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Cultural awareness: enhancing counselor understanding, sensitivity, and effectiveness with clients who are deaf.

During their professional career, counselors may encounter a client who is deaf; however, they may feel unprepared to work effectively with this population. Counselors who have an understanding of individuals who are deaf through their history, language, and other important considerations might be better prepared to work with this unique and underserved population.

A lo largo de su carrera profesional, los consejeros pueden encontrarse con un cliente que sea sordo; sin embargo, puede que no se sientan preparados para trabajar efectivamente con esta poblacion. Aquellos consejeros que tienen un conocimiento de los individuos que son sordos a traves de su historia, lenguaje y otras consideraciones importantes podrian estar mejor preparados para trabajar con esta poblacion singular y desatendida.

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How many persons who are deaf live in the United States? It depends on whom you ask. The United States Census put the number of individuals ' unable to hear at 1 million according to its general survey from 2002 (United States Census Bureau, 2006). The National Center for Health Statistics cited a little more than 6 million as being deaf based on 1994 statistics (Harrington, 2004); however, the Gallaudet Research Institute, citing data from 1990-1991, estimated that there are almost 21 million individuals who are deaf or hard-of-hearing (Holt, Hotto, & Cole, 1994). The disparity appears to be in how the term deaf is defined. The census uses "Unable to hear normal conversation" (Harrington, 2004, p. 2) as its criterion, the National Center for Health Statistics defines the term as "A lot of trouble [hearing] or deaf' (Harrington, p. 2), and the Gallaudet Research Institute uses "Have hearing problems" (Harrington, 2004, p. 1) for its statistics.

For purposes of this article, I use the terms deaf and hard-of-hearing interchangeably. In a short review of the literature, I found that both terms refer to individuals who have significant hearing loss (i.e., hearing loss to the point where sign language is the primary method of communication). In addition, the deaf culture, as with other cultures, has significant within-group differences. These differences encompass individuals who were born deaf, individuals who are deaf but whose parents can hear, individuals who became deaf after they had attained language, individuals who know sign language, individuals who do not know sign language, and individuals who have cochlear implants.

I am a hearing counselor and have had significant interactions with people in the deaf community where I reside. The perspectives gained from these interactions have afforded me the opportunity to understand how counselors can enhance their work with clients who are deaf by appreciating the deaf culture. This article provides a general framework for working effectively with clients who are deaf, but counselors must always be aware of the many within-group differences among the deaf population.

historical background

To answer the question of whether people who are deaf constitute a culture, it may be helpful to understand how they have been treated historically and how they have responded. Deaf people have encountered many challenges, just as has any other group who is not part of the mainstream. Their inability to hear and effectively use oral language seems to be the most important cause of these challenges. People who are deaf have been victims of what appears to be paternalistic attitudes and practices meant for their own good. Harlan Lane (1992) found several traits, such as being "neurotic, paranoid, psychotic, hedonistic, clannish, disobedient, unintelligent, and thinking unclear" (p. 36), have been historically attributed to individuals who are deaf. Furthermore, many deaf people were misdiagnosed or labeled as mentally retarded or psychotic (McEntee, 1993), then placed in asylums and institutions for the mentally ill. Children who were deaf were often labeled as mentally retarded, held back in school, or taught inappropriately (Gulati, 2003; Padden & Humphries, 2005; Schein, 1989).

In response, several strategies have been attempted to address these concerns. One solution was to put these children into schools for the deaf. These were often residential schools. In fact, until 1970 in the United States, most deaf children were educated in such schools (Padden & Humphries, 2005). The schools provided a safe environment where the children were accepted and could be exposed to others who were also deaf. Because Scheetz (2004) has reported that 90% of those who are deaf had parents who could hear, the residential schools provided a much-needed sense of belonging. Residential schools, however, prevented children who were deaf from exposure to the hearing world, to which many of them would eventually return, and this lack of exposure further separated them from mainstream society. Another response was the beginning of clubs for individuals who were deaf. These were places where deaf adults could meet and socialize and where they were also protected from the hearing world (Padden & Humphries, 2005). Moreover, given that people who are deaf have been defined primarily by their disability (Andrews, Leigh, & Weiner, 2004; Lane, Hoffmeister, & Bahan, 1996; Senghas & Monaghan, 2002), they felt a sense of kinship in that they shared this label.

