Organization of the Courses

This information is presented as a 2-part course. Part 1 contains the following information:

• introductory materials, including the introduction, the background, the nature of the study, the purpose of the study, the need for and significance of the study, the definition of terms, the assumptions, and the limitations and delimitations;

• Relevant Characteristics of the Deaf Population, describes those characteristics of the deaf population that are related to substance abuse and its successful treatment;

• a review of the literature on alcoholism as it relates to the deaf;

• a review of the literature on drug abuse and the deaf.

Part 2 of the course will cover the following information:

• a review of programs for deaf substance abusers that have been described in the literature or described for the writer, at his request, for this course;

• a discussion that ties together all the various threads into one coherent whole, and discusses implications of certain viewpoints which have been developed in answer to several pre-eminent and salient questions about deafness, the ramifications of present trends toward prevention and treatment of substance abuse among the deaf, and proposed and/or projected developments in the field;

• the summary, conclusions and recommendations for future research and practice to help prevent substance abuse among deaf people and to help deaf substance abusers overcome their disabilities and lead normal, productive lives.

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Chapter 1  

INTRODUCTION

 

In 1988, some 21 million Americans were identified as having some hearing impairment. These impairments ranged from minimal to severe and were cited as potentially contributing to a variety of psychological, educational, social and vocational disabilities. Perhaps 10% of this group of Americans with hearing loss are severely or profoundly deaf. It is estimated that about 15% of these largely-deaf individuals also suffer from some form of substance abuse.

 

Comparatively little attention was paid to these multi-disadvantaged Americans until recently. The first published reference to the interaction of hearing disabilities and alcoholism appeared in the Alcoholics Anonymous newsletter Grapevine in 1968.  The first treatment program designed specifically for deaf alcoholics dates from a decade ago in the San Francisco area.   Programs were developed independently in Minnesota, Michigan, and elsewhere in California, but did not proliferate in the country as a whole.

 

Deaf alcohol abusers have received little meaningful assistance. Additionally, their quest for sobriety was not studied in a timely manner, so that identification of any special needs of this group had been quite tardy. The earliest studies date from 1978 which deal with the incidence of substance abuse among the deaf. These studies found that the incidence of substance abuse among the deaf was about the same as for the population as a whole; in the absence of detailed demographic studies, this conclusion has remained unchallenged.

 

While solid, large-scale research remains scanty, ample evidence has accumulated that the network of services developed to help substance abusers works poorly for the deaf. Communication between helpers and clients has been and remains a major problem. Even when steps are taken to solve this problem by providing an interpreter, the deaf client typically: a) needs extra time to absorb the materials, due to the probability that they are difficult to comprehend, b) experiences fatigue sooner than do other clients, c) misses many of the nuances of group interaction, and d) may not even be able to see the interpreter clearly, because of poor lighting. After-treatment and community support services for deaf clients are also often minimal.

 

Even with these daunting considerations, progress has undoubtedly been made in helping deaf substance abusers. Effective programs are increasingly available, scattered throughout the country. Many small-scale studies using a variety of assessment methods and populations have accumulated in the literature. Still lacking is some kind of synthesis, or even a comprehensive survey.

Background of the Study

The background of the study includes a basic statement regarding types of hearing impairment, the consequences of this disability, and the complicating factor of substance abuse.

 

Etiologv of Hearing Los

The major causes of deafness are: heredity, illness, accident, aging, and some forms of substance abuse. Heredity is the principal cause, with about half of all deafness in infants the result of genetic factors. Down’s syndrome and RH factor incompatibility of the parents’ blood are two of the many genetic factors implicated.

 

Many illnesses can cause deafness. Rubella (German measles) damages the auditory nerves of embryos when contracted by the mother in the early stages of pregnancy.  Other prenatal diseases can have the same effect, as can premature-birth, Meningitis, mumps, measles, and other diseases of childhood. High fever, infections, and even some medications all can affect hearing.

 

Experiential and environmental factors are also involved. I. King Jordan, the new president of Gallaudet University, lost his hearing as a result of injuries in an automobile accident. H. Latham Breunig, a former member of the presidential commission on deafness, was born hard-of-hearing, then he lost more hearing after scarlet fever at the age of five, and became deaf at age seven as the result of a skull fracture.

 

Loud noises, either sudden or prolonged, e.g. explosions or rock concerts, respectively, can also damage hearing severely. Hearing tends to deteriorate with age, additionally, and finally, excessive use of alcohol and drugs can also adversely affect hearing.

Types of Hearing Loss

Four major types of hearing loss are recognized. A central hearing loss results from impairment to the nerves or nuclei of the central nervous system. Conductive hearing losses are the results of disease or obstructions in the outer or middle ear. In conductive hearing loss, typically, all frequencies are evenly affected, and remedial intervention often can be taken. Sensorineural hearing loss comes from damage to the sensory hair cells of the inner ear or the connecting nerves; Hearing loss from this cause can range from mild to profound, and remediation is usually impossible. External hearing aids ameliorate the situation, but not the loss itself. Mixed hearing losses involve both the middle and inner ear. Additionally, some writers have identified psychological or “hysterical” deafness, where the loss of hearing is psychogenic; when relieved of psychological stresses, persons suffering such cases of deafness can hear again normally.

