Typically, when therapists are asked to define “cultural competence” their response is usually race-based or location-based. Occasionally some include gender and sexual minorities, age, and ability. It’s rare that clinicians and therapists with little experience in deafness consider “Deaf” as a culture.  

The topic of deafness and Deaf culture is vast, with many aspects to consider. It would be impossible to cover everything in only a few blog posts. This series of articles about working with Deaf and Hard-of-Hearing (DHH) clients is intended as a starting point for clinicians to begin their own research into deafness and Deaf culture.

This article will be fairly broad and will look at various aspects of deafness and how they can impact the therapeutic process. The second article will look at interpreters and accommodations, and the third will focus specifically on therapy and assessment.

Living Our Core Values

In my doctoral program at Eastern Kentucky University, our faculty stress cultural competence as one of our program’s core values. I noticed, however, that despite EKU being home to one of the most selective and difficult American Sign Language (ASL) interpreting programs in the country, our clinic and psychological services were not set up to receive Deaf and Hard-of-Hearing clients. It was just something that our clinic did not encounter enough to justify changing.  

I spent about a year working to update our clinic. I added a dedicated videophone (it looks like FaceTime but is typically used on a television), so now we can take calls in ASL without going through a relay service.  Here is our set-up in the graduate student workroom:

Our services can now be advertised as multilingual: we can do therapy and assessments in English, but also in ASL. Since we began offering these services, not only have we seen Deaf clients but we have also consulted with schools about best practices with deaf and hard-of-hearing students.

I realized that these changes were some of my classmates’ first encounters with anything related to deafness. My goals somewhat changed: rather than always being the “go-to” for anything Deaf-related in the program, I wanted to give my classmates a crash course in deafness.

I contacted the interpreting program and worked out a time for their students to come over to our clinic for mock therapy sessions with Deaf clients. For the classmates who volunteered to be mock therapists, I threw them in the deep end with very little information about what to expect.

I did so because that is how Deaf people usually encounter therapists. For therapists, doctors, nurses, and those in any other health-related profession, the majority of Deaf people will see someone who has little to no knowledge of deafness and Deaf culture. Many do not even consider Deaf clientele a possibility until suddenly there’s a Deaf person in their office.

Participating in these mock sessions gave my classmates the opportunity to think through some of the issues before encountering Deaf people in the real world and not having any idea where to even start. The activity was uncomfortable for my classmates because many realized that they never would have considered some of the difficulties they encountered during the mock sessions.  

Understanding the Terminology

Let’s start with something you might have noticed throughout the preceding paragraphs: frequent changes between deaf and Deaf. This is intentional, as “deaf” (or “little-d deaf”) tends to be the medical term, the literal inability to hear. The term “Deaf” (or “big-D Deaf”) refers to the Deaf community: individuals who are activists in the culture, support the use of ASL, study the shared history of the Deaf community, and have similar values and experiences.

Deafness can be seen as a spectrum. Some hard-of-hearing people hear enough that they are invisible and show no obvious signs of deafness, while at the opposite end are those with profound hearing loss. Some are born with very little hearing, others lose their hearing as they age, and a few lose their hearing suddenly due to accident or illness. Some begin learning ASL from birth, others learn later in life, and there are those who use oral methods, which relies primarily on speech-reading and using what hearing they do have.  

The Deaf Experience

I must stress that the examples I use are fictional and do not refer to specific people. Some Deaf people have the experiences mentioned here, others do not.  

Where a person falls on each of these components (among others) will affect that person psychologically. The point should be made that deafness itself rarely causes mental health difficulties, just like being tall or short does not cause psychological illness. It is the response of the surrounding environment that has the most effect on mental health. Let’s use the tall/short simile as an example:

A fifth-grade child is the shortest in class. Other students make comments and jokes about the student being unable to reach items on tall shelves or not being cut out for basketball or football, and the student is always mistaken for a student in an earlier grade level. Such comments and occurrences leave the student feeling sad and isolated. Thus, the student’s height is not the difficulty, it is the environment the student is in that does not appreciate the student’s difference.

Now let’s consider a deaf fifth-grade child. More than likely, that student is the only one with hearing loss in class. Anyone can see the student is deaf due to the large hearing aids (or cochlear implants, which are becoming more common), or an interpreter sitting in the front row where everyone can see. The student doesn’t verbally speak well. When the student does speak, others make fun or say things like the student talks “weird.” The student is rarely asked to join in games or activities because others have difficulty explaining the rules, so the student is often left alone.

Similar to our height example, the deaf student feels sad and isolated. But again, the student’s deafness is not the direct cause of those sad feelings, it is how the student is treated by other classmates.  

Not only are many Deaf individuals the only one in their class or at work, they’re typically the only ones in their family. It’s oft cited that 90% to 95% of Deaf individuals are born to hearing parents.

The likelihood that the parents know any sign language at all is slim.  Since the introduction of the Individuals with Disabilities Education Act (IDEA), students have the opportunity to be educated in the least restrictive environment (LRE) in schools. As a result, they are frequently mainstreamed into regular classrooms.

As a result, schools for the Deaf, where a student is placed in a signing-rich environment, are losing the numbers necessary to keep them open. The Deaf school in my state, the Kentucky School for the Deaf, had as many as 400 Deaf and hard-of-hearing students at one point. Today, the number is less than 100.  

For many Deaf people, English is their second language, not their first. ASL also does not have a dedicated written component, so for many writing in English can be difficult as well. If the clinician is not familiar with the different grammatical structure of ASL or that English is the client’s second language, a clinician might erroneously diagnose a Deaf person with a thought disorder or a learning disability.

It would be similar to diagnosing someone using Google Translate, as for many languages a direct word-for-word translation to English appears disjointed. It’s rare for a Deaf person to see a therapist or clinician who signs, so they often write back and forth for communication. At times, they may use the word order or rhetorical questions that are components of ASL grammar.

Here’s an example of an English sentence “translated” into ASL:

English: My appointment is at 4PM next week.  


Next Up: Interpreters and Accommodations

We’ve just barely scratched the surface of working with DHH clients, but hopefully this is enough for readers to get started. There are a few websites available that simulate different levels of hearing loss, and I highly recommend looking into them and trying them out for yourself.

Part two of this three-part series is coming up, but until then, I challenge you to do your own research on these topics:


[1] Though ASL does not have a dedicated writing system, “glossing” is typically used in which the name of the sign is written in ASL word order. It is impossible to write down many grammatical features of ASL.

This article was originally published on March 12, 2018. 

Clinton Nowicke, PsyD
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