words in language B best reflect those in language A. However, interpreters are not translation machines and each brings his or her own cultural background and developmental history to the communication. The expanded, interpreted, version of our communication model becomes this:

1. Person A forms a conceptualization
2. That conceptualization is put into words and articulated.

3. That articulation is perceived by an interpreter (X), and understood in terms of their own conceptual lexicon.
4. Those concepts are put into signs and articulated

5. Person B perceives the signs and understands them in terms of their own conceptual lexicon. That is, he conceptualizes meaning from the signs observed...
6. He then conceptualizes a response.
7. That conceptualization is put into signs and articulated.

8. That articulation is perceived by an interpreter (X), and understood in terms of their own conceptual lexicon.
9. Those concepts are put into words and articulated

10. Person A perceives the words and understands them in terms of his own conceptual lexicon. That is, he conceptualizes meaning from the words heard.

There are now eight points at which error (of both types) is introduced:

1) Where the conceptualization is put into words.
2) Where the words are perceived and “understood” by the interpreter.
3) Where the interpreter puts his conceptualized interpretation into signs.
4) Where the signs are perceived and “understood” by Person B.
5) Where B’s conceptualized response is put into signs.
6) Where the signs are perceived and “understood” by the interpreter.
7) Where the interpreter puts his conceptualized interpretation into words, and
8) Where the words are perceived and “understood” by Person A.

Eight is a lot.

The extent to which each of these points introduces error depends upon circumstance.

1 above depends upon how articulate is Person A.
2 depends upon the extent of cultural, professional and linguistic differences between the Person A and the interpreter
3 depends upon how articulate is the interpreter, and also (for they are not the same) their ability to describe a conceptualization deriving from one cultural background, to a person from another often very different background.
4 depends upon the cultural differences between Person B and the interpreter.
5 depends upon how articulate is person B.
6 depends upon the extent of cultural, professional and linguistic differences between the Person B and the interpreter
7 depends upon how articulate is the interpreter, and their ability to describe a conceptualization deriving from one cultural background, to a person from another often very different background.
8 depends upon the extent of cultural, professional and linguistic differences between the Person A and the interpreter.

Conveniently, these can be collapsed to two main areas – each individual’s articulation skills, and the cultural distances amongst the individuals. Interpreting skill would be another area, however the purpose of this essay is to highlight that even assuming the most skilled interpreter possible, there are many points at which considerable error may arise in a communicating interaction.

Relaxation Therapy with Interpreters

noreply@blogger.com (Jim Cromwell) — Tue, 16 May 2006 08:51:00 +0000

I have been asked quite often about how to provide relaxation therapy to Deaf people via interpreter. I know of no specialist tools such as visual relaxation DVDs, so my brief advice is as follows:

Use regular transcripts with a live BSL interpreter. The two things to do with that would be to

1) Amend any obviously silly bits of transcript, like "you can hear a distant seagull across the gently lapping waves" - Though it is always better to get the client to invent their own scenarios (for later use) anyway... and

2) Shut your eyes. Eye-shutting during relaxation therapy with Deaf people has always struck me as impossible, until someone at a conference suggested that the point of eye-closing is to break the social contact with the therapist so as to feel unjudged and safe. While the client cannot shut their eyes if they are looking at signing, THE INTERPRETER AND THERAPIST CAN. All it needs is for a signal to be agreed to get you to open your eyes if necessary. I suggest the client touches the interpreter's knee.

Good poetic BSL lends itself beautifully to rich, imaginal storytelling, and so a good interpreter can be an asset, rather than just a means to access a standard therapy.

The Perceptual Characteristics of Voice-Hallucinations in Deaf People

noreply@blogger.com (Jim Cromwell) — Fri, 05 May 2006 08:52:00 +0000

The Perceptual Characteristics of Voice-Hallucinations in Deaf People: Insights into the Nature of Subvocal Thought and Sensory Feedback Loops
Joanna R Atkinson (2006) Schizophrenia Bulletin. March 1.

This is not my paper, but I am linking to it as it is critical. Download the PDF here.
Or mirrored here.

Abstract:
The study of voice-hallucinations in deaf individuals, who exploit the visuomotor rather than auditory modality for communication, provides rare insight into the relationship between sensory experience and how ‘‘voices’’ are perceived. Relatively little is known about the perceptual characteristics of voice-hallucinations in congenitally deaf people who use lip-reading or sign language as their preferred means of communication. The existing literature on hallucinations in deaf people is reviewed, alongside consideration of how such phenomena may fit into explanatory subvocal articulation hypotheses proposed for auditory verbal hallucinations in hearing people. It is suggested that a failure in subvocal articulation processes may account for voice-hallucinations in both hearing and deaf people but that the distinct way in which hallucinations are experienced may be due to differences in a sensory feedback component, which is influenced by both auditory deprivation and language modality. This article highlights how the study of deaf people may inform wider understanding of auditory verbal hallucinations and subvocal processes generally.

Deafness and The Art of Psychometric Testing

noreply@blogger.com (Jim Cromwell) — Thu, 24 Nov 2005 21:46:00 +0000

The Psychometric Assessment of Deaf People post on this site (link) has been published in a friendlier form in The Psychologist, Bulletin of the British Psychological Society, Vol 18, Part 12, Dec 2005.

You can download the article here. (67KB pdf file)

© Copyright The British Psychological Society.

Rivermead Behavioural Memory Test

noreply@blogger.com (Jim Cromwell) — Mon, 07 Nov 2005 09:36:00 +0000

The Rivermead Behavioural Memory Test is a nice screening test of everyday memory functioning that at first glance seems reasonable to use with prelingually propfoundly deaf people. However there is still a great deal of adjustment to be made to make it usable, and when adjusted the screening cut-offs become unreliable in unpredictable ways.

These are my rough adaptations for deaf subjects. None of these adaptations are standardised, or necessarily any good. But if they are applied consistently then change in memory can be estimated over time. The RBMT screening cutoffs should not be used.

1. Remembering a name
Fingerspell this, but call her Jane Clark.
(This makes it more verbal than sign, being also visual, and is shorter then c-a-t-h-e-r-i-n-e-t-a-y-l-o-r.)

2. Remembering a hidden belonging
This should be fine as it stands.

3. Remembering an appointment
This is OK but the alarm cannot be used, obviously. Try to find a vibrating alarm. Failing that you could just remind them later. If this is attempted remember you must not prompt at all, so you need an empty reminder like “the alarm is going off now.” Record whatever you do for next time.

4. Picture recognition
May cause problems since you need to be sure the responses are names of objects and not mimes of the object use (as this is a common strategy in anomia. Allow fingerspelled or signed words, but be aware of the miming problem.

5. Immediate prose recall
Sheesh… No good. You need to sign it, but you need to have developed a scoring system based on signed concepts rather than written ones… See below for my best attempt so far.

6. Test pictures
See 4 above.

7. Face recognition
Should be fine.

8. Remembering a short route
Fine for deaf people, but hard to administer generally! Make sure the start point is away from both of your original test positions and indicate “start” and “finish” clearly to the subject.

9. Remembering to deliver a message
Fine.

10. Test face recognition
Be clear that you are asking the subject to say if you showed them the face before not if they have seen the face before. Subjects, particularly in BSL, often understand that to mean “do you know this person?”

11. Orientation
(Borrowed from my adapted MMSE, but following the same order as RBMT…) Ask, in BSL:

YEAR WHAT?

MONTH TODAY WHAT? JANUARY FEBRUARY MARCH ETC WHAT?

TODAY, MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY, WHICH?

THIS BUILDING NAME (or number if client’s home) WHAT?

WHAT TOWN THIS?

YOU. HOW OLD?

YOU. BORN. WHEN? (Clarify the year if only birthdate is given.)

BRITAIN GOVERNMENT. PRIME MINISTER (BOSS) WHO? (or NAME WHAT?)

AMERICAN GOVERNMENT. PRESIDENT (BOSS) WHO? (or NAME WHAT?)

The last two are rubbish as they index incidental learning, which is demonstrably lacking for Deaf people. However, they can remain for comparison over time.

12. Date
Fine.

13. Remembering an appointment
See 3 above.

14. Delayed Prose recall
See 5 above.

15. Delayed recall of route
See 8 above.

16. Remembering to deliver a message
See 9 above. Fine.

17. Remembering a name
See 1 above.

18. Remembering a belonging
Fine.

Prose recall:
This needs to be signed fluently and competently. These prompts are really to remind me about the BSL version in my head, so good luck! If you can decode the BSL from these prompts, then remember also that placement is absolutely key in this story.

Immediate recall

Last Monday // where, Brighton // 4 men // each masks have // want rob bank money // one have // gun // gun silver //.

