Working with people who are deaf or hard of hearing.

The field of rehabilitation has evolved continuously since its beginnings over 70 years ago. This evolution has been a healthy response to broader societal trends, including changing attitudes (and concomitant public policy) toward people with disabilities, greater consumer advocacy, new methods of delivering services, and emerging rehabilitation professions.

The professionalization of the various provider roles in rehabilitation settings developed in response to the complex service needs of people with disabilities, who are now entitled to a broad array of services under the Rehabilitation Act of 1973, the Individuals with Disabilities Education Act (IDEA) of 1991, the Americans with Disabilities Act (ADA) of 1990, Title XX of the Social Security Act of 1975, the Job Training Partnership Act, the TechnologyRelated Assistance for Individuals with Disabilities Act of 1988, and related policy initiatives. The sheer scope of programs and services and the daunting responsibility to individualize service plans necessitates well-qualified as well as specialized personnel.

Specialization in Rehabilitation

Rehabilitation specializations can be viewed from several different perspectives. Some specializations evolved in response to specific job roles and functions (e.g., rehabilitation counselor, vocational evaluator). Others emerged because of new service settings (e.g., job coach, independent living specialist), while still others developed to more appropriately serve certain populations (e.g., interpreters for people who are deaf or hard of hearing, mobility specialists for people who are blind or have low vision). A certain amount of overlap among these specializations inevitably occurs, as it does in any cluster of professions in which human services are provided.

Specialization in Hearing Loss

Rehabilitation specialists who work with people who are deaf or hard of hearing were among the earliest specialists to emerge. The need for specialists to work with people who have hearing loss originally came from the distinct communication requirements of this population: obviously, communication barriers must be removed before a provider-consumer partnership can be developed. Communication is the first step in serving people who have a hearing loss, but it is not the last. Hearing loss presents unique issues for the provider which must be understood if appropriate services are to be arranged or provided.

Specialists who work with people who have hearing loss come from various professional disciplines (e.g., counseling, education, psychology), are represented at all levels of professional training, and work in a variety of rehabilitation settings (although less frequently in business and industry).

These specialists usually have generic knowledge and skills provided by discipline-specific education programs and then later obtain additional training in working with people who are deaf or hard of hearing.

Although specialization by disability is now a well-established approach within rehabilitation, recent initiatives toward mainstreaming and a philosophical reluctance of policymakers to "fragment" the disability community have led to questions about the appropriateness of this strategy. Sometimes professionals who work with deaf or hard-of-hearing people are challenged to defend the reasons they work with only one disability group. Can't broad knowledge about disability issues in general transfer to specific applications with deaf and hard-of-hearing people? My answer is invariably "yes and no." There are many universal issues and applications common to all people with disabilities. From one perspective, human beings--with or without disabilities-all have similar needs, drives, motivations, and emotions. Nevertheless, from another perspective, we are each sufficiently distinct so that the configuration of our unique needs, drives, motivations, and emotions makes each of us individual and separate from one another. From yet a third perspective, people who are members of specific cultural, ethnic, or disability groups--to name a few of the many ways people may be grouped--share many characteristics, values, and is- sues in common while also differing from each other on other equally im- portant dimensions. The professional who understands and respects these differences, while also not stereotyping members of a particular group, is better prepared to work with the individual who happens to be a member of that specific group. This is particularly true for those professionals who work with people who have hearing loss. Lack of understanding of the implications of hearing loss have lead in some cases to serious misdiagnoses and the denial of human rights. Several highly publicized cases about deaf youngsters who were mistakenly placed at an early age in institutions for people who were mentally retarded have sensitized the public to the most sensational violations. Other, less egregious, but nonetheless potentially harmful practices still occur among uninformed professionals. For example, the use of a verbal test of intelligence with a person who has been deaf from an early age is always invalid. Such a test measures the consequences of profound, early hearing loss and English language usage, not innate intelligence or the ability to learn and perform. This is very standard and basic knowledge for deafness specialists. All graduate training programs for rehabilitation specialists in hearing loss emphasize the most appropriate uses and potential misuse of various assessment instruments for people who are deaf or hard the integrity of the test ahead of the integrity of the client ! Hearing loss is a deceptively complex spectrum of disabilities. It is invisible and something we will all experience if we live long enough. Yet, it is much more than merely the inability to hear, and this is what makes it misunderstood, more often than not, by the public and even by professionals. It occurs across a continuum, so that people who have a hearing loss may be profoundly deaf or mildly hard of hearing. It also occurs at different developmental stages from birth (most rare) through old age (most frequent). Depending on many factors-including age at onset, degree of loss, and other characteristics of the person and his or her environment--hearing loss may be experienced by the person as a source of cultural identity and pride, as a minor nuisance, or as a traumatic, life-altering event. For those for whom it is a minor nuisance, rehabilitation services may consist of the pro- vision of assistive devices or interpreting services to make the environment more accessible. For those for whom it is a life altering event, rehabilitation interventions may be considerably more comprehensive and extensive, requiring the "multiple services over an extended period of time," which is the criteria within the state-federal system for priority services to people with severe disabilities.