 

The extent of hearing loss is an important variable. Approximately two million persons in the United States have a complete, and usually irreversible, loss of hearing.   Hearing loss encompasses a wide-range continuum, with many intervals of gradation.

 

Also crucial is the age at which hearing loss takes place. The most physically disabling condition, albeit not the most emotionally isolating one, occurs when hearing loss precedes the normal development of oral language and speech. In the pre-lingually deaf, oral language development is adversely affected, thus the ensuing emotional and intellectual development of each stage of growth is delayed. Other individuals become deaf at some point after normal language and speech have developed. While these post-lingually deaf have fewer communication difficulties and intellectual disadvantages, loss of hearing at any age can be a traumatic experience requiring medical and psychiatric intervention. Moreover, people who lose their hearing as adults may have to master alternative means of communication at a time when they do not have the advantages of flexibility and mental agility of youth.

The Consequences of Hearing Loss

As with most disabilities, the consequences of deafness can be greatly mitigated, and deafness does not preclude greatness. Many famous men and women were deaf at some point in their lives, perhaps the most remarkable being Ludwig van Beethoven, who composed his greatest music when be could no longer hear. ¹³ Countless other deaf people achieve great things, despite their handicap.

 

Today, hearing loss no longer represents the same degree of impediment to success, in most professions, that it formerly did. As Stepp said, “Two generations ago, young deaf people were treated as if they were retarded, shunted off to state residential schools, and prepared for blue-collar jobs such as printing and sewing. The next generation began climbing the professional ladder, rung by rung, and today’s generation has fully arrived. Today, deaf people have entered most of the professions. Starting salaries for Gallaudet graduates have increased markedly in recent years to be commensurate with salaries of hearing people in the same profession.

 

Nevertheless, hearing loss is a major impediment that can be overcome only with struggle. Congenitally deaf children cannot learn speech as normal children do, through hearing, repeating, and having their speaking behavior reinforced.To complicate things further, parents of deaf infants may not even realize their child’s deafness, and when hearing loss is finally suspected, the family may have difficulty obtaining a definitive diagnosis. Delays, mixed signals from the professional community, and similar problems may result in developmental impediments which may or may not be overcome at a later date. (The literature dealing with this aspect of the problem will be reported in detail in a later chapter.)

 

In a perceptive review of the literature on linguistic deficiency and thinking, Furth concluded that pre-lingually deaf children normally suffer developmental lags similar to those of culturally-deprived or culturally-different children. Early linguistic and cognitive deficiencies normally are overcome with appropriate interventions.

 

Unfortunately, however, agreement is not universal on what constitutes appropriate intervention. The deaf, and those who work with them, remain divided on such matters as “mainstreaming” versus special education and the best way to teach communication skills. Hearing parents with a deaf child may not know which way to turn in the face of conflicting advice.

 

Numerous studies, up to and including the early 1980’s found that deaf people experience a high incidence of psychological problems related to deficiencies in conventional communications skills. Lack of empathy, inadequate insight into the impact of their own behavior, inadequately developed impulse-control mechanisms, relatively mild depression, and an array of personality disturbances are reported in the literature on the deaf. Some of the same writers who cite these findings also note, however, the absence of definition and measurement of both hearing impairment and of mental illness and emotional disturbance. It is also acknowledged that serious mental illness, as measured by the number of hospital admissions, is no greater among the deaf than among the hearing.

 

More recent studies are less prone to such generalization. Nevertheless, growing up with a hearing handicap and seeking to cope with a hearing world throughout a lifetime does put a strain on an individual who is deaf, just as being in a minority inherently decreases the probability of one’s being experientially understood by the majority.

 

Until recently, deaf people tended to be economically disadvantaged. Although educated non-hearing individuals found employment at about the same rate as their hearing counterparts, the former tended to have lower-paying jobs. Non-hearing people with little education had much higher levels of unemployment than their hearing counterparts. For example, the 1988 unemployment rate for deaf New England young adults was 17%, while for the hearing young adults of the area, the rate was 11.2%. As acknowledged earlier in this chapter, opportunities for deaf persons graduating from colleges and universities today are greater than at any time in the recent past. But earning deficits remain for the mass of relatively uneducated deaf people now in the marketplace.

 

One study of the employment problem concluded:

 

Deficient education and underemployment have been clearly documented . . . Obviously, a deaf person victimized by poor education and under­employment and unemployment will suffer in his social, psychological, family, and spiritual achievements and satisfactions.

 

While this characterization is obviously not relevant to everyone, a significant number of deaf people still feel themselves to be caught in the circularly reinforcing undesirable circumstances. We can understand that these people might turn to alcohol and/or other substances in their search for solace and satisfaction. Of course, the majority of deaf people do not succumb to substance abuse.