He been shot man // man name Brian // Kelly // self work in bank //

Many people see. // Next day // police // been question question question them // One person – lady been explain // Man, Brave, // he been try punch // man (enumerate) // and fight fight fight.

Delayed recall

Last Monday // where, Brighton // 4 men // each masks have // want rob bank money // one have // gun // gun silver //.

He been shot man // man name Brian // Kelly // self work in bank //

Many people see. // Next day // police // been question question question them // One person – lady been explain // Man, Brave, // he been try punch // man (enumerate) // and fight fight fight.

Mini Mental Status Examination

noreply@blogger.com (Jim Cromwell) — Sun, 21 Aug 2005 20:20:00 +0000

This is a form of the Mini Mental State Examination amended for use with deaf people who use sign language. The items are intended to represent written English prompts for BSL signs. The BSL vocabulary that you think these prompts represent may well be different to that that I would use. For this reason, as well as the fact that no work has yet taken place to validate this amended scale, all diagnostic conclusions you may draw must be explicitly cautious.

Download it here. (34KB pdf file.)

The notes should never be detached from the body of the scale.

Training Deaf Psychologists

noreply@blogger.com (Jim Cromwell) — Fri, 29 Jul 2005 21:15:00 +0000

This is taken from my chapter in "Deafness in Mind: Working Psychologically with Deaf People Across the Lifespan" Edited by Sally Austen, Susan Crocker. Available here.

1.0 Introduction

“You cannot know what you are entering into.”

Counselling Psychology Training Course Director

“What are we entering into?!”

Clinical Psychology Training Course Director

The above are quotations from training staff who have had or who continue to have deaf trainees on their courses. While each appears at face value a little helpless, the spirit with which they were said in fact reflects the opposite. Although it is inevitably important to prepare as comprehensibly as possible for both the trainee’s arrival and continued training, it is similarly vital to accept that complete preparation is a fantasy - to not fret about the challenges the deaf trainee might both face and present to the course, or about the technicalities of communication support, deaf awareness, equal access to resources – to not become so embroiled in the practical challenges that all space for reflection, learning, and indeed training are lost.

It is attitude that counts, not getting it perfect.

Deaf trainee

The information in this chapter is based upon available literature, interview with deaf trainees and courses who have trained deaf psychologists, and personal experience as a qualified clinical psychologist working with deaf people of supervising deaf trainees. While this chapter will endeavour to provide the reader with as much advice, anecdote and food for thought as is feasible, two caveats exist: That no two deaf people are the same and so no operational checklist for courses will cover all eventualities; and that two interpreters, a notetaker, a palantypist, deaf awareness training and devout adherence to the Disability Discrimination Act themselves do not make a qualified psychologist. Training courses should not deny themselves the space to reflect upon and to enjoy the issues that may arise while facilitating a deaf trainee’s progression through the course.

The centipede was happy, quite,
Until a toad in fun
Said, ‘Pray, which leg goes after which?’
This worked his mind to such a pitch,
He lay distracted in a ditch,
Considering how to run.

Mrs Edmund Craster (1847)

1.1 Disability Discrimination Act
While this chapter will emphasise the positively challenging side of training deaf psychologists, there is nevertheless a stick that should not be forgotten: discrimination legislation. In the United States this is the Americans With Disabilities Act (ADA; United States of America, 1990) and in the United Kingdom, the Disability Discrimination Act (DDA; Great Britain, 1995). Both the DDA and ADA require services such as training courses to make “reasonable adjustment” to allow fair and equal access for people with disabilities. “Reasonable” is determined by the size of the service or the size of that service’s budget – and that budget has been defined, in the instance of training courses in the U.S. (ADA), as the total available funds of the academic institution and not of the department alone. There is, therefore, a legal obligation to be accessible and fair, and it is nearly always illegal to deny a request for, for example, interpreter services (Gutman & Pollard, 1999).

1.2 Effects on Training
It has been argued (Gutman, 1999) that training courses benefit from a richness and diversity among their students, across the placements offered, and across the perspectives presented by the student body to itself and to the course. Robert Pollard Jr (2002), has noted also that
deaf trainees are pursued for leadership positions in advance of their hearing colleagues
hearing colleagues of deaf trainees are often strongly and positively affected by the experience and that training programmes are able to demonstrate very visibly their commitment to multicultural initiatives.

It is likely also that deaf trainees will possess skills that will enhance the training experience for their peers; perhaps a significant sensitivity to body language and expression, strengths in communicating in difficult and compromised situations and overcoming isolating and minoritising attitudes. Gutman and Pollard (1999) add that the presence of a deaf trainee, with accompanying communication support, also focuses attention on communication processes – vital when one considers the coal-face of therapy: communication.

2.0 Selection
Processing and shortlisting applicants, arranging and conducting interviews and then reaching a decision about which applications ultimately succeed are all time-consuming and often timetabled with little room for manoeuvre. It is however at this time that the course is first faced with challenges which must be addressed in order to enable a fair opportunity for selection to the deaf applicant. These challenges take time to address properly, but it is also important not to allow what delays may occur to impact negatively on the applicant, for example by expecting the applicant to be interviewed later than everyone else or by forcing a longer wait to hear the result than for the hearing applicants.

2.1 The Interview and Selection Process
Preparation for the interview process mostly concerns communication support. For prelingually profoundly deaf applicants, Sign Language Interpreters are the most likely support to be needed. At interview, as it would be throughout the training experience, it will be important to try to find interpreters with experience of mental health settings and related jargon. More important information regarding the use of interpreters may be found elsewhere in this book. It is important for those involved in selection to be fully apprised of the related issues before interview in order that issues of logistics do not compromise the time available for the applicant to prove herself. Like any tool, one must learn how to effectively use interpreter support, rather than just rely on the purchase of it to cover all the issues.

At interview, supposing that all issues of communication and access are appropriately addressed, it is possible to proceed with the selection process as normal – that is equally and fairly. At a face-to-face panel interview, or a presentation to the panel, it is probable that the presence of interpreters will quickly not be felt. However in any group task, the examiners should be aware of further issues:

Time lag. No matter how promptly the interpreter interprets, the deaf applicant will always be momentarily behind the hearing group members in the flow of the discussion, and examiners can misunderstand this as failure to follow the discussion. How the applicant involves herself in the discussion will likely be noted as part of the appraisal, but should be considered carefully in the context of the interpreting situation. For example, if she appears slightly aggressive by talking over somebody is this a function of being behind in the conversation and needing to claim ‘air-time’? If she appears reluctant to take part is this instead a function of time-lag and an effort to not interrupt, such that her own contribution arrives late and appears incongruous? Group members should be respectful of ‘interpreter-time’ – that is, to monitor their own discussion and to not respond to an utterance until it is clear that it has been interpreted; so dispensing with the iniquity of the time-lag by all experiencing it together. A good chairperson ought to manage this. It is also advisable to schedule additional time for formal selection procedures to allow for the impact of these issues to not disadvantage the applicant.

Interruption. Some interpreters tend to act in addition as advocates for the deaf person with whom they are working. It might be appropriate for the examiners to discuss beforehand with the interpreters and the applicant which of them is responsible for asserting the right of the applicant to take part in the discussion, such that it is possible for the examiners to know if they are evaluating the applicant or the interpreter at the time.

The selection process should always focus on the applicant’s clinical skills and qualifications, not her hearing loss. Questions regarding how she might work with different clinical groups, how she might introduce herself as a deaf clinician, how she might introduce the interpreter, or how to deal with challenges from clients unfamiliar with a deaf clinician are all reasonable. Making assumptions about her clinical limits, making challenging comments about the feasibility of pursuing this career, of treating hearing clients, or of funding for interpreter services would all be inappropriate. Allowing the applicant’s hearing loss, or the support that entails, to influence the decision of whether or not to select would be illegal.

3.0 The Training Experience
While it is desirable for the deafness of our trainee to not take centre-stage and to minimally impact on the training experience of all parties, in order for this to happen as smoothly as possible it is necessary, paradoxically, to face up to it from the start. Throughout training, issues will arise which will bring the deafness to the forefront once again – so in order to limit the chances of this happening it is helpful to address as many issues as possible from the outset. It will be helpful to educate trainees and staff regarding use of interpreters. Deaf Awareness Training ought also to be offered, and can be purchased easily from deafness-related charities and organisations - introducing the idea of deaf people as a cultural and linguistic minority rather than as a disabled group. This shift in perspective provides a discussion point for trainees which contributes positively to their training as well as presenting an important paradigm shift for relating to their deaf peer. Interestingly, while Deaf Awareness Training is best offered by professional providers (as it is of a higher quality, and makes the focus Deaf people in general and not this person), trainees have found that on placements it is better conducted personally, with an interpreter, since then the placement is meeting the trainee in the context of the issues of Deaf Awareness and she is seen to be proactively helping them understand a situation that is likely new to them. Certain training course staff have even attended Sign Language courses in advance of their trainee’s arrival. While this should in no way be seen as an obligation it demonstrates considerable commitment to the trainee, and it is surprising how much conversational Sign it is possible to learn in a relatively short time – reducing the sometimes exhausting need to rely on interpreter support for even the simplest conversation.
Preparation attenuates anxiety, and deaf trainees have pointed out that their own anxieties are considerably reduced by their courses having evidently prepared for, or at least considered, the various issues. A course which is quietly confident in its ability to offer a fair and equal training opportunity demonstrably puts the trainee at ease, while those which are manifestly agitated appear to their trainees to be seeing the deafness first and the trainee second. The trainee can experience course staff continually asking and checking about deafness-related issues to be unsupportive.

