Serving Deaf Adult Psychiatric Inpatients

Specialized psychiatric units that serve persons who are deaf are uncommon in the United States. Such units provide the best opportunity to profile the treatment needs of deaf inpatients. Many states do not have specialized services for deaf persons or a database of care provided to deaf persons by specialized clinicians. A dedicated psychiatric unit for persons who are deaf will have staff members who are expert in manual communication and deaf culture, as well as with the diagnoses and the treatments of major mental illnesses. Although a few private hospitals offer specialized deaf units, generally public programs offer this service. In this paper the term "deafness" encompasses patients who could not hear spoken language well enough to understand its meaning.

Even psychiatric units that specialize in working with persons who are deaf will vary in their criteria for inpatient admission on the basis of state rules—for example, the concurrent diagnosis of mental retardation may preclude admission to a state hospital, and many units will not accept individuals who are primarily in need of substance abuse services. Our report focuses on the unique treatment needs of patients who are deaf and are on a psychiatric inpatient unit with broad admission criteria.

Methods

All records of patients discharged from the Mental Health Center for the Deaf between July 1, 2000, and June 30, 2001, and the charts of any patients on the ward who were not discharged during the year were reviewed. The Mental Health Center for the Deaf is a ward at Western State Hospital in Staunton, Virginia, for persons who are deaf, deaf and blind, or hard of hearing. The center includes a psychiatrist, a psychologist, and a social worker, all of whom are proficient in sign language. In addition, many nursing and aide staff sign, and two full-time interpreters are employed.

Patients are admitted for a variety of reasons: civil commitment, voluntary admission, and forensic admission. Some patients are admitted solely for substance abuse services. Persons with mental retardation are accepted, although persons with moderate to profound mental retardation are referred to a state training facility. Elderly persons who are deaf and use sign language are accepted on a case-by-case basis; their nursing care needs determine whether or not they can be appropriately served.

Results

A total of 43 persons were served on the ward during the fiscal year: 37 persons who were deaf, five who were hard of hearing, and one who was deaf and blind. The onset of hearing loss occurred prenatally or from birth to three years. In most cases the etiology was unknown. Causes identified by family members or medical personnel included rubella (N=4); toxoplasmosis, cytomegalovirus, and herpes symplex virus (N=2); Wardenberg syndrome (N=2); meningitis (N=2); rheumatic fever (N=2); varicella (N=2); Usher's syndrome (N=1); Rh incompatibility (N=1); Johanson-Blizzard syndrome (N=1); and perinatal infection (N=1).

A total of 27 patients (63 percent) had a diagnosis of schizophrenia (N=9), bipolar disorder (N=8), major depression (N=7), or schizoaffective disorder (N=3); 22 (51 percent) had a diagnosis of substance use; 11 (26 percent) had a dual diagnosis of major mental illness and substance abuse; seven (16 percent) had a diagnosis of mental retardation; and four (9 percent) had a diagnosis of borderline intellectual function. A total of 17 patients (40 percent) had other diagnoses, which included all anxiety disorders (N=8), pervasive developmental disorders not otherwise specified (N=4), depressive disorder not otherwise specified (N=3), and paraphilia (N=2). Other diagnoses included psychosis not otherwise specified, oppositional defiant disorder, various personality disorders, cognitive disorder not otherwise specified, adjustment disorder, and dysthymia.

Patients in the unit communicated expressively through a formal signed language system, predominantly American Sign Language (26 patients, or 60 percent); through incomplete signed language (five patients, or 12 percent); through oral communication (four patients, or 9 percent); through simultaneous oral communication and sign language (four patients, or 9 percent); and through minimal language skills, such as relying on gesture, pantomime, and pointing (four patients, or 9 percent).

Discussion

Treatment needs

Offering therapeutic services to psychiatric inpatients who are deaf, especially to persons who lack full language competency, requires clinicians to know sign language as well as the deaf culture. With this knowledge staff members can convey concepts to persons who lack much of the general fund of knowledge that is possessed by hearing patients. Because 90 percent of the children who are deaf are born to hearing parents, they are at risk of language deprivation during the ages of birth to five years, a critical period of development (1). If children who are deaf are not exposed to a usable language system, they risk becoming conceptually stunted despite normal intelligence. Possession of a language system facilitates abstract thinking; therefore, without such a system some persons who are deaf lack the ability to abstract, to generalize, or to manipulate concepts of time and money.