Being stereotyped, being sent to residential schools for the deaf, attending clubs specifically for individuals who were deaf, and being defined as disabled have all contributed to deaf people self-identifying as a "cultural minority who choose to use sign language and associate primarily with other Deaf people" (Andrews et al., 2004, p. 12). Hays (2001) reported that culture includes language and history, and Schein (1989) took this a step further by saying, "Deaf culture's most distinct feature is American Sign Language (ASL)" (p. 26). Furthermore, Glickman and Gulati (2003) asserted that without the language difference (speaking orally versus using sign language), the deaf culture would likely come to an end. This history and responses to it, both by individuals who can hear and those who are deaf, have helped to shape the deaf culture. Although one may argue the extent to which these responses may have been positive or negative, what has emerged has been this: Individuals who are deaf have developed a distinct cultural identity based on several factors. These factors center on the need to accommodate to living in a hearing world, and they are both a product of deaf individuals' shared language and their treatment by people with normal hearing.

To engage effectively in a counseling relationship with a client who is deaf, it is necessary to examine the counselor's views and biases related to groups that are different from his or her own (Sue & Sue, 2003). As the research indicated, the people who are deaf have been identified and treated in negative ways. By being aware of their views and biases related to deaf people, counselors are in a position to avoid perpetuating those views of them. Several authors reported that the best way to become aware of, appreciate, and accept the deaf culture, as with all cultures, is exposure (Lane et al., 1996; Scheetz, 2004; Williams & Abeles, 2004). It can be uncomfortable when one is introduced to a different culture, and it is no different when one comes into contact with the deaf culture. Attending functions for individuals who are deaf, sitting in on sign language classes, reading books about the deaf culture, and viewing movies that focus on people who are deaf are all examples of ways that counselors can gain exposure to this culture.

Following is a discussion of how the mental health system has affected people who are deaf. Understanding the historical events that have shaped the deaf culture and the experiences of people who are deaf have had with the mental health profession will likely assist counselors working with this population.

deaf people and mental health

Research suggests that persons who are deaf or hard-of-hearing appear to have more mental health issues than hearing persons (Cooper, Rose, & Mason, 2003; Lane, 2005). This may be due, in part, to additional stressors that are unique to individuals who are deaf. For example, the obvious language barrier between a client and a counselor (unless the counselor is fluent in ASL) is particular to clients who are deaf. In addition, deaf people have been marginalized by the hearing world, which looks at them as being disabled. One consequence is that they are not permitted to participate fully in society. Furthermore, clients who are deaf may be misdiagnosed (e.g., psychotic or low intellectual functioning) simply because they cannot communicate effectively (Gulati, 2003; Marschark, 2006). However, schizophrenia affects the deaf and hearing populations equally (Scheetz, 2004). In a recent study, Marschark reported that cognitive and intellectual abilities of people who are deaf have more to do with language than anything else. In addition, Marschark asserted that intelligence can be measured in various ways, and, in fact, children who are deaf scored higher than hearing children on measures of visuospatial ability. It is now known that for minorities, traditional IQ tests may not provide as accurate a picture of cognitive ability as nonverbal tests, such as the Universal Nonverbal Intelligence Test and the Leiter International Performance Scale (V. S. Heppner, 2003). This also seems to hold true for deaf individuals, who, because of their lack of oral language, are often misdiagnosed as having low intelligence (Marschark, 2006; Padden & Humphries, 2005).

Deaf people's attitudes toward and perceptions of mental health professionals have been generally negative (Cooper et al., 2003; Cooper, Rose, & Mason, 2004; Steinberg, Sullivan, & Loew, 1998). This is partly because people who are deaf or hard-of-hearing have not always received appropriate or quality services from mental health professionals (Andrews et al., 2004). An example of this mistreatment occurred in the 1950s with the emergence of psychiatric interest in individuals who were deaf (Altshuler & Abdullah, 1981). Concurrent with this interest was the discovery of a new class of antipsychotic drugs, such as Thorazine and Haldol, used to treat schizophrenia and other psychoses. Because people who were deaf communicated to a large extent by gestures and sounds, behaviors often associated with schizophrenia and other psychoses, they were often institutionalized and given these powerful medications, which had profound side effects. In addition, another common misdiagnosis given to many of the patients who were institutionalized was "psychosis with mental deficiency" (Altshuler & Abdullah, 1981, p. 101). The combination of misunderstanding, misdiagnosing, and mistreatment, albeit with good intentions, led to mistrust of mental health professionals.