The Deaf and Substance Abuse

Studies of small populations indicate that the incidence of substance abuse among the deaf is about the same as that for the general population of the United States. Several authors, extrapolating from these studies, have estimated that in 1980 there were about 73,000 deaf alcoholics; 8,500 deaf heroin users; 14,700 deaf cocaine users; and 110,000 deaf people who use marijuana on a regular basis.   There are no reliable national statistics based on direct counting. Extrapolated statistics can probably serve, however, to suggest the general magnitude of the problem.

 

The principal difference between deaf and hearing substance abusers is that the former often cannot find services readily available to the latter. According to Scanlon:

 

Where is there an Alanon group for deaf parents of a substance abusing child, and the Alateen, Alatot? These services are provided for the hearing community and they should be available for deaf people. I think we’re really seeing the need for assertiveness training for many deaf people, especially for deaf women. Where can you set those up?

Nature of the Study

The study is an exhaustive review of the literature dealing with substance abuse among the deaf population of the United States. Considerable background information on deafness, alcoholism, and drug abuse is reviewed and summarized in order to arrive at precepts, methods, and techniques useful in helping deaf substance abusers overcome their self-destructive habits. Exemplary programs have been identified; their literature studied and described.

Purpose of the Study

This study is intended to help those who work with deaf substance abusers by providing them with relevant background information, descriptive material on successful programs, and valid generalizations based on the literature and sound practice. It is given with the hope that it will be useful in itself, and also might later serve as the basis for published reference regarding the best ways to treat deaf substance abusers. Such published materials can then be disseminated to all who are in the helping professions related to deaf substance abusers. This study, and any published materials which might derive from it, might also be useful to policy makers responsible for programs and budgets.

Need for and Significance of the Study

Becoming a victim of alcohol or drugs is a terrible fate for the individual and a loss for society.  The losses are compounded when the victim is already handicapped, and when remediation is difficult to find.

There now exist significant impediments for the deaf in using existing social services. Difficulty of communication can be a major barrier, prohibiting access.  If the social service agency does not have staff who sign or interpreters for deaf clients, deaf clients are unlikely to receive much benefit from treatment. Virtually all modes of counseling involve “talking things out”; if counselor and client cannot “talk” to one another freely, successful treatment is unlikely.

 

Moreover, even the use of interpreters can pose problems. The deaf client, who typically views his addiction as a “fall from grace” may find an interpreter a threat to confidentiality, and thus refrain from disclosing to the counselor in the presence of an interpreter. Client and interpreter, moreover, may have differing communication modes, e.g. American Sign Language vs. Pidgin Sign English.

 

Trust between counselor and client is essential, but may be difficult to develop between a hearing therapist and a deaf client. Many deaf people have received short shrift from institutions and authority figures in the past, and therefore they tend to be mistrustful and skeptical. According to Chough, when deaf people are in need of professional help, “they feel diminished as individuals, as a result of paternalistic attitudes on the part of professionals.  

 

Because the deaf community tends to be closely knit, failure to treat one deaf person effectively and with respect can lead to a virtual boycott by the community. Loyalty to those perceived as “like them” and more than a hint of suspicion towards “do-gooders who don’t understand” are not uncommon.

 

Finally, the trust that develops over time in a bilateral healing relationship can be difficult to establish when three people (the two plus an interpreter) are linked together, merely because of group and personality dynamics. Alcoholics Anonymous reaches out to all alcoholics, but deaf people have been more likely than other people to lack information regarding the organization and its mission. If deaf people do turn to AA for help, they may find an insuperable language barrier. They may not have the reading skills necessary to comprehend AA literature.

 

Because deaf substance abusers have such a difficult time finding and receiving the help they require, there is a need for an exhaustive and careful study summarizing facts, experience, and theory scattered in hundreds of published articles. The significance of this study is that it is an honest attempt to meet this very real need.

Definition of Terms

A number of specialized terms have been used in this chapter, and many more will be found in the body of the study. Most of these terms can be defined in context, or they become self-evident if viewed in context. Those which are not self-defining or which are particularly crucial are defined below.

 

Alcohol abuse: “. . . any use of alcoholic beverages that causes damage to the individual or society or both.”   “Abuse” implies a lack of control to a point where the individual can no longer function effectively in his/her society. 

Communication: The act of transmitting information, thought, or feeling so that it is satisfactorily received and understood by others. Communication is broader than the use of words, including art, signs, and body language.

The deaf may communicate by speaking, speech reading, writing, and manual communication. Manual communication includes: 1) American Sign Language (ASL), which has its own vocabulary, idioms, grammar, and syntax, distinct from those of English; 2) Fingerspelling, which is spelling with the fingers in the air, usually used in combination with ASL or with spoken English (Rochester method); 3) Manual English or Pidgin English (PSE), involving the vocabulary of ASL and fingerspelled words presented in English word order; and 4) Cued Speech, a system of communication in which eight hand shapes in four possible positions supplement the information visible on the lips of the speaker. Total communication is a method combining all possible methods of communication to help deaf children acquire language and all deaf persons to understand. Historically, there have been major disagreements between the proponents of the various schools of communication.