The sheer diversity of a person's response to his or her hearing loss is as different as are people themselves. Obviously, all people with disabilities are not alike but share common issues which may be addressed by certain programs, adaptations, and services. So, too, people with hearing loss are not all alike. It is a truism that bears repeating: deaf and hard-of-hearing people have as many differences as they have similarities. However, they do share certain characteristics, environmental barriers, memories of frustrating or denigrating experiences within the larger society, and a core cultural identity--as a deaf or hard-of-hearing person--that sets them apart, individually and as a group.

Professionals who work with people who have hearing loss must understand the shades of distinction among people with a hearing loss and the meanings these distinctions have for the individual. They must also possess knowledge about the ramifications of this loss--personal, social, educational, and vocational--information about assistive devices, community resources, and appropriate technology, as well as have the skill to conduct valid assessments and utilize adequate interventions. And, increasingly, the professional must understand the self-definition and identity of the person with a hearing loss: Deaf (with capital "D" for culturally deaf),(1) deaf (small "d" for audiologically deaf),(2) hard of hearing, or, less frequently, "hearing impaired." They must also understand how these identifications may shape the entirety of the person's existence.

Rehabilitation professionals who work with people who have hearing loss include those who work in increasingly diverse service settings. They include the rehabilitation counselor: deafness specialist (RCD), independent living specialists, rehabilitation psychologists and mental health counselors, rehabilitation teachers and aides, job coaches, and vocational evaluation and work adjustment specialists, and many others. A unique professional is the interpreter--most frequently for sign language but also increasingly for oral or cued speech interpreting-whose role is to provide communication accessibility for people who have hearing loss. All of these careers require training in the particular profession with additional training and experience, and sometimes credentialing, to work with deaf and hardof-hearing people. A few of these careers will be highlighted below.

The Rehabilitation Counselor: Deafness Specialist (RCD). Rehabilitation counseling is one of the oldest and most established rehabilitation professions. The profession originally developed within the context of the state-federal rehabilitation program as authorized under the Rehabilitation Act of 1954 which provided training grants to prepare master's level rehabilitation counselors to work in state rehabilitation agencies. It is still used as a job title for personnel within most rehabilitation agencies, although qualifications for personnel within state agencies lack consistent standards. Despite the continued existence of rederally-funded master's level training programs, an accreditation process for these training programs, and a certification process for generalist rehabilitation counselors, people hired as counselors by state rehabilitation agencies frequently lack appropriate pre-service education. However, the professional practice of rehabilitation counseling has expanded over the years and now transcends the single service setting of the state rehabilitation agency.

The rehabilitation counseling specialty of working with deaf and hardof-hearing people arose in recognition of the unique communication needs of deaf adults who use sign language. It was fostered originally by cooperative arrangements between state rehabilitation agencies and state residential schools for deaf students and, more recently, by greater sensitivity to the complexity of needs of people who are deaf or may have other degrees of hearing loss. There is now increased awareness among RCD's of the needs of people with a mild hearing loss who may be overlooked by an educational or rehabilitation setting because the disability is viewed as "not severe enough."

There are many more hard-of-hearing adults than there are deaf adults. Specialized training in the continuum of hearing loss is the preferred background for master's level RCD's, not only because of the many similarities in these populations but because including all people with a hearing loss can provide sufficient numbers to justify a specialized caseload. However, in many rural areas, population density cannot support specialized rehabilitation counselors for people who are deaf or hard of hearing. Even in heavily populated areas, people who are hard of hearing and do not use American Sign Language (ASL) are frequently served by generalist rehabilitation counselors rather than RCD's. In these situations, generalist counselors who are otherwise qualified as rehabilitation counselors should be able to adequately serve hard-of-hearing people. If a generalist counselor is a Certified Rehabilitation Counselor (CRC), the hard-of-hearing consumer can be reasonably certain that the counselor will have the minimal educational background, have passed a certification examination, received appropriate supervision, and taken a requisite number of continuing education credits to stay current in the profession. However, generalist counselors will need to work closely with consultants, such as a qualified RCD or state coordinator in deafness and with qualified interpreters, to appropriately serve culturally Deaf clients.

