Mental Health Care of Defa People

Mental Health Care of Deaf People
A Culturally Affirmative Approach

Mental Health Care of Deaf People
A Culturally Affirmative Approach
Edited by
Neil S. Glickman
Westborough State Hospital
Assumption College
Sanjay Gulati
Harvard Medical School
The American School for the Deaf
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Library of Congress Cataloging-in-Publication Data
Mental health care of deaf people : a culturally affirmative approach /

editors, Neil S. Glickman, Sanjay Gulati.
p. cm.
Includes bibliographical references and index