Deafness Refers to the inability to hear and understand speech. Hearing impairment comprises the entire range of auditory disorders from less than normal hearing to total deafness.

Drug Abuse: Any use of drugs, licit or illicit, in inappropriate ways or amounts, as determined by adverse effects upon the user and/or his society.

Substance Abuse Any use of alcohol or drugs which interfere with the optimum functioning of the individual or society, or both.

Treatment: The method or technique used to help substance abusers overcome their problem.

Assumptions

Since this is not an experimental or statistical study, only general assumptions have been made. In the broadest sense, it has been assumed that people who are deaf or are hard of hearing may view their hearing loss as a handicap, but that the loss need not be disabling. It is further assumed that the nurturing and development of the rich creative gifts of individual people in what ever physical condition they are, is worthwhile to society, and that time, effort, energy and resources spent enabling people to function at their highest level are worthwhile investments.

Limitations and Delimitations

The principal perceived limitation of the study is one that is typical of any review of literature: since this is not an experimental study, and the writer’s own experience in dealing with deaf substance abusers will enter only obliquely into the treatment of the subject matter, the study can be only as strong as the literature itself. The study will only be as insightful as the literature is insightful; it will only be as complete as the literature is complete, etc. The writer believes that the literature is vast, varied and often useful, and that this limitation is therefore relatively minor.

 

In addition, certain delimitations have been imposed on the study by the researcher. Only English-language materials have been used, but these include research from outside the United States. Materials in other languages might have been useful had they been available in English-language translation.

 

The materials researched were limited to alcoholism, substance abuse, and deafness. Occasionally, the writer found it necessary to search through psychological and social work research for answers to specific questions, but this literature was not covered in any systematic way.

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Chapter 2

RELEVANT CHARACTERISTICS OF THE POPULATION

 

Introduction

The purpose of the course is to help those who work with deaf substance abusers by providing them with relevant background information, descriptive material on programs, and valid generalizations, based on the literature and practice.  This chapter shall cover the literature which describes those characteristics of the deaf population that might be relevant to substance abuse and treatment.

 

This chapter originally was meant to be a comprehensive review of relevant literature using accepted research methodology and dealing with problems of deafness. Unfortunately, some research of this type was found to be misleading and occasionally outlandish. Common problems include the use of atypical populations, such as psychiatric patients, to develop generalizations meant to apply to the deaf population as a whole, extremely small populations, and a lack of understanding of the typical deaf experience. Viewed in its entirety, that literature which purports to be scientific, while falling below the minimum threshold of acceptability, cannot be considered a reliable guide for those who work with deaf substance abusers. Most of such studies, therefore, are not covered in this chapter.

 

By contrast, some material considered valuable in this researcher’s opinion, is experiential or in anecdotal form. “Experiential” means written out of experience, rather than in accordance with such research principles as control groups and statistical procedures. As might be expected, much of this is the work of deaf scholars.

 

Aspects of Population

The latest available figures on the deaf were cited in Chapter 1 of this study and need not be repeated. It should be noted, however, that all of the figures cited in the literature represent estimates or educated guesses. A recent book on the deaf experience in the United States states flatly: “There are no reliable figures on the number of Deaf people in the United States and Canada.”   Official statistics generally attempt to estimate or count the number of deaf individuals in the country. It is not possible to develop from these numbers, for example, how many of these people cannot hear at all and how many use some variety of sign language.

 

Moreover, the experience of more than a century and a half of attempting to estimate or count the deaf population indicates that there are not likely to be any easy solutions. Between 1830 and 1930, the United States Bureau of the Census attempted to enumerate the deaf population without success.

 

Beginning with the 1970s, the Census Bureau adopted a sampling method; in 1975, interviews were conducted in approximately 44,000 households containing about 134,000 people. Even the authors acknowledged that sampling errors might have tainted the results.

 

In 1978, Stewart attempted to remedy some of the gaps in the official estimates. According to his figures, about 3.2% of the population (some 6.5 million Americans) had significant hearing loss in both ears. Slightly less than 1% of these were severely deaf, unable to hear or understand speech. Still, this enumeration involved nearly two million people.

 

The pre-vocational deaf (deaf before the age of 19), constituted 2.3% of the population; the prelingual deaf (deaf before the age of 3) represented almost 1% of the population. In addition, Stewart estimated the numbers of individuals with impaired hearing who were also developmentally disabled. These figures included the deaf who were also autistic, cerebral palsied, epileptic, and mentally retarded.

 

A significant recent study of the demographics of deafness by Karchmer was based on the 1982-3 Annual Survey of Hearing-Impaired Children and Youth, and the 1983 national norming of deaf students on the Stanford Achievement Text. He noted that the number of students reported to the United States Department of Education by the states did not include deaf-blind students, students with hearing loss included under “multi-handicapped,” or students not being served by the states.  It may appear, therefore, that students with severe hearing problems are routinely undercounted.