Vignette. Mr. A is mildly retarded and deprived of a language system. Despite his handicaps he was able to obtain jobs as a laborer. He never was able to fractionate time, so he used the sign for "yesterday" for anything that had happened in the past, whether it was the day before, a month before, five years ago, or at any other point in the past. He was unable to fractionate time linguistically and cognitively.

Treating psychoses

A total of 58 percent of our patients (25 patients) had a psychotic illness. In utero insults can be associated with an increased risk of psychoses. For example, the rubella epidemic of the 1960s produced many cases of deafness. Brown and colleagues (2) administered the Diagnostic Interview Schedule to persons who were exposed to rubella and found an increased relative risk of 5.2 for schizophrenia compared with matched controls in a New York catchment area. The study also found a 16.3 increased relative risk compared with the rate found in the Epidemiologic Catchment Area survey. Among patients with Usher's syndrome, which causes congenital deafblindness, the reported rate of psychosis is 23 percent (3).

The average adult who is deaf reads English at a fourth grade level (4). Many of the patients at the Mental Health Center for the Deaf read English at a first grade level or less. Thus some common English words are unfamiliar. For example, although the concept of "delusion" and "hallucination" can be explained, these are abstract English words.

Vignette. Mr. B is a middle-aged man who is deaf and has a history of paranoia, delusions, and hallucinations. Education at the center focused on explaining that his notion that others were trying to kill him was a "false belief"; his experience of feeling electric shocks from a computer was an example of a "false feel." He accepted these explanations and learned more about symptom identification.

Vignette. Mr. C has a diagnosis of schizophrenia. The hand shapes he uses when signing are not made accurately, rendering his communication difficult to understand. His psychotic disorder of thought form is manifested manually—that is, he has a hand shape neologism instead of a verbal neologism.

Substance abuse

Because of lack of access to "normal" recovery pathways, many patients who are deaf are referred for initial treatment for their addictive illnesses. Obtaining outpatient substance use services for a deaf person can be difficult outside of an urban setting, which would have a relatively high concentration of persons who are deaf. In urban settings 12-step groups for persons who are deaf are more common than in rural areas. Most deaf persons lack the resources to pay interpreters for 12-step meetings, and programs like Alcoholics Anonymous do not have funding for interpreters.

Vignette. Mr. D has diagnoses of schizophrenia and alcoholism. Before coming to the center, he had never been treated for either problem in the community. In groups with other deaf addicts he was able to see how his symptoms were similar to those of other group members and learn how his addiction adversely affected him.

Cognitive impairment

The high rate of impaired cognition among the patients in our unit (ten patients, or 23 percent) may be a function of the etiologic insult that resulted in deafness. Individuals who experience a perinatal trauma that results in deafness—for example, toxoplasmosis, rubella, cytomegalovirus, and herpes symplex virus; being born premature, and postnatal meningitis—are also at risk of developing cognitive deficits.

Pervasive developmental disorders

A total of four patients (9 percent) at the center had a diagnosis of pervasive developmental disorder not otherwise specified. This rate is significantly higher than the reported rate of .65 percent in the general population for all pervasive developmental disorder spectrum disorders (5). Rubella, a well known cause of deafness when contracted in utero, is also one of the many conditions associated with an increased prevalence of autism. Although we have treated patients with full-blown autism, more commonly we see patients whose deficits are in the domains of social intelligence and social communication, that is, pervasive developmental disorder not otherwise specified. Patients with this disorder have difficulty befriending fellow patients who are deaf, have a history of job failure because of an inability to grasp the implicit social demands that are present on most job sites, and often end up in altercations because of their rigid cognitive styles and inability to appreciate another's point of view. Early literature about inpatients who are deaf describes some of the patients as "invariably immature" or "egocentric" (6) or as suffering from "primitive personality—a pervading social and cognitive immaturity" (7). Unfortunately, authors of early reports applied these characteristics to all inpatients who were deaf, which resulted in a predictable backlash from the deaf community. Although these comments were inaccurate for the majority of deaf patients, such remarks describe patients who present with pervasive developmental disorders.