3.1 Teaching
As already mentioned regarding selection, communication support will need to be discussed with the trainee and booked in advance of the teaching modules. Sign Language Interpreters are in very limited supply and it will be necessary to book them well in advance and ideally the same people for each lecture of a block of teaching. They most commonly work as single-handed freelance workers but ought ideally to be booked in pairs such that they may support each other and alternate the role of active interpreter. A single interpreter will need a 5-10 minute break every forty minutes and should have a longer break after two hours. Without these breaks the amount of error in the translation reaches significant levels and the deaf trainee can no longer be said to have equal access to the taught material (Kyle & Woll, 1985). One course has pointed out the importance of remembering that two interpreters take up two seats! An extra two bodies can make what was an adequately sized classroom suddenly inadequate. Another course also mentioned that once they had a deaf trainee acoustic difficulties of certain rooms, hitherto unnoticed, became apparent. Sign Language Interpreters will make it their business to properly hear everything said in the room and will interrupt in order to seek clarification. Using a quiet room with good acoustics will limit the amount of interruption from the interpreters.
Lecturers, particularly those visiting from outside, will need to be

informed that there is a deaf trainee on the course and to consider how that might (or not) influence how they present their session
provided with information about interpreters and what to expect
told how to use interpreters and about the need for breaks
asked to provide copies of their notes and handouts to the interpreters at least the day before the lecture is to be delivered
given a little deaf awareness information such as advice not to talk while writing on a board, covering the mouth, or while showing a slide unless they are simply reading the contents of that slide.

If slides are to be used, they should not be used in a darkened room. Video presents special challenges to the interpreters, who would be helped by the opportunity to review the tape in advance of the session. Where the use of role-play might seem onerous with interpreters it has in fact been found to be quite straightforward, with fellow (hearing) trainees reporting that the interpreter is not a hindrance.

3.2 Appraisal
Trainee psychologists are usually appraised by written submissions (case reports and essays), process report (discussion and self-appraisal based upon an audio tape of a particular clinical session), and supervision on placement. The process report presents obvious difficulties due to the use of audio tape. With a deaf client the session could be videotaped, although it is hard to clearly record two people signing a conversation in a room. Even if the session were videotaped, while the trainee would be able to go through it and comment on the process, the staff appraising her would be required to rely upon the interpreter for access to the recorded clinical work, and while not immediately prohibitive, a comprehensive discussion of the process of the session requires access to more of the session than just the content. Some courses expect trainees to transcribe the recording for the report. For a deaf trainee this would require a process of translation as well as transcription and I would suggest that the former should be the responsibility of an interpreter. Appraisal more than anything else needs to be demonstrably fair for all concerned. The special nature of the process report indicates that the deaf trainee cannot be appraised in the same way as her hearing peers, and a modality-for-modality trade by way of using video instead of audio does not effectively address the issue. Those courses to have faced this already have found that it highlights the need for a system which judges trainees against equal standards but which makes no stipulation about the means. It may be possible, for example, for a qualified psychologist with signing skills to observe a session and then to discuss process with the trainee and course staff.

3.3 Written Work
It has been suggested (Conrad, 1979) that the median reading age of deaf school leavers is nine. While trainees will have a reading age commensurate with their academic record it is worth considering the context of this statistic.

Deaf signers converse in a language which cannot be written, which differs considerably in grammatical form from the dominant language locally, and which involves some concepts and linguistic structures which cannot easily be translated into English. Because signed languages cannot be written, the first written language of even a native signer will be that of the hearing society in which she lives. Hearing people almost always speak and write the same language and so exposure to written words continues to shape their speech just as everyday exposure to speech shapes and refines their written skills. This mutually beneficial relationship between the verbal and written language is not available to deaf people.

When appraising the written work of a deaf trainee it is important to be clear about what is being appraised. While a person’s written English and the concepts they are conveying are of course significantly related (a concept must be clearly expressed for us to appraise it confidently) they are nevertheless distinguishable in certain ways – for example an intelligent exploration of “scitzophrenia” is no less so because of the dreadful spelling. For courses requiring a good first degree as an entry requirement this issue ought not arise, but for those with different admissions criteria it may. For them it may be worth treating the deaf trainee as a student with English as a foreign language and to adhere to the guidelines and principles already established for that.

With a good interpreter, particularly if the same one is used for supervision as for the direct clinical work, the appraisal conducted by supervisors at the end of placements should be unproblematic.

3.4 Peer Group
Most courses agree that peer-support is an invaluable part of the training experience and, while it cannot be engineered or specifically timetabled, the early days of training are often deliberately moderately paced in order to allow the trainees time to get to know each other and to join as a group. In most cases there will be only one deaf trainee in a cohort and it is easy for that person to become marginalized – she is difficult to talk to, hard to understand, may confront others with their own inevitable misconceptions and politically sensitive attitudes, and is often accompanied by two interpreters. Courses can probably do no preparatory work in this regard, but it is worth being aware of the special effort all the trainees will have to be making in order for them to join effectively as a group. The deaf trainee will be all too familiar with this need, but it remains a difficult though not insurmountable gap to bridge:

I either had to be on the fringe and watch and understand nothing, or be proactive and get involved – ask what the conversation was etc… But then the focus shifted to me, i.e. I became dominant in the conversation. I hated not being able to just passively soak up conversation.

Deaf trainee

The trainee will often also feel that she is the last to know everything and this may have make her feel on the fringes of the group at best.

Where there is another signer on the course the benefits are probably obvious (although that person should never be used as a cheap alternative to a qualified interpreter). However there is then a danger that the deaf trainee and fellow signer create their own micro-group talking only to each other – the rest of the group breathes a sigh of relief and chats to itself, leaving a communication vacuum between them. This can also happen with the deaf trainee and interpreters and the trainee would be well-advised to avoid this happening for fear of excluding herself from that important source of informal and moral support – her peers.

A few years of postgraduate vocational training, in which one is often expected to practise what has only just or is yet to be taught, to only do that for a few days a week while also attending taught modules and to somehow produce a large and impressive-looking piece of research, in a field which inevitably causes us to look within ourselves and face whatever might be found is stressful. Courses will be familiar with the ways in which these stressors promote anxiety in the cohort, which manifests in many ways and with a deaf trainee in the group it is perhaps no surprise that that can become the target for feelings actually related to the training experience. For example hearing peers have been noted to become angry if their deaf peer understands a point or passes an assessment and they have not, and it seems clear that they feel threatened by this disabled trainee. Hearing peers may suspect that the deaf trainee reflects tokenism on the part of the course and sometimes these suspicions are aired in anger.

For the deaf trainee most stresses will ultimately be able to be shared with the group as they will be course-related issues of difficult clients, looming deadlines and omnipotent ethics committees. There will, though, be additional stresses of working in two languages at once (since reading and lectured material will be presented in English and sign respectively), of meeting a client for the first time who has not met a deaf person or worked with an interpreter, and of interpreters not arriving when the family has arrived for therapy. It may be the case that such things can only be truly shared by talking to other deaf psychologists, but practically it may perhaps be prudent to allow for such discussions during meetings with the trainee’s tutor or supervisor.

4.0 Placements / Internships
Before the year begins, course staff should have considered whether to provide the deaf trainee exclusively with deaf clients, hearing clients or a mixture. Local constraints of course are the major determinant, but those aside a broader discussion should take place about the competencies which would be expected to be derived from the placements, commensurate with the award at the end of the course, and whether or not they would be gained from only seeing deaf or hearing clients. Courses differ in the competencies they expect to be met in order to confer the particular award of that programme – some for example expect a broad range of clients while others a broad range of presenting problems, of models of therapy, or a combination. A question may be raised of whether or not a trainee who sees only deaf people should only be awarded a qualification which is restricted in terms of only enabling the person to see deaf clients. Ultimately it is incumbent on the course to provide equal and fair opportunity to the deaf trainee to achieve the same qualification as her hearing peers – a qualification which makes no distinction about the hearing status of potential clients. Indeed, hearing trainees who meet only hearing clients during their placements are never awarded qualifications which disallow them from seeing deaf clients. It would therefore be unreasonable to argue that the deaf trainee must see hearing clients on placement in order to then be qualified to meet them in the future.