 

Vernon discussed a number of present, and probable future, trends that will affect the prevalence of hearing impairments. More liberal sexual practices in the larger society have resulted in the transmission of viral pathogens, herpes simplex, and cyromegalovirus, all of which can infect the fetus and cause deafness, cerebral palsy, mental retardation, and other handicaps. The huge bulge of youth deafened by the 1963-65 rubella epidemic will continue to require post-secondary education, training, and other forms of assistance. Moreover, rubella will continue to pose a threat because:

a) about 20% of women of child-bearing age have not been immunized,

b) the duration of the immunity conferred by existing vaccines is not clear, and

c) the prevalence of rubella as a cause of deafness since the presently used vaccine was licensed in 1969 remains about 12-13%.

 

Psychological Characteristics

Research includes scores of studies dealing with purported psychological problems of the deaf. Many are from foreign countries; some concern themselves with atypical populations, e.g. patients in mental institutions; and all tend to reach conclusions without taking all the variables into account. For example, a British study, after finding that deaf people were over-represented in mental institutions, admitted that the reason might be mislabeling, particularly since there was little communication between patient and staff.

 

Psychological Health of the Deaf

In a 1969 paper, Vernon surveyed the literature dealing with the psychological factors associated with hearing loss. Some 50 independently-conducted studies indicated that the deaf or hard-of-hearing population has essentially the same distribution of intelligence as the general population. These statistics would seem to indicate that the potential for abstract thought is as prevalent among deaf people as among the hearing. However, educational attainments of the deaf are generally lower than for their hearing counterparts, partly due to neglect or inadequate teaching. As a result, deaf people have been more likely to end up in menial jobs offering little future and financial return, contributing to less than optimum psychological states.

 

Vernon concluded that the level of schizophrenia was no higher among the deaf than among the general population. However paranoid schizophrenia may be more prevalent among those who became hard-of-hearing later in life than among the prelingually deaf. Less is known about the prevalence of neuroses, character disorders, and other mental problems not considered psychoses. Such kinds of disorders are not easy to diagnose in the deaf population. Vernon offered the following “tenuous” conclusions from his review of the literature:

1. Impulse control problems and their related syndromes are more common among the deaf;
2. There is frequent lack of insight, with externalization of blame for psychosocial difficulties; and
3. there is therefore less conscious anxiety or motivation to seek treatment.

 

Altshuler reported his conclusions based on sixteen years of study of the deaf in New York State psychiatric hospitals. He reasoned that deaf people are precluded from certain accoutrements of sound, in particular the emotionality aroused or transmitted by sound, and therefore often are hampered in the timely development of language. Often oral language usage in people who have not experienced the reinforcing aid of sound is permanently stunted. Awareness of this lack lays an additional burden of stress on the deaf individual trying to communicate orally.

 

Among deaf schizophrenics, auditory hallucinations occur in about the same proportion as in the hearing population. This is reasonable since hallucinations are presumed to be psychogenic rather than organic in nature.

 

Altshuler also noted the prevalence of impulsive behavior among the deaf population in New York State mental institutions. He hypothesized that auditory potential was necessary in order for a person to internalize rage. The absence of a given perceptual mode might, he thought, preclude certain adaptive options, while its presence might enable (but not guarantee) the choice. For example, the development of insights which encourage control of one’s impulses becomes highly unlikely.

 

Altshuler collaborated with Rainer in another study of deaf in-patients in New York State mental hospitals. In the area of personality and character disorders, the authors noted:

 

. . . a lack of empathy, a diminished under­standing and regard for the feelings of other people, a lessened awareness of the impact of one’s behavior on other people, and the tendency toward impulsive behavior, with limited control and restraint. One corollary of the latter is that rage lies close to the surface without becoming internalized, and indeed little or no retarded, depressive symptomatology was noted.

 

Paranoid symptoms and projective mechanisms were observed, but were no more prevalent than among the hearing population. However, the writers admitted that they could not tell whether these character traits and symptom patterns were related to absence of verbal language or to deficiencies of parent-child communication in the formative years. The authors state that many observers have noted similarities between some deaf children and culturally-deprived children. They labeled some of their deaf patients primitive personalities, referencing a social and cognitive immaturity found among those who were brought up with minimal communication at home.

 

Elements of the family backgrounds of some New York State mental hospital deaf patients would seem to have predisposed them to schizophrenia. These factors included disturbances in parent-child relationships, covert maternal wishes of rejection, and denial of the needs and limitations of the child. Nevertheless, there was no increase in the schizophrenic rate among the deaf population there as compared with the hearing patients of that hospital.