Vignette. Mr. E has pervasive developmental disorder not otherwise specified. He has no friends and cannot live at home. He has failed all job placements because he does not appreciate the significance of instructions. When his expectations of his job are not met, he explodes and is fired. On the ward, he wanted to order food, but he had only $4 and the minimum order for delivery was $7. When staff said they could not place his order and suggested that he solicit other patients to see if anyone else would add to his order to meet the minimum order, he blew up and threatened staff.

Forensic patients

Nine patients (21 percent) had forensic issues, including pretrial assessments of competency and criminal responsibility, restoration to competency orders, not guilty by reason of insanity status, treatment as a condition of probation, and treatment in lieu of sentencing. It is crucial that deaf persons with a language disorder or cognitive impairment are assessed by a specialized forensic team. Such defendants typically need not only formal forensic evaluations but also neuropsychological or speech-language evaluations.

Restoration to competency orders for persons who are deaf often revolve around issues of language capacity and unfamiliarity with many aspects of the legal system, more so than what is typically needed to treat hearing persons. Advanced education and training are often involved in restoring persons who are deaf to competency, because of their poor language skills or naivete. It is difficult to imagine where such a process could be undertaken other than a specialized inpatient unit.

Vignette. Mr. F was admitted to the center on a restoration to competency order because he was charged with sexually assaulting a child. He was mentally retarded and had minimal language skills. Because he had been employed, returning shopping carts to a store in the mall, the commonwealth's attorney felt that Mr. F could stand trial. An outside evaluator, using an interpreter, felt that Mr. F may have been competent. When we interviewed him we found he echoed what was said and would readily endorse nonsense items, for example, he would reply "Yes" to questions such as "Are you a fish?"

This behavior is typical of the "deaf nod" that is alluded to in forensic literature, in which some persons who are deaf indicate they understand proceedings so they will not appear ignorant. In a forensic setting, this automatic agreement can be disastrous (8).

Vignette. Mr. G was found to be incompetent because of his naivete with the legal system and because of his language and cognitive shortcomings. He was sent to the Mental Health Center for the Deaf for restoration. We used an American Sign Language video of the trial of Goldilocks to introduce him to an adversarial proceeding—although most of the center's patients have never heard the story and need to become familiar with it first. We also held mock trials on the ward.

Conclusions

Virtually every state in the country is under grave financial stress. In such circumstances it is doubtful that states will elect to set up specialized psychiatric inpatient units for deaf persons. Many inpatient programs for persons who are deaf and have mental illness have come about either through a lawsuit, as in Maryland; proximity to a lawsuit, as in Virginia; or the threat of lawsuit, as in South Carolina and North Carolina. Thus, even though states may be loath to spend scarce dollars on inpatient care for persons who are deaf, further lawsuits may force them to do this. The Mental Health Center for the Deaf's only cost above that for other units is for two full-time interpreters. A unit for persons who are deaf that relies on interpreters rather than signing staff will have higher costs and diagnostic accuracy will suffer when inevitably subtle diagnostic points are lost in translation. Several lawsuits are pending in which courts have found that deaf persons are entitled to services provided in their language, rather than via an interpreter. Also, because the needs of some deaf psychiatric inpatients are so complex, they cannot be met on inpatient units for hearing persons. Inpatient units for persons who can hear frequently fail to provide adequate interpreter hours, in my experience, and have diagnostic and therapeutic shortcomings for deaf persons with significant linguistic and cognitive comorbidities, especially language disorders.

Should states desire to set up inpatient programs, serious consideration should be devoted to admission criteria. In our experience, strict criteria would prevent some persons from using services that they cannot get anywhere else. Persons who are deaf and use sign language, whether or not they are primarily substance abusers or mentally retarded, generally benefit from receiving care in a signing milieu. Such a milieu facilitates self-expression, which, in turn, promotes better diagnosis and more complete treatment planning. Discharge planning is complex, because most communities are unfamiliar with serving deaf clients. A social worker who is experienced in working with persons who are deaf is essential for establishing adequate supports for both deafness and mental health in order to ensure successful community tenure. Overall, a treatment team that is skilled in the diagnostic, cultural, and language needs of deaf patients can best perform the comprehensive assessments and treatments these inpatients require.

Dr. Haskins is affiliated with the department of psychiatry at the University of Virginia in Charlottesville and the department of psychiatry at Western State Hospital, WSH Box 2500, Staunton, Virginia 24401 (e-mail, [email protected]).