Courses may consider that fair and equal placement experience would be gained from expecting the trainee to attend exclusively hearing placements, but this makes the error of assuming equality of means yields equality of opportunity, since the experience of a deaf trainee in a hearing placement is not the same as that of a hearing trainee in the same placement. Long debates about equality of experience can be quickly dispensed with by focussing on equality of access to the competencies expected by the exam board. The question to be asked when a placement is to be offered is the same for all trainees, deaf or hearing:

“Given the placements in which this trainee has already worked, would the next one continue to provide fair opportunity to gain the competencies expected of this award?”

The audiometric profile or cultural affinity of the client group is irrelevant. In addition, to dispute a concern that has been aired by certain courses that hearing people would not want to see a deaf therapist, in the experience of those deaf trainees who see hearing clients interviewed for this chapter (and from Pollard Jr, 2002), at the time of writing no hearing client in the UK has ever refused to be seen by a deaf trainee, because she is deaf or indeed for any other reason at all. One trainee made a point of asking, at the end of therapy, what sort of effect if any her deafness may have had:

“One client in particular said that she preferred talking through the interpreter. She had worked with a hearing therapist before and found it made her feel vulnerable and exposed, she clammed up and dropped out of therapy, whereas through the interpreter the conversation was more paced and measured, and as a result she felt safer.”

Deaf trainee

Although hearing clients have universally responded positively to their deaf therapists, the question is nevertheless raised of whether or not a client has the right to decline to see a therapist on those grounds. The best working answer to this is probably that clients have a right to be informed that their therapist will be deaf but that they may not have the right to reject that therapist (should they wish to). Clients should be informed that their therapist is deaf and often works with an interpreter and this seems to be most sensitively achieved by stating it very simply at the bottom of the first piece of correspondence with an offer to discuss this should the client so wish.

It is helpful for courses to target supervisors thought to have a real interest in supervising a deaf trainee, for example one who is interested in how interpreters might be used imaginatively in structural family therapy, rather than simply pairing up available supervisors with unallocated trainees, and to allow time for those supervisors to take the idea back to their teams for discussion as the team provides the context for the placement experience. An ideal placement would also offer a range of options to the trainee rather than, for example, just a small routine schedule of outpatient clinics, and would have a supervisor who is well integrated themselves into the wider team. Courses have also found it beneficial to highlight to teams that the aim of the placement is parity of outcome in terms of skills and competencies rather than parity of process through the placement. A degree of flexibility and creativity with regards the process of the placement, the opportunities presented, will be necessary to ensure a fair outcome.

4.1 Supervision
Supervisors of course have different styles; some are almost parental in the protection of their charge while others monitor the trainee’s work from some distance and can feel absent. Some may seem controlling, others disinterested. If the course feels nervous about their trainee it may be tempting to locate a placement with a more comforting and protective supervisor. However, while a supervisor who is relatively present and supportive is desirable, one who is overly cautious and protective will likely, unintentionally, undermine and de-skill the trainee by appearing to be doubtful of her competence. The trainee’s confidence will remain at its initial low level for longer than is necessary. Likewise one who appears unsupportive and dismissive may empower the trainee and boost confidence much quicker, but at the risk of expecting her to cope with so much that she drops out of the programme. This is not to say that deaf trainees are more vulnerable or sensitive than hearing ones – but that training is onerous for all trainees and never more so than at the first placement, and the deaf trainee has the additional concern of working psychologically through interpreters with hearing clients. At least one course has addressed this issue by allocating the first (core adult mental health) placement in a broad adult mental health service for deaf people, such that the trainee could face all the usual anxieties and doubts about seeing people clinically without being concerned about interpreter issues, communicating with the supervisor, or working with hearing clients. Ordinary clinical concerns at least partly addressed, the trainee can then move on to a hearing placement with enough cognitive and emotional space to be able to address more clearly the other hearing-deaf concerns.

Notably it appears that it is not just the deaf trainee who fears the first hearing placement – courses who have not trained a deaf psychologist before feel it also, and just as the confidence of course staff is picked up by the trainee who then feels correspondingly more positive, so a confident supervisor and a positive placement experience reassures the course. Clinical placements feel like the acid test for all the preparatory work conducted by teaching staff by way of teaching and assignments, and as such the first placement visit or appraisal can be very beneficial, not just for the trainee but for the course. Also there will inevitably be considerable learning – regarding working with a deaf trainee - on the part of the placement supervisor (and indeed the whole team) and it is important to ensure that there is a mechanism for these experiences and insights to be handed over to the next placement, and back to the course.

5.0 Summary
For a variety of reasons few deaf people have trained as psychologists at this time and so few courses will have faced the issues inherent in training a deaf psychologist. These issues are myriad, and range from the imperative through curious to negligible. This chapter has attempted to provide a starting-point for thinking about and planning the training of deaf psychologists and in so doing has highlighted a variety of issues, concerns, and perhaps philosophical challenges. While it would be no excuse to flagrantly disregard these issues it remains the case that the ultimate aim is the successful training of a psychologist, and to compromise this by focusing exclusively on the deafness would be disastrous.
There is room in this exercise for curiosity, enlightenment and enjoyment – for the deaf trainee, for the hearing peers, and for the course.

6.0 References

Conrad, R (1979). The deaf school child. London: Harper Row

Great Britain. Acts. (1995). Disability Discrimination Act 1995. Chapter 50. London: The Stationery Office Limited.

Gutman V & Pollard RQ (1999) Working with Deaf Interns and Internship Applicants. APPIC Newsletter, November 1999.

Kyle J & Woll B (1985) Sign Language: The study of deaf people and their language. CUP: Cambridge

Pollard Jr RQ (2002) Program for Deaf Trainees: Ten Years of Experience. Personal Communication.

United States of America (1990). Americans with Disabilities Act Handbook. Appendix 0: Title III Highlights (Public Law 101-336). Washington, DC: The US Government Printing Office.

Sleep Management

noreply@blogger.com (Jim Cromwell) — Tue, 08 Feb 2005 15:47:00 +0000

Many sleep problems are simply that people

sleep when they don’t want to and
can’t sleep when they do.

It is easy for this to happen. We sleep and wake in patterns. Most people prefer to sleep at night and stay awake during the day. Sometimes we start to sleep during the day – maybe because we are ill, or tired. If we sleep during the day, when we go to bed we don’t feel very tired. So, we don’t fall asleep for a long time. Then we either wake up late the next day – so when we go to bed we don’t feel tired again. Or we get out of bed at the normal time, but feel tired in the afternoon because we didn’t get enough sleep. You can see in the diagram that it means a circular pattern starts to happen. This doesn’t always happen. If you have a job, for example, then you have to get up in the morning and you can’t nap in the afternoon – so the cycle is broken and sleep returns to normal.

So how do I sort it out?

Before you do anything you need to decide when your ideal getting-up time is, and when your ideal going-to-bed time is.

The best way:
Don’t sleep in the day. This can be hard, but the worst that can happen is that you feel very sleepy. You may need to wake yourself up early, or stop napping in the day. Or both. The first day is difficult, but the next day is much easier. If you can stay awake all day (between your getting-up and going-to-bed times) you will be worn out at bedtime and you will fall asleep more quickly. When you wake up next morning you will have had a full night’s sleep and you won’t feel tired during the day. It will be easier to stay awake that day and your sleep pattern will return to normal very quickly.

The next best way:
1) I sleep late in the morning. To sort this out you need to get up earlier. If it is hard to just do that straight away – do it in easier steps. Notice what time you usually get out of bed. Then the next day get out of bed one hour earlier. The next day get out of bed another hour earlier. Do this every day until you are getting out of bed at your planned getting-up time. If it is hard, get up at the same time for a few days until you are ready to save another hour. Or you could do it in half-hour steps. The important thing is to keep slowly getting up earlier until you are getting up at your planned getting-up time.

2) I take naps in the day. Get up at your planned getting-up time, and go to bed at your planned going-to-bed time. Also, make a note of how long your naps are, on average. On day one set an alarm to wake yourself up when you have had your usual amount of rest. On day two set the alarm with fifteen minutes less time. On day three set the alarm with another fifteen minutes less. Keep doing this until your naps are so short you don’t bother with them.

3) I sleep late in the morning and I take naps in the day. You need to do number 1 and number 2, but it will be hard to do both at the same time. Measure your nap time and make a note of what time you usually have it. Then concentrate on doing step 1 first so that you get out of bed nearer and nearer to your planned getting-up time. Throughout step 1 keep your nap time and the length of your nap the same. Then when step 1 is finished, do step 2.