 

In a later article, Altshuler attempted to trace significant developmental differences between deaf and hearing children. The absence of auditory potential in a newborn child limits its ability to its surroundings, and may inhibit its development, he reasoned. Sound soothes a troubled baby during the early, symbiotic period of development. Later, when the child is more clearly learning to individuate and develop a sense of self, hearing its mother in the next room often boosts confidence enough that the toddler is encouraged in exploring the world. Without hearing, spontaneous mimicry and learning derived from that are impossible, Altshuler states. The deaf child has the capacity and readiness for language development, but he/she needs help which may not be readily available. As stated before, without verbal communication between parent and child, the internalization of control by the child is extremely difficult. (Altshuler apparently assumes the deaf child is born into a hearing family; if the parents are able to communicate with the child in nonverbal ways, the consequences sketched by Altshuler would not necessarily follow.)

 

From the standpoint of hearing parents, deafness in their child is usually an invisible handicap for at least the first few months of life. Parents may note that something is wrong, but may have difficulty finding a doctor who is able to make an accurate diagnosis and provide useful advice. Parental reactive depression may result in confused, ambivalent treatment, then, of the child. Unfortunately, such crises tend to develop at the stage of development when the child is trying to pass from symbiosis to individuation. Once the deaf child enters the world outside the family, there ensues a struggle to teach communication and content. A tendency may develop for the youngster to remain dependent instead of exploring, and to learn largely by rote instead of insight.

 

“In view of the foregoing,” Altshuler writes, “it is nothing short of miraculous that the majority of deaf children develop to be normal neurotics like the rest of us.”  With the minor exceptions previously noted, major forms of psychotic illness are no more frequent among the deaf than among the hearing.

 

However, deaf children are by no means a homogeneous group. Some are born with multiple handicaps, complicating their prognosis for normal development still further. About 10% of all deaf children are born to deaf parents. In this case, most of the factors that militate against development of the deaf child do not apply. The parents know what to expect and how to cope. Deaf parents’ communication with their deaf child is more facile than that of hearing parents with a deaf child. Deaf children of deaf parents are often described as better adjusted, they have higher achievement test scores, and receive higher teacher ratings on items relating to maturity, responsibility, sociability, initiative and appropriate sex-role behavior than do deaf children born to hearing parents.

 

In 1978, Altshuler wrote an important paper on the question of whether there really was a “psychology of deafness.” A number of researchers have reported important differences between hearing and deaf subjects, with the latter being characterized as socially immature, emotionally labile, volatile and brittle, with ego rigidity, having difficulty with abstractions, etc. However, Altshuler points out, the research on which these, and other such, generalizations are based may be tainted by the use of tests on which the deaf might be expected to do less well than hearing people. Almost any study using a standard psychological test interprets results in accordance with data standardized on hearing populations. Moreover, even if the results are taken at face value, there remains the question of whether the outcome is a stereotype or a composite. Not every deaf person will be aberrant in all, or any, of the characteristics measured by particular research instruments; nevertheless, some people view the research as describing a “typical” deaf person. In addition, those who work closely with deaf persons emerge with “clinical impressions,” which may be reported, but do not constitute  clinical facts.

 

In order to differentiate between ephemeral and intrinsic factors, the author participated in a cross-cultural study with New York State and Yugoslav colleagues. The study compared psychological test results of normal deaf and hearing adolescents in New York State and Yugoslavia. The two environments were considered so different that the effects of deafness itself, rather than cultural influences might be expected to emerge. The results of the study indicated that the deaf in both countries scored higher for impulsivity than the hearing adolescents in both countries. There was a striking absence of overlap between deaf and hearing sub-groups in both countries. Moreover, a related but separate investigation of deaf patients in Yugoslavian mental hospitals showed that those patients demonstrated impulsive, aggressive, and bizarre symptoms similar to those noted of deaf patients in New York. The results suggest either that the tests are meaningless (deemed unlikely by the author), or that they tapped different aspects of what is considered impulsive behavior. The author suggests that these studies should be expanded to adolescents whose parents were themselves deaf, or of hearing parents who diagnosed the problem early and communicated with their deaf children in sign language. Pending such studies, the author does not believe it possible to interpret what role sound alone plays in development. It would therefore be erroneous to conclude that “a psychology of deafness” is justified from these studies alone.

 

A study of the type and prevalence of psychiatric illness among deaf people was published by Lebuffe and Lebuffe. Because hearing is the sense best adapted for the continuous scanning of the environment, it has often been postulated that deafness might dispose the individual toward paranoia. In fact, most of the relevant studies indicate that this outcome is only likely when a hearing person loses the sense of hearing, usually late in life. There is no indication that the pre-lingually deaf are likely to show paranoid traits. Because deafness in an infant might result in major emotional upheavals in the parents, and also might result in faulty mother-child communication, schizophrenia has been thought to be likely to afflict the deaf. However the extreme of psychosis is not verified by empirical evidence, which shows that the pre-lingually deaf are not predisposed to schizophrenia. Severe depression requiring hospitalization is extremely rare among the deaf, as is the classic obsessive-compulsive neurosis. On the other hand, deaf people are not immune to mild and moderate feelings of depression or discouragement.