Another issue that may have contributed to the deaf community's suspicion of the mental health profession concerns the relationship between client and counselor. Individuals who are deaf tended to communicate in concrete terms, and thus counselors treated them within that context. One consequence of this was that the counselor chose not to do a great deal of exploring or looking into deeper meanings behind clients' behaviors. Many times, this resulted in superficial counseling that was not particularly effective (Altshuler & Abdullah, 1981). The deaf culture was, and continues to be, cohesive, which meant that communication traveled quickly within the deaf community (Padden & Humphries, 2005). The implications were that (a) one asks for help and may get pills, (b) one sees a counselor and does not feel better, or (c) everyone knows one's business. It seems clear that individuals who are deaf may have had good reason to be suspicious of the mental health profession.

Counselors are in a crucial position and have an ethical, moral, and professional responsibility when working with this population. As with any group that has been the victim of discrimination, oppression, and marginalization, it is imperative to take into account the context in which individuals who are deaf have developed their cultural identities.

considerations

AWARENESS OF THE DEAF CULTURE

Arguably, the most important consideration is to understand the deaf culture. As with any cultural group, becoming multiculturally or cross-culturally competent is critical (Green et al., 2005; P. R. Heppner, 2006; Sodowsky, Taffe, Gutkin, & Wise, 1994). Several authors reported that in order to be effective in working with a client who is deaf, it is necessary both to understand and appreciate the deaf culture (Andrews et al., 2004; Glickman, 1996; Scheetz, 2004; Williams & Abeles, 2004). Although this may seem obvious, it may be challenging to actually implement such an understanding.

Cooper et al. (2004), in their survey of mental health professionals' attitudes toward deaf clients, found that the professionals who were comfortable working with these clients had received some training in issues related to individuals who were deaf. Counselors who may consider working with a deaf client could enroll in a sign language class or attend a class on deaf culture. Counselor education programs may want to consider these classes as electives in their training programs.

ATTENTION TO NONVERBAL BEHAVIOR

A second area that warrants consideration is the nonverbal aspects of a deaf client. Nonverbal behaviors are quite important to a person who is deaf (Scheetz, 2004; Williams & Abeles, 2004). Communication via sign language involves a great deal of facial expressions, body and hand movements, and close proximity to others (Andrews et al., 2004; McEntee, 1993; Scheetz, 2004; Williams & Abeles, 2004). Moreover, given that sign language is visual, clients who are deaf place a great deal of emphasis on eye contact. In fact, Glickman (1996) found that clients who are deaf generally held eye contact for a full 5 seconds compared with 1 second for hearing clients. As a culturally competent counselor, it is important to understand this and to be comfortable with increased and maintained eye contact.

FOCUS ON WELLNESS

A third area that is crucial in working with clients who are deaf is keeping in mind the wellness model. Although this may be fundamental to many counselors and is the foundation for most counselors (Glosoff & Rockwell, 1997), it takes on particular significance when working with clients who are deaf. Historically, deaf persons have been identified specifically by their disability (Cooper et al., 2004; Lane, 2005). This has had a tremendous impact on these individuals (Lane, 1992; Paul &Jackson, 1993). One consequence, according to several authors, is that individuals who are deaf have generally lower self-esteem and lower self-concept than do hearing individuals (Finn, 1995; Lane et al., 1996; Scheetz, 2004). However, people who are deaf, and their advocates, would argue that their deafness is not a disability; it is their identity and should be celebrated (Benderly, 1980). Furthermore, their shared values, experiences, and activism demonstrate positive aspects and attributes of the deaf community (Lane et al., 1996; Scheetz, 2004).

Glickman (1996) pointed out that a strength-based approach to counseling may help to offset the pathology-based model that traditionally had been used with deaf individuals. The American Counseling Association's (2005) ACA Code of Ethics, Standard E.5.c., addresses the implications that pathologizing has had on groups and individuals.