Whatever way you do it:

Never be tempted to go to bed early.
Never be tempted to get up late, unless it is part of the plan.
Never be tempted to have a nap, unless it is part of the plan.

But I can’t stay awake!

The biggest thing to stop you achieving a healthy sleep pattern is having nothing to do. It is very hard to stay awake when you feel tired if you have nothing to do. If you can organise things to do for these days it will be much easier to achieve your aim of a healthy sleep pattern.

Online Publications

noreply@blogger.com (Jim Cromwell) — Fri, 28 Jan 2005 15:05:00 +0000

Links to the few online things with my name on.

The Oblique Effect in Orientation Acuity. Vision Research.
Considering the Use of Sign Language Interpreters in Therapy. Conference proceedings. Scroll to C4, or click here for the same information.
Consciousness. Letter to The Psychologist.
Talking Scents. Letter to The Psychologist.
Run With Your Patient. BMJ. (May require a password these days.)
Certified Meaningless. Letter to The Psychologist.
Assertive Community Treatment with Deaf People. (Link to buy the document).
Deafness and the Art of Psychometric Testing. Article in The Psychologist. (Requires BPS login, though not if you click here).
Community Mental Health Teams' perspectives on providing care for Deaf people with severe mental illness. JMH, Vol15, #3, 2006. (Link to purchase the article).

"Clinical Psychology Forum" submissions are not online.

Time Management

noreply@blogger.com (Jim Cromwell) — Wed, 12 Jan 2005 16:18:00 +0000

To-do Lists are prospective. They remind you of what you have not done. Tick items as they are completed but also compile a Done List by always adding tasks to the to-do list that were unplanned but were necessary and completed. This way it becomes retrospective also and actually rewarding.
Time cannot be managed, work can. Prioritise tasks in a 2x2 matrix with urgency as one axis and importance as the other. These variables are different in important ways.

What is Mental Health?

noreply@blogger.com (Jim Cromwell) — Mon, 11 Oct 2004 15:50:00 +0000

This is an information sheet I made, available on the Royal Association for Deaf People's website (www.royaldeaf.org.uk)

(you just might not realise it…)

We are all "mental". This means that we all are able to think about the world and about the things we do. We are also all emotional. This means that we all feel happy or sad, excited or bored, stressed or relaxed, and so on.

There is more to us than blood to keep us alive, muscles to move us about, and bones to hold us up. Those are the physical parts of us. We also have ideas, beliefs, fears, wishes, dreams, worries, relationships and so on. They are not physical, so to make it easy to talk about them we call them all "mental".

Sometimes our ideas, beliefs, and feelings can start to make life difficult for us. When that happens we have problems - but they are not physical problems. They are problems with the mental parts of our lives.

You might call them "mental health problems"…

Mental Health

What is mental health? Well… what is physical health?

We are physically healthy when we are not ill and when we feel good and fit.	We are mentally healthy when we are coping with life, feeling OK about ourselves, and relating well to other people.
We can get unwell or unfit in many different ways - physical health problems can be just a small problem like a cold, or a big problem like cancer.	We can get mentally unwell or unfit too - mental health problems can be just a small problem like being frightened of spiders, or a big problem like believing wrongly that people want to kill you.
They can be simple like a broken leg or complicated like kidney failure.	They can be simple like a phobia or complicated like schizophrenia.

Probably nobody is 100% physically healthy. Some people are weaker than others; some people get out of breath quickly; some people always have a cough. Probably nobody is 100% mentally healthy either. Some people get stressed easily; some people worry all the time; some people don't go out much because they are frightened that something will happen. We are all physically healthy in some ways and physically unhealthy in others. We are also all mentally healthy in some ways and mentally unhealthy in others.

Being Labelled

People worry about being labelled "mentally ill" - but what does this mean? Most people we see who we think are "mentally ill" are on the news. Also, they are on the news because they have done something terrible. We do not see people on the news who have not done anything wrong. So nearly all the people we see who we think are "mentally ill" are on the news and all those people have done something terrible. That's why they are on the news. So people think that all people with mental health problems are dangerous or out of control - but that's wrong.

Also most people with mental health problems we see on TV have schizophrenia. But most mental health problems are simple - like stress, feeling depressed, or being scared of something harmless.

Having a problem with your mental health is nothing to be ashamed of - just like having something wrong with you physically is just a part of life

It is a shame that people do not ask for help with mental health problems because they are worried about what other people will think of them. If people talked about their problems more, they would find out that other people have them too and that difficulties with emotions, thoughts and beliefs ("mental health problems") are just a part of life. We all have them and there is nothing to be ashamed of.

Mental Health Problems

Nobody can do everything. If you have a leaking water pipe, a plumber can help you. If you are confused about your money then your bank manager can help you. If you cannot make shelves then a carpenter can help you. If you find it difficult to feel happy, or to stop feeling stressed, or to stop feeling frightened then therapy can help you.
Some people can fix their own pipes, and some people can sort out their feelings - but there is nothing wrong with asking for help. ("Therapy" means talking to a counsellor, or taking medicine, or joining a group.)

Plumbing problems are about leaking and not leaking. Mental health problems are about coping and not coping. We can have problems coping with stress, with our emotions, with our fears, or with our worries. BUT a leak is easy to see. It is not easy to notice when we are not coping very well.

Emotions, thoughts, beliefs and worries, are all invisible - so it is hard to notice when we are not coping well, and it means we do not really see other people with similar problems either. If your problems upset you, or if they stop you from getting on with life, then it makes sense to ask for help from somebody who understands emotions, beliefs, thoughts, and worries.

That could be a counsellor, a psychologist, a psychiatrist, a psychotherapist… and so on. They mostly help by talking about the problem, because talking makes us think and thinking about the problem helps us to understand. When we understand the problem we can cope better, and when we can cope with it, the problem goes away. Sometimes our GP or a psychiatrist will give us medicine to help us cope. That can help too because medicines can help to calm us down if we are too wound up, or to cheer us up if we are feeling depressed.

Mental "Illness"

Nearly all mental health problems are problems with emotions, stress, worries, or bad thoughts. These things are normal problems that have become bad enough for the person to have trouble coping by themselves, so they ask for help.

A few of us have mental health problems that are so complicated and that upset us and disrupt our lives so much that it is difficult to understand what is going on.

Those problems are called "psychoses" or "schizophrenic illnesses", for example. If you have a problem like this, it is difficult to sort it out by talking about it and thinking about it because 1) the problem is very complicated and because 2) our thoughts become so mixed up that it is hard to think clearly about what is going on

Doctors usually mean these complicated problems when they say somebody has a "mental illness". Sometimes those problems make it impossible for us to think clearly enough to make decisions for ourselves. Usually we decide when to ask for help and who to ask for it, but if we have a very complicated and serious problem that stops us from being able to decide for ourselves, then certain doctors are allowed to make that decision for us. Even then, they need a social worker and a second doctor to agree with the decision.

Sometimes it is useful to think about a mental health problem as an illness and sometimes it is not. Thinking in this way can be a bit black and white, but that means we can be clear what we are talking about.

Here, we say the people on the right are "ill" and the people on the left are "well".
For physical health and illness this is a good way to think about it.
Sometimes with mental health it is useful as well.

More often it is useful to think about a mental health problem as being normal but that has started to make your life difficult or unhappy. For example if you are frightened of going out in public that can be normal anxiety, but if it means you never leave your house then it might be a bigger problem.

Here, we don't say anybody is ill or well. We say people have problems that can be small or big. If a person's problem gets so big that they suffer from it, then they can get help. That decision is theirs unless they have very serious problems which mean they are not able to make decisions for themselves.

For most mental health problems it is usually not very helpful to think "am I ill or well?" It usually makes more helpful to think "do I think that I am coping with my life well, or am I having some problems with it?" If you feel like life is sometimes too much, it makes sense to ask somebody to help you cope.

People are scared of these "mental illnesses" because of what they see on the news - but we know that the news does not give us the full picture. Nearly all people with mental health problems have normal, simpler problems and therapy can help them to sort them out.

BUT

Many people decide not to ask for therapy because they are frightened of what other people will think. But really that doesn't make sense - it is like not going to hospital with a broken leg just because other people in the same hospital have scary problems like cancer.

A mental health problem can be any problem to do with thoughts, beliefs or emotions - that's what "mental" means - and we should always ask for help if we cannot cope alone.

Provocation

noreply@blogger.com (Jim Cromwell) — Wed, 01 Sep 2004 11:08:00 +0000

These are potential essay questions or discussion points for people working in mental health and deafness. None of them are things I have concluded, but they are all things I reckon I would conclude if I thought about them enough...