 

Here again, there is a difference between the pre-­lingually deaf and those who lose their hearing relatively late in life, with the latter being much more prone to severe depression. Deafness is a severely handicapping condition, and yet deaf people do not, as a group, rank significantly at the pathological extreme on the continuum of mental health.

 

Impulsivity is an often-noted characteristic of the pre­-lingually deaf, but it does not normally assume significant proportions (e.g. criminal behavior), and it may well reflect developmental delays rather than any permanent character traits. There is no evidence of increased psychosocial problems among the deaf; their divorce rate, for example, mirrors that of the general population. Despite continuing language problems in some cases, the evidence suggests that deafness delays, but does not limit, the development of intelligence.

 

Evans and Elliott attempted to develop screening criteria for the diagnosis of schizophrenia in deaf patients. They pointed out that misdiagnosis is all too common; mental health professionals have been known to diagnose individuals with unrecognized deafness as schizophrenic, and to maintain the erroneous classification for 25 years. When confronted with gesticulating, excited patients who cannot be understood, schizophrenia is often used as a “wastebasket” classification. The authors suggest using Schneider’s criteria scales because they do not include symptoms that might be indistinguishable from deafness. Even using these scales, great care is essential, and the patient should, optimally, be interviewed in sign language.

Critchley and his colleagues agreed that communications problems, even when sign language is used, make psychiatric diagnosis of deaf people extremely difficult. Psychiatrists traditionally have noted the presence of thought disorder in the diagnosis of schizophrenia, but the language barrier makes this difficult to access in deaf people. Schneider’s criteria, which depend on the analysis of hallucinations, have generally been accepted as the best way to diagnose schizophrenia in deaf populations. An experiment with deaf patients conducted by the authors found that 10 of 12 deaf patients tentatively classified as schizophrenic had experiences which, in hearing patients, would be described as auditory hallucinations, a sign of schizophrenia. Many of the patients used the sign for talk or talking to describe the experience. One patient described hearing a “voice like a bell.” The authors found this aspect of the experiment difficult to understand. In addition, 10 of the 12 subjects described visual hallucinations. The writers concluded that great caution was necessary in classification because “the nature of communication, where thinking ends and vocalization begins, is imperfectly understood.”

 

In a recent interview, Harlan Lane attacked the credibility of much of the psychological research on the deaf, specifically in the area of methodology. Going back to the 1920s, he found that various researchers, usually on the basis of inappropriate tests, had labeled deaf people’s behavioral patterns as: aggressive, androgynous, conscientious, hedonistic, immature, impulsive, lacking in initiative, limited in interests, showing slow motor development, presenting undeveloped personality, possessive, rigid, stubborn, suspicious, and lacking in confidence. The emotional nature of deaf people, if one were to believe every report ever written, would include the following often contradictory and mutually exclusive characteristics: displaying no anxiety, depressive, easily emotionally disturbed, lacking in empathy with other people, explosive, easily frustrated, irritable, moody, showing neurotic behaviors, having a predisposition toward paranoid states, passionate, displaying psychotic reactions, serious, temperamental, and insensitive to others’ needs.

 

Clearly these can not all be generic characterizations of deaf people. Extrapolating from one person’s observed personality characteristics to assert that they should also apply to other persons, merely on the basis of shared dysfunction of the ears has not shown any validity.

 

One of Lane’s conclusions is that, in order for deaf people to benefit to any significant degree from the aid offered them, they must have control of the systems and agencies directed at them. In particular, deaf professional workers should be involved in the process of designing and administering psychometrics and other measures upon which research is to be based, implying that experience is the only path to understanding.

 

Lane suggests that deaf people are more inherently qualified to be sensitive to the needs of other deaf people. A problem with implementing this admittedly solipsistic view arises because there have been few, if any, deaf individuals qualified to address the psychological and psychiatric problems of the deaf. The situation is certainly improving, although there are not yet enough deaf mental health professionals to treat all the deaf clients presenting themselves for treatment. In terms of research, deaf psychologists and psychiatrists, with insights borne of their own experience, might have avoided making some of the more gregious generalizations which can be found in literature regarding deaf people.

 

Much of the stricter research of the recent past seems to agree with Lane. Study after study lists stereotypes of psychological profiles of the deaf offered by very early studies, and concludes that there is no evidence for acceptance of these descriptions. Researchers such as Altshuler concluded that there was no such thing as a “psychology of the deaf,” but at most, only the psychology of a particular form of socio-cultural deprivation. This deprivation does not stem from the lack of hearing, but from the lack of help from parents, significant others, and helping professionals. The controlling mechanism of possible future pathology is not the auditory deficit, per se, but the quality of interpersonal relationships which develop as a result of that deficit.