In 1967, a group known as the Professional Rehabilitation Workers with the Adult Deaf (PRWAD) became the first organization for rehabilitation counselors who specialize in working with people who have hearing loss. Subsequently, the organization changed its name to the American Deafness and Rehabilitation Association (ADARA) and expanded its membership to include other human service professionals. In the ensuing years, the numbers of RCD's grew, training programs were established, core competencies for practice were identified, and employment opportunities for RCD's opened up in rehabilitation programs and facilities outside the state-federal system.

There are currently less than 10 master's level rehabilitation counselor education programs nationwide that train RCD's. Some of these programs train only RCD's. Others have both an RCD program and also a generalist rehabilitation counselor education program. All programs emphasize core rehabilitation counseling competencies as required by the Commission on Rehabilitation Education (CORE) and specific competencies in working with people who have hearing loss.

Most RCD's work in the public or not-for-profit sector rather than in private rehabilitation settings. This is because programs for people with hearing loss are usually publicly funded through federal, state, or local programs. An exception would be the rehabilitation counselor in private practice who might work with the individual who became deaf or hard or hearing through a work-related injury.

Employment settings for RCD's are exceedingly diverse and include programs that provide vocational and independent living services to people with hearing loss at different stages in the lifespan, at different levels of education, and with additional disabilities. For example, RCD's work in high school transition programs, post secondary programs with services for students with disabilities, senior citizens programs, community advocacy agencies, social service agencies with vocational and independent living programs, facilities with supported employment programs, independent living programs, rehabilitation centers with services for people with hearing loss, drug treatment programs, and community re-entry programs for in-patient mental health treatment centers. The passage of the Individuals with Disabilities Education Act of 1991 with its inclusion of rehabilitation counseling services opens up new employment opportunities for rehabilitation counselors in public school settings.

The specific roles of RCD's depend on the mission of the employing agency or setting and the needs of the consumer population the agency serves: some will emphasize certain job functions such as assessment, counseling, consulting, advocacy, placement, or service coordination more than others.

Although RCD's represent the oldest and largest rehabilitation profession to work with deaf and hard-of-hearing people, there is still an acute shortage of qualified RCD's in all rehabilitation service settings. The passage of the Americans with Disabilities Act along with increased accessibility for deaf and hard-of-hearing people in educational and rehabilitation programs will bring a parallel demand for increased numbers of RCD's throughout the 1990's.

Other Specialties in Hearing Loss

The mental health counselor and rehabilitation psychologist who work with people who have hearing loss are emerging specialties. Although some role overlap with RCD's exists, these professionals focus more narrowly on the mental health diagnostic and treatment needs of people with hearing loss. These include marital and family issues, chemical dependency, and more pervasive and long-standing interpersonal and intrapsychic issues. Growing public recognition that people with hearing loss have the same mental health needs as everyone else-- but with more limited access to appropriate services--has contributed to the growth of programs with mental health services.

There is also increased recognition about issues of loss, adjustment, and identity for an adult who developed as a hearing person and then became deaf or hard of hearing. Sometimes this person will need environmental modifications, such as the provision of assistive listening devices, oral interpreters, or notetakers. But frequently he/she will need intensive, long-term counseling or therapy to cope with the multiple stressors--internal and external-that are a consequence of hearing loss and the possible disruption of lifestyle, personal identity, and important life roles.

Because the recognition of the mental health needs of people who have hearing loss is so recent, the shortage of these professionals remains acute. Very few programs exist, particularly for mental health professionals who are trained to work with culturally Deaf people and are fluent in American Sign Language. Gallaudet University has long had a master's level RCD program. More recently, it established a master's level mental health counseling program and a Ph.D. program in clinical psychology. Because Gallaudet is the world's only liberal arts university for deaf undergraduates, its graduate programs--which serve both hearing and deaf students-- are particularly accessible for people who have hearing loss.

Although the mental health needs of people with hearing loss have received a great deal of attention recently, vocational issues--career choice, work adjustment, occupational mobility and advancement--remain the preeminent concern of most deaf and hard-of-hearing people. This concern is even more acute for the "lower achieving" deaf or hard-of-hearing person. There has been an increase in the past decade in the number of rehabilitation facilities and programs serving the deaf or hard-of-hearing person who has minimal educational and language skills, may have multiple disabilities, and has limited work skills and marginal work behaviors. The demand for services for this population continues to outstrip the supply as does the need for qualified vocational evaluators, work adjustment specialists, job coaches, and allied personnel who can work with this population.

A pivotal professional role is that of the interpreter. Demand far outstrips supply for competent interpreters who are qualified to provide services in medical, legal, educational, and rehabilitation programs. Interpreters are usually contractual employees hired through interpreter referral agencies, although some freelance and others are full-time permanent employees, usually employed by government agencies.

Sign language interpreting standards have existed since 1972, when the Registry of Interpreters for the Deaf (RID) developed a performance based national certification system. A 1989 revision to this certification system now recognizes two certificates: one in interpretation and the other in transliteration. Some states have also established separate quality assurance standards for interpreters.

In addition to sign language interpreters, there are also oral and cued speech interpreters. Cued speech is an adjunctive system which aids in speechreading by using handshapes around the face to represent consonant sounds, and positions about the face to represent vowel sounds. Cued speech interpreters are referred to as transliterators. To date, there are no nationally recognized standards for training or competencies for oral interpreters or cued speech transliterators.

Interpreter services are considered a "reasonable accommodation" under Section 504 of the Rehabilitation Act of 1973. The Rehabilitation Act amendments of 1978 mandate the hiring of personnel (either interpreters or counselors) in programs funded under the act who can use the client's method of communication. The Americans with Disabilities Act will most certainly further assure access to interpreters as a reasonable accommodation for people who have a hearing loss.

Shortages and Standards in Professional Specialties

As might be expected, there is a shortage of qualified rehabilitation professionals in every aspect of service to people who are deaf or hard of hearing. These shortages are more acute in the professions which typically require a doctoral (e.g., psychology) or master's degree (e.g., counseling) to practice professionally and less acute in those professions which are more loosely defined and do not have recognized standards of professional practice, such as independent living specialists, job coaches, rehabilitation teachers, and aides.

Services and programs for and with people who have a hearing loss, particularly for Deaf people, have expanded enormously in the past two decades. Rehabilitation careers with these people have expanded accordingly. More recently, advocacy efforts on behalf of people who are hard of hearing, particularly efforts by organizations such as Self Help for Hard of Hearing People, Inc., have increased the awareness of training programs and providers to the needs of the later-deafened or hard-of-hearing population. The demand for well-trained, committed people to work with all people who have hearing loss will remain high for the next decade.

One last step in consumer protection that remains is the development of reasonable standards for specialists who work with people who have hearing loss regardless of professional discipline. Although there should be room for flexibility based on whether the professional will serve predominantly people who are deaf or hard of hearing, it appears likely that standards will be developed and implemented within the next few years, thus providing quality assurance in rehabilitation services for all the nation's deaf and hard-of-hearing citizens.

Notes

1. People who are culturally Deaf have a shared identity as "Deaf people" which includes the centrality of ASL as their native language, common social, organizational, and voluntary networks, and enculturation as Deaf people through similar experiences, typically during the developmental years.

2. People who are audiologically deaf perceive themselves as "people who are deaf," use English (or another language used by hearing people) as their native language, whether signed (e.g., signed English) or spoken, participate in organizations and community networks which consist primarily of hearing people, and have typically developed an identity as hearing people through early personal, educational, and social experience.

Resources

Following is a list of contacts for information on professional training programs in various disciplines serving people who are deaf or hard of hearing:

American Deafness and

Rehabilitation Association (ADARA)

P.O. Box 251554

Little Rock, Arkansas 72225.

National Information Center on Deafness,

Gallaudet University

800 Florida Avenue, NE

Washington, DC 20002.

Registry of Interpreters for the Deaf (RID)

8719 Colesville Road

Suite 310

Silver Spring, Maryland 209103919.

Dr. Danek is Professor of Counseling and co-director of the rehabilitation counseling program at Gallaudet University, Washington, DC.