1) The more severe the mental illness, the more interpreters do more harm than good. Discuss.

2a) Why do we believe a psychotic deaf person who says he hears voices, yet we don't believe the same person when they say they are followed in the street?

2b) Why do we believe the self-report of clients who sometimes cannot reliably report what they had for breakfast that day?

3) SSE is an affront to deaf people and should never be used except for teaching English.

Run With Your Client, Not After

noreply@blogger.com (Jim Cromwell) — Tue, 31 Aug 2004 12:21:00 +0000

This article has been published in the British Medical Journal (BMJ 2004;329:1176 [13 November], doi:10.1136/bmj.329.7475.1176). So if you are citing it, please do so accordingly. Well... They seem to have had a GCSE student re-write it, so if you want to quote this superior version instead, that would be your prerogative...

Chris was always climbing the fence. It was tall, a mosaic of chain-link and climbing weeds, about eight feet, and surrounded the euphemistic “garden” on three sides – the fourth being a three-storey red-brick ward. The ward was a home of sorts to a dozen people with learning disabilities and challenging behaviour and, similarly, a half-dozen nurses. Chris’s most prominent behaviour was “absconding from the ward”, a curiously circular reason for his admission and an activity he engaged in quite successfully on a daily basis.

Absconding was more often than not preceded by a few minutes of artfully presented nonchalance, entirely cloaking him from the watchful eyes of the nurses posted strategically about the place looking for, and only seeing, those behaviours listed in the various reports and management guidelines currently in action. The abscond itself was never witnessed. By sheer well polished sleight, Chris would fade imperceptibly from the consciousness of the assembled staff and then appear, as if conjured from ether, running full-tilt away from the fence.

The staff would snap into action. Blood, previously thickening in our veins, would course effervescently around our bodies. A unified flock-consciousness would drive us towards our joint and single purpose: to catch Chris and bring him back to within the confines of the fence.

To catch Chris.

Our prey stood in excess of six feet and, with daily practice, had developed both the athleticism and gait of an ostrich. He could turn in an instant and be suddenly careering in a completely different direction with no evident change in speed. He could slow down and speed up with no suggestion of inertia or momentum. His flight, essentially, was Brownian.

We would fly from the ward like light streaming from an opening door. We had a purpose. We had a plan. Roles were never discussed but somehow we knew to break into smaller units and try to bisect Chris’s unknowable path. We would run at break-neck speed towards him as if locked onto him like missiles. We would run orthogonally to limit the available directions he might take. We would unspokenly gather volunteers to the chase as if in a stampede. We would hide behind trees.

Catching Chris, despite the iniquity of numbers, invariably took upwards of an hour. Pursuers would retire from the chase exhausted, or perplexed. Sometimes entire shifts would change over the duration of the hunt. Ultimately, however, Chris would be apprehended in a frenzy of arms, legs and divots, attracting staff and onlookers like flies around a kill. Only partially subdued he would be guided, in a ruck, back to the ward where more often than not he would be carefully watched for the rest of the day while he returned our gaze repackaged as a scowl.

I don’t know how it happened. Nobody remembers, if they ever knew.

Chris had breached the fence again and was high-tailing it across the grounds. Somebody went to fetch him back. The mood was completely different, completely at odds with the usual galvanizing sense of mutual excitement. Perhaps we no longer cared. Perhaps, somehow, we were inspired. Our solitary staff member didn’t pursue Chris. He didn’t barrel after him like a Pamplona bull. He just ran. Within a few minutes he was shoulder-to-shoulder with Chris and running alongside. And they kept running. They ran for a further ten or so minutes and then returned to the ward. Nobody laid a finger on Chris. Nobody said a word. There was a ten-minute run and then home.

There were no absconds after that. Just runs.

Hearing Staff in Deaf Services

noreply@blogger.com (Jim Cromwell) — Tue, 31 Aug 2004 12:04:00 +0000

Deaf services often have a considerable number of policies regarding communication. These documents are intended to cover a variety of needs, but the one thing they all have in common is the access to information and discussion for the staff and client groups with their variety of communication modalities, registers and systems.

Often, however, the assumptions held by staff - and the culture and attitude of the institution - fail to yield the equal access to information and discussion which we would like to believe we foster.

The main area in which we fail is the use of interpreters in meetings.

Staff always try hard to make sure enough communication support is provided by interpreters. This of course is great, and we pride ourselves on this and criticise other services for not providing interpreters themselves. However the way in which we use interpreters gives rise to a major problem which is an inconsistency between philosophy and practice:

1 Hearing staff believe that, regardless of their level of BSL competence, the presence of an interpreter allows them to ignore the signing policy - which usually states, in its simplest form, that all staff should sign when a deaf person is present. Rarely does it say that staff may disregard the signing policy in this instance. So despite the presence of an interpreter all staff should aim to sign in the company of a deaf person.

2 Unfortunately, the vast majority of qualified staff are usually hearing. Thus, the discussion is inevitably led by hearing staff. A problem arises when

i) Those hearing staff are not signing and

ii) They are not respecting “interpreter-time” (the delay between the endings of the spoken utterance and the signed translation). In failing to respect interpreter-time, hearing staff respond to each other immediately after the other person has stopped speaking. This means the deaf people present are not able to contribute to the discussion on equal terms with the speaking people. This is why I am making a distinction between access to the information and access to the discussion. Current practice allows deaf people access to the information, but it is impossible for deaf staff to access and contribute to discussions to the same extent as staff who are not signing.

3 On those occasions that deaf staff do contribute, it is equally important for them to respect interpreter time to allow equal access to those who do not sign.

4 Signing policies often state that everyone’s choice of communication modality and system should be respected. However it is extremely difficult for hearing staff who may want to sign to do so. There are a number of reasons for this:

i) In any meeting there will be hearing staff with a range of signing competencies, and so most staff will be in the presence of others whose signing skills far outshine their own. When those (usually senior) staff refuse to sign, the person who wishes to follow policy and sign for themselves is made to feel ridiculous as they are singling themselves out. Also they inevitably wonder whether their beliefs about signing for themselves are correct - after all senior staff with advanced signing qualifications are not doing so.

ii) When other staff members who can sign are not doing so, a person who believes that he or she should be signing for themselves may often think that the other staff members feel the same, but have other reasons to avoid signing themselves. In my experience a hearing staff member signing for him/herself can project their anger that other people are not signing onto the other staff, and this is then experienced as extreme hostility from the signing hearing staff who choose not to sign. This feeling can be enough to stop the person signing for themselves. It is also possible that other staff actually are hostile to the signing hearing staff member, as they are being confronted with their own guilt about not signing, or their own fears that their signing is not very good.

iii) It inevitably feels strange to sign to a hearing person who does not sign and so does not directly understand what is being said. This is especially so for signing hearing staff. This feeling is compounded by being the only one.

iv) Initially it is difficult to sign while listening to one’s own signing being voiced over as this is both distracting and can be perceived as providing immediate feedback about the quality of one’s signing. However, ignoring the voice over is a skill which is quickly learnt.

5 When hearing staff avoid signing in meetings, their signing skills will suffer.

i) In mental health care most deaf staff are Health Care Assistants and work shifts, so the majority of staff in a meeting will be hearing. Meetings are one of the few places where staff could, in principle, observe their peers signing and this would make the different competencies and styles of signing within the staff group more transparent. In this way staff would be able to realistically appraise their own signing skills. When the only staff seen signing are deaf native signers, one’s confidence inevitably vanishes. With our confidence goes our inclination to sign at all, and an environment is established in which it is impossible to gauge one’s own signing competence by comparison with hearing staff.

ii) Equally, it is impossible for staff to receive objective feedback about their signing competence from the rest of the staff group. Such feedback would be both positive and negative, but both forms are constructive and lead to increased signing competence, increased signing confidence, and increased signing. In this way the vicious circle of lack of feedback leading to decreased confidence leading to less signing leading to less feedback can be reversed into a positive cycle of objective appraisal leading to increased competence leading to increased confidence leading to increased visible signing leading to further appraisal.

What can be done about this?

In my opinion this can lead to an anti-sign culture which is both oppressive and disheartening. Seeing others signing can enable everyone to feel confident about their skills, and to realistically appraise their own weak areas.

There will inevitably always be a number of staff who correctly feel they cannot sign in these situations - but interpreters are available to allow those people access to the meetings. At the moment interpreters are used to avoid exposing our signing skills to peer-review, to (consciously or not) oppress the deaf staff and clients, and to pretend that we are enabling equal access when in fact we are not. We should be using interpreters solely to support those staff who do not yet sign, and we should respect interpreter time in order that those staff have equal access to both the information and the discussion.