 

To know, merely, that a given individual is deaf is to know nothing significant about that specific person’s psychological make-up; group psychological studies are similar to insure statistics in that they contain information about probability, incidence percentage, etc., rather than precise predictions that composite conclusions will apply to any one individual. Pre-lingually deaf people are as varied as are others of the human race. The literature on deaf people is full of clinical observations, case studies, and self-report evidence offering accumulative evidence of personality trends and vulnerability in certain areas. Research makes that point on the basis of reason, evidence, and scientific method rather than on the basis of emotion and undocumented assertion. Moreover, psychological literature on deaf people stresses the importance of early diagnosis and treatment of deafness, to minimize its effects in the lives of deaf people. Current literature reveals graphic examples of the tragic waste of human potential that ensues when deaf children and adults are misclassified and relegated to the back wards of institutions, rather than receiving appropriate and adequate treatment.

 

The Psychological Consequences of Hearing Loss

Research summarized in the previous section dealt mainly with pre-lingually deaf people. Considerable attention has also been paid to the psychological problems associated with late-onset deafness, particularly deafness among geriatric populations. However, since the problems of the post-lingually deaf are of a different order and are less central to the focus of this work, they will be covered in less detail.

 

According to Rousey, the loss of hearing, either sudden or gradual, constitutes a threat to psychological integrity of an individual. Loss of hearing results in mourning for something precious that has been lost; the world suddenly (or gradually) has become dead where it was alive before. There is fear of being cut off from one’s normal society, even when hearing aids can be used. There is often a loss of self-esteem involved. The loss of hearing often meets with projection and denial. These and related factors greatly complicate the treatment of hearing loss.

 

Cornforth and Woods generally agree with Rousey. They declare that “the impact of sudden severe deafness is one of the most psychotraumatic events that an individual can experience.”  The most common result is a severe reactive depression, sometimes leading to suicide attempts.

 

Mahapatra investigated links between hearing loss and mental health. In one experiment, he found a significantly higher incidence of psychiatric illness among post-lingually deaf people than among the general population. The same author in another study used the Cornell Index to show that the post-lingually deaf revealed a greater propensity than did the controls to psychiatric and psychosomatic disturbances.

 

An article in the British journal, Lancet, summarized what is known about the consequences of deafness that strikes late in life. Depressive reactions are among the most common emotional reactions, and the whole family can be affected. Of the functional psychoses, paranoid psychosis seems to be the most likely outcome of depressive reaction. The writer points out that “prelingual deafness constitutes a sensory deficit, acquired deafness a sensory deprivation.” While the pre-lingually deaf usually acquire manual language, the elderly deafened cannot be expected to do so. Communication with these individuals is very difficult, adding to the expected negative prognosis of treatment.

 

One of the few dissenting voices regarding deafness was that of Rosen, who concluded, on the basis of an exhaustive review of the literature, that “the hearing impaired as a group have not been established to differ from the general population on psychiatric or psychological variables.”  Her reasons were:

1. Clinical decisions are often made on the basis of answers to informal questions.
2. Hearing disability questionnaires vary widely and have not been validated.
3. Attitude surveys of the general population have found little sympathy for, or understanding of, problems of people with impaired hearing.
4. Hearing handicaps vary in nature and seriousness depending on the situation and the interlocutors. And
5. Accordingly, self-report scales which are not verified by acoustical testing may be misleading. It may be argued that her stated reasons do not observably prove her assertion; they only point to the lack of proof of common contrary assumptions.

 

Rosen’s conclusions were disputed by Luey, who wrote from the perspective of a social worker. Communication problems almost always cost the deaf person some friends, she noted, because people are often over-extended, and when they believe they can’t handle everything well, the first areas to be neglected are “extras” like sensitivity to people whose needs seem to be different than their own. When a newly-deafened person feels that a friend has let him down, a sense of alienation from society creeps into the disappointment, connecting the hearing loss with the social problem. Newly deafened persons frequently experience an identity crisis as a result of major changes in their lives. At some point in the adjustment process, the deafened individual passes through a crisis similar to that experienced by most people going through catastrophic change. The adjustment process consists of the usual phases of denial, anger, bargaining, and guilt, before a constructive adaptation can take place.

 

Psychological Treatment

Deafness clearly complicates the psychological or psychiatric treatment that may be required for any psychological illness or condition. Relatively few articles have addressed this problem: some of these are summarized in the following pages.

Before presenting these reports, it should be noted that the field of treatment for psychological disabilities is highly fragmented among theoretical lines. e.g., Peterson lists six major approaches to counseling and psychotherapy:

1. Cognitive, with major proponents Ellis, Beck, and Raimy;
2. Learning Theory, propounded by Dollard & Miller, Wolpe, Kanfer, and Phillips, Rotter & Meichenbaum;
3. Psychoanalytic, led by Freud, and amended by Homey, Alexander and Jung;
4. Perceptual-Phenomenological, represented by Kelly, Berne, Pens, Lewin, and Rogers;
5. Existential, as represented by May, Frankl, Buber, and Kirkegaurd; and
6. Eclectic, most clearly propounded by Harte and Thorne.

 

These broad, general classifications may undercount, e.g., the range of different schools of psychoanalytic theory and practice (Adler, Jung, and Sullivan). Each school of thought interprets psychological problems in the light of its