CONFIDENTIALITY

Confidentiality is an area that all counselors know to be crucial to the establishment and maintenance of a therapeutic relationship; however, with clients who are deaf, it takes on particular relevance. Historically, people who are deaf have often had decisions about them made without their input (Gutman, 2005; Williams & Abeles, 2004). Another concern is that the deaf community, even in large cities, tends to be small and cohesive. Consequently, it may become common knowledge in the deaf community that a client is attending counseling sessions (Gulati, 2003; Gutman, 2005).

Simon and Williams (1999) looked at the problem of maintaining confidentiality with hearing persons in small towns and found discussing anticipated confidentiality concerns at the very beginning of counseling to be helpful. Discussing confidentiality concerns early in counseling informs the client that the counselor is aware of and sensitive to the issue of confidentiality within the deaf community. Another strategy is to periodically check with the client about any concerns that may have come up since the last session. Reinforcing to clients that the counselor respects them and solicits their input in the counseling process is important because clients who are deaf have typically been left out of their own treatment (Williams & Abeles, 2004).

SIGN LANGUAGE INTERPRETERS

A final but significant consideration concerns the use of sign language interpreters in the counseling session. It should be clear at this point that communication and barriers to it are relevant aspects of the deaf culture. Moreover, sign language is vitally important, regardless of whether it is facilitated by the counselor or through the use of an interpreter (Haley & Dowd, 1988). Research suggests that clients who are deaf prefer a counselor who also is deaf (Freeman & Conoley, 1986; Williams & Abeles, 2004). However, according to Williams and Abeles (2004), most mental health professionals do not know how to use sign language, and thus it is fair to assume that many counselors who work with clients who are deaf use sign language interpreters or other forms of communication such as note pads.

In the absence of a counselor who is fluent in sign language, the use of an interpreter is the appropriate means of providing counseling (Cromwell, 1998), and clients who are deaf are often amenable to using sign language interpreters (Steinberg et al., 1998). For example, Porter (1999) found that having an interpreter in the session when working with a deaf client had no untoward effects on the counseling relationship.

Regardless of whether the client or the counselor provides the interpreter, there are some points to keep in mind. According to Scheetz (2004), it is imperative that the client make the final decision as to whether an interpreter will be used. Another area concerns confidentiality when there is a third person present in the session. Having an interpreter who is certified through the Registry of Interpreters for the Deaf (RID) provides an assurance that strict adherence to confidentiality is maintained. The RID (2005) has a Code of Professional Conduct that addresses confidentiality as its first tenet. In addition, a sign language interpreter's only responsibility is to provide communication between the client and the counselor. In some cases, however, the client may pay attention exclusively to the interpreter, thus making the counselor the outsider (McEntee, 1993; Williams & Abeles, 2004). A solution may be to explain during the initial session that the interpreter is solely a facilitator of communication (Scheetz, 2004). If the client, counselor, and interpreter are all clear about their respective roles and responsibilities, the sign language interpreter can be a link between the deaf culture and the hearing world (Williams & Abeles, 2004).

conclusion

This article provides several recommendations for providing competent and effective counseling services to clients who are deaf. As with any culture that is different from the counselor's, it is important to be cognizant of the context in which that culture was formed. Looking at the interaction of the dominant group (persons with normal hearing) with the minority group (persons who are deaf) provides valuable information. Moreover, an awareness and appreciation of the deaf culture will enhance the working alliance between client and counselor. Concomitantly, counselor awareness of personal biases and assumptions related to the individuals who are deaf will likely assist this relationship. The additional considerations of an awareness of nonverbal behaviors, a focus on wellness, special emphasis on confidentiality, and the use of sign language interpreters are all integral aspects of being an effective counselor for persons in the deaf culture.

references

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Scott w. Peters, Counselor Education and Supervision Program, The University of Texas at San Antonio. Correspondence concerning this article should be addressed to Scott W. Peters, Counselor Education and Supervision Program, The University of Texas at San Antonio, 501 Durango Boulevard, San Antonio, TX 78207 (e-mail: scott.peters@utsa.edu).
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Author:Peters, Scott W.
Publication:Journal of Multicultural Counseling and Development
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Date:Jul 1, 2007
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