It is my view that:

All staff who can sign, should sign at all times.
Staff who cannot sign should be trained appropriately and supported.

Therefore all staff who are not attending, or who are not about to attend, a signing course, should be signing for themselves. If they are not, that person’s line manager should address the issues which prevent him or her from signing. This means that all staff with advanced or confident signing skills should be obliged to sign. All other staff should be encouraged to sign - both directly through line management, and indirectly by the culture and attitude of the unit shifting to enable everyone to feel safe enough to sign.

Interpreters, Psychosis, and Voices

noreply@blogger.com (Jim Cromwell) — Tue, 31 Aug 2004 10:23:00 +0000

From the Psychology Department Newsletter June 2004.

Using an Interpreter

It is almost entirely true to say that in psychology if you can’t talk to your client you can’t do your job. It is certainly entirely false to say that with an interpreter (of any language) you can get on with your job ‘as normal’. The immediate impact of a third party is probably obvious – dynamically, temporally (with spoken language interpreting, being sequential), and transferentially (particularly with BSL interpreters where the client’s emotional relationship is often more powerfully with the interpreter than the clinician). Alongside these more immediately apparent difficulties lies a more pervasive problem of accurate communication, understanding, and - for want of a better term – empathy. While the relation between language and thought is a complex one, it is nevertheless fairly clear that expressed language in any modality is an encoded version of the concepts intended by the person speaking. Just as the vocabularies of two languages never perfectly correspond, so the vocabulary of one’s own language only approximates the “vocabulary” – the concepts – of our thoughts. When I talk to you I am encoding my thoughts, ideas, beliefs into English. This is a process of translation / interpretation which necessarily loses information. When you read my English you attempt to decode the meaning using the phrasebook of your pre-existing understanding, beliefs and expectations. This again is a process of interpretation. Between my ideas and your understanding of them (even supposing I am making sense, possibly a moot point) there is already considerable potential for miscommunication, and we share a common language. It is likely we share a common “culture” too – that of western psychiatry and medicine (like it or not). When working with a client who speaks a different language from you, the interpretation between those languages is variably, and sometimes considerably, prone to information loss or distortion just from a lack of vocabulary equivalence. In addition, you and the client will likely come from different cultures – ‘culture’ meaning in this case not just sociological and anthropological differences but cognitive and conceptual ones. A Chinese person explaining parenting to you in terms of “guan” is presenting a concept alien to Western Europe and not a part of western psychological parenting work. The biggest pitfall of using an interpreter is assuming that you do not only understand what the other person is saying, but also what they mean. This pitfall is not confined to interpreting situations.

Interpreters can work in a variety of different ways, the simplest model of which being a notional continuum of verbatim translation to interpretive meaning - or from a word-for-word level through noun-phrase, sentence, paragraph levels to whole document/speech/session levels. The lack of lexical correspondence between two languages renders verbatim interpretation a nonsense, and the other end of the continuum leads to practical difficulties. However the model is useful when considering what you want the interpreter to do.

Psychosis

Conducting a psychological assessment of a psychotic client using an interpreter is arduous. The only time it does not feel that way is if you are not aware of the complications that the interpretation is bringing to the assessment. Interpreters constantly tread a line between ‘telling you what the person said’ and extracting meaning from the utterance and presenting that – and you don’t know which they are doing! Quite often the absence or distortion of meaning is the clinically relevant feature, but it is the task of the interpreter to understand and, quite professionally, they may clarify and clarify with the client until meaning is found in the language when potentially there was none there to start with. With no clear word-for-word translation possible, how can one interpret word salad, for example? Conversely, if the client appears to make no sense how can thought disorder be distinguished from communication difficulties or difficulties of interpretation? Without an interpreter there are still, of course, two interpreting processes going on…

Voices

Nascent employees of the Deaf Directorate almost always learn within a matter of days that prelingually and profoundly deaf people with psychotic disorders hear voices. In a service that, upon recruitment, immediately deskills us, fascinating titbits such as this are survival aids. This assertion is rarely questioned, and much has been written about the neuronal activity of deaf hallucinating psychotic people, the phenomenology of deaf psychotic voices, and so on. Perhaps obviously to those outside of this field, the assertion makes no sense. Clinically I have rarely if ever managed to have a (one to one) conversation with a deaf person said to hear voices where the deaf person has been able to describe the pitch, timbre, vocabulary, volume, or location of the voice. Even if there were some way of demonstrating (with a magical functional MRI) that the person really was experiencing an English-speaking female voice of rather low volume, telegraphic prosody, commenting on her clothes from behind her - volume, prosody, the gender of the voice and auditory location are not things that a prelingually profound deaf person could reliably report upon.

Could it be that asking specific questions about such symptoms gives the client (deaf or hearing) a lens through which to evaluate quite probably chaotic and confusing internal experiences? Why do we trust the report of a prelingually profoundly deaf person on the nature of their psychotic experiences when that same client, at the same time, is not able to reliably report upon where they think they are or who they are talking to? Psychotic experiences may well be (who knows?) the cognitive equivalent of dropping all the pages of your thoughts in a puddle and reassembling them, soggy, in the wrong order. The process of encoding those experiences must be even more prone to misrepresentation than non-psychotic mental phenomena. In the context of a clinical interview, deliberately or otherwise asking questions which are even only slightly leading (“Do you sometimes hear a voice that seems to come from nowhere?”) is equivalent to showing a Rorschach blot and asking “Do you see a bat?”

The ABC model of voices suggests the voice is an activating event triggering beliefs about it. Quite possibly the voice is delusional as well. But what’s the difference?

Mental Health Act Language

noreply@blogger.com (Jim Cromwell) — Tue, 31 Aug 2004 10:13:00 +0000

Often mental health services, particularly inpatient teams, use the language of the mental health act when discussing patients, not just the detained ones. I think this is unhelpful because a) it is misleading, but b) because it reflects a mindset that detention and the restriction of patients’ liberties is the norm, when in fact it is the exception. Even if the majority of patients are detained, we should still maintain the attitude that detention is the departure from normal practice in the extreme situations that the MHA is intended to cover.

As examples, we never hear of patients (non-detained) saying that they are going home for the weekend – instead it is always that x is requesting leave and is that OK. We know that it is not our decision and that x can go whenever he likes, but the default perspective that we are in charge of / responsible for other people when we are actually just offering a service they can take or leave I think is damaging. It is worse still if x really thinks he has to ask, and not just that it is being reported in the language of the MHA.

Also we hear a lot in discussions of non-detained patients that “well we can’t detain him” as if there is an air of regret around that! It scares me that we have to think on our feet about ways to cope with the fact that we can’t just force the person to comply. That somebody is undetainable is a good thing, in my opinion, and that people who are detainable are so for reasons that are awful for them (that is, they need detention in their own best interests for specific reasons, that they are horribly ill and pose a risk to themselves or others.) If we regret that a person may not be detained, that suggests that we are losing the ability or the willingness to work with people collaboratively and that would be terrible.

I would be the first to roll my eyes at the political over-correctness of identity politics, for example levering in the word “people” after politically sensitive adjectives makes my flesh creep, however my concern here is that language use not only reflects, but influences our mind-set and attitude towards the people we work with, most powerfully in the way trainees, students and new staff absorb assumptions that it appears from our language that we make.

What are the effects of using interpreters in therapy with British Sign Language users ?

noreply@blogger.com (Jim Cromwell) — Fri, 27 Aug 2004 19:11:00 +0000

“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.

Summary:

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.

References

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.

Elliot H., Glass L. & Evans J.W., eds (1987) “Mental Health Assessment of Deaf Clients: A Practical Manual.” Little, Brown & Co, Boston.

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.

Hindley P. (1993) “Signs of Feeling. A prevalence study of psychiatric disorder in deaf and partially hearing children and adolescents.” RNID, London.

Hoyt M.F., Siegelman E.Y. & Schlesinger H.S. (1981) “Special Issues Regarding Psychotherapy with the Deaf.” Am J Psychiatry 136:6.

Jeffers J. & Barley M. (1975) “Speechreading (lipreading).” Charles C. Thomas. Springfield, Illinois. 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.

Kyle J.G. and Woll B. (1985) “Sign Language. The study of deaf people and their language.” Cambridge University Press. Cambridge.

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.

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.

Schein J. & Delk M. (1974) “The deaf population of the United States.” National Association for the Deaf. Silver Springs, Md.

Schlesinger H.S. & Meadow K.P. (1972) “Sound and Sign: Childhood Deafness and Mental Health.” Berkely. University of California Press.

Stansfield M. (1981) “Psychological Issues in Mental Health INterpreting.” RID Interpreting Journal, 1 18-31. 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.

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.

Vernon M. & Andrews J. (1990) “The Psychology of Deafness. Understanding Deaf and Hard of Hearing People.” Longman, NY.

Vernon M. & Brown D.W. (1964) “A guide to psychological tests and testing 1 procedures in the evaluation of deaf and hard-of-hearing children.” Journal of Speech and Hearing Disorders, 29, 414-423.

Psychometric Assessment of Deaf People

noreply@blogger.com (Jim Cromwell) — Fri, 27 Aug 2004 18:57:00 +0000

There are very very few psychometric instruments available for use with prelingually profoundly deaf people. When testing such people therefore, there is a great deal to be borne in mind.
The most important point to consider is that of the validity and reliability of the tests used, both in and of themselves, and as a result of any changes that would need to be made to the formal administration in order to communicate the task to the client. Four main questions can help with this:

1. Does the test consist of verbal test items or performance items? Verbal items are inappropriate for deaf people, particularly prelingually deafened. Such people usually have difficulty with English syntax and vocabulary independent of cognitive function, as a result of English being a purely visual (and unspoken, and therefore considerably less frequently encountered) language for deaf people. Deaf people’s mean reading age (compared with hearing peers) has been estimated to be at the 3rd or 4th grade level irrespective of intellectual function.

2. Do instructions for the test require verbal communication? This is important even if the tasks themselves are considered to be “performance” tasks. For those measures that offer little or no flexibility in the way in which instructions are presented (such as the WAIS-III), departure from the formal administration departs also from the standard administration with the normative sample and comparison with that sample then becomes misleading in ways that cannot be predicted or allowed for. The same problem is more frequently met when comparing hearing people tested in the formal manner with those tested with more flexible instruction.

3. Do any test items discriminate against (or for) an individual with an auditory impairment? Test items may discriminate directly or indirectly against, or for, deaf people. Those that discriminate against are more common, but both for and against present problems of comparison with a normative sample. An immediately obvious example would be from the Vineland Social Maturity Scale which contains an item “Makes Telephone Calls”. Clearly this would underestimate the individual’s functioning. Perhaps less obviously, but equally critical, an attempt to address the cultural validity of this item by converting it to “Makes Minicom (Textphone) Calls” still underestimates the ‘true’ level of functioning since a deaf person’s experience of using a textphone differs entirely from a hearing person’s with a telephone (in terms of when one is first seen used, how often they are seen on TV, and so on.) Similarly there is some evidence that BSL users are advantaged when using the block tapping tasks (such as Corsi’s) – but advantaged in such a way that disappears when the person sits alongside the examiner instead of opposite.

4. Are deaf people included in the normative sample provided by the test developer? Apart from a very select handful of tests the answer to this question is always no. Norms for deaf people are rarely provided. There are good arguments for and against comparing this deaf person with deaf or ‘hearing’ norms, and the answer depends on the reason for testing. However there is only ever an argument for ‘hearing’ norms if that normative sample contained deaf people in equal proportion to the population of concern and that the results from that sub-sample are demonstrably as reliable as those of the hearing subjects. Such norms are rarely if ever established, and prelingually profoundly deaf people are more likely to be formally excluded from the normative study. The interpretation of results of clients who do not mirror individuals for whom the test was designed must therefore be explicitly cautious.

These main areas make the assumption that communication with the client, in sign, is unproblematic – that is, that the assessor is able to sign. When that is not the case, further issues of the reliability of the interpretation are raised:

5. How reliable is your communication support? The ability of the interpreter(s) must be stated in the report and considered when interpreting the results. Even if the interpreter is Level IV accredited and a registered Sign Language Interpreter, which ought really to be the only acceptable standard for psychometry, the reliability of the interpretation will decline significantly after 35 minutes. Two interpreters should be used and regular breaks should be introduced (which can itself conflict with a formal test administration). Interpretation will always add to the error in the estimated level of function, and it is impossible to say whether it contributes to an over- or an under-estimation. The extent of this error is, in part, a function of the competence of the interpreter(s).

6. How reliable is perfect communication support for this measure? Even if the communication support is 100% perfect (and this is in truth only available in our imagination) then it is important that each item of each test be discussed in advance with the interpreters. (There is no such thing as a perfect translation. There can be a best translation but that is hard to find and is only a “working-best” until a better one is noted in the future.) However, even supposing perfect interpretation, the assessor must be fully aware of the nature of the signed administration in order that the psychometric equivalence of the standard and the signed administration of that item can be judged. For example, the Similarities subtest of the WAIS-III contains the question, in English, “In what way are a coat and a suit alike?” It is fairly easy to translate this into a British Sign Language equivalent with little debate. However the nature of the most common signs for coat and suit make it self-evident that both are articles of clothing – a response which receives maximum points. Conversely the signs ‘rhyme’ in terms of both being bimanual and symmetrical, sharing the same location in space, employing very similar movements, and handshapes differing only in terms of thumb position. It could be argued that these phonological similarities are unreasonably misleading and/or that they imply alternative false answers (the location of both signs is commonly used for emotions) in a way that the spoken English items do not.

These concerns all contribute unknown amounts of error to the estimated level of whatever psychological construct is under scrutiny (such as intellectual function). In addition the ways in which these concerns may be addressed (that is by departing from standard administration in a variety of ways) also contribute error to the estimate. The magnitude of this error and the overall direction of it are both unknowns and lower the reliability of the obtained results.
The validity of obtained results remains in question when the normative sample is exclusively hearing.

Generally, examiners should be advised to:

• Assess the deaf person with support from qualified British Sign Language Interpreters.
• Discuss each item of each test in advance with the interpreters, and afterwards such that any instances of note may be raised and accommodated in the interpretation of the results.
• Consider which, if any, tests to use in the light of points one to four above.
• Interpret results with extreme caution in the light of points one to six above.
• Make each of these shortcomings explicit in the report such that future readers will not jump to erroneous conclusions.
• And generally to assume that obtained results reflect a hypothetical minimum value, and never imply a ceiling to the individual’s ability or potential.

[Snip this URL as: http://snipurl.com/testdeaf]

Deafness Links

noreply@blogger.com (Jim Cromwell) — Mon, 16 Aug 2004 17:52:00 +0000

My Things
British Sign Language Fingerspelling * Photographic ABC in British Sign Language.
You CAN use your PC as a TDD * Software for TDD communication via your PC. With links.
Set up Hyperterminal as a minicom * Instructions with pictures based on Andy Arthur's instructions.

UK Organisations
BSMHD * The society for the promotion of the positive mental health of deaf people in Britain.
ESMHD * International Non-Government Organisation for the promotion of the positive mental health of deaf people in Europe.
National Deaf Services Home Page * Mental Health Services for Deaf People in the UK.
RNID * The largest deafness charity in the UK.
Sign Community * Formerly the British Deaf Association.
National Deaf Children's Society * The only UK charity solely dedicated to providing support, information and advice for deaf children and young people, their families and professionals working with them.
Royal Association in Aid of Deaf People (RAD) * Promoting the welfare and interests of Deaf people.
SENSE * The UK's largest organisation for children and adults who are deafblind or have associated disabilities.
Signed Performances in Theatre (SPIT) * The leading national body for promoting BSL interpreted performances of mainstream theatre.
Deaf Connections * One of the world's oldest charities working with Deaf and Hard of Hearing people.
Deafax * Using technology to promote Deaf literacy and achievement

Academic Organisations
Gallaudet University Home Page * The University for Deaf People in Washington.
Gallaudet Research Institute * GRI researchers gather and analyze data concerning the social, academic, and perceptual characteristics of deaf and hard of hearing populations, primarily to provide information needed by educators in the field.
National Technical Institute for the Deaf * The world's first and largest technological college for students who are deaf or hard of hearing.
University of Bristol - Deaf Studies Department * Europe's only academic institution that concentrates solely on research and education that aims to benefit the deaf community.

Other Useful Links
Forest Bookshop * Specialist in books and other media on Deafness and Deaf Issues.
See Hear * The BBC programme for Deaf people. Reviews and summaries.
A-Z of Deafblindness * Help to Blind or deaf people, and especially deafblind people, and those who provide specialised services for those who are deafblind.
World Recreation Association of the Deaf * Providing programs, services, and activities to hearing, deaf, and hard of hearing persons.
DEAF-INFO Web Site * Omer Zak's info. Particularly about the Deaf-L listserver.
ASLI * Association of Sign Language Interpreters.
Deaf Library * Karen Nakamura's online collection of reference material and links intended to educate and inform people about Deaf cultures.
"About" - Deafness * Guide to further deafness-related sites.
RNID library * Based at University College London.
Deaf-UK News and Discussion Group * Contents may be hot.
Typetalk * UK relay service.
Deafsign* Cath Smith's useful information and some nice clear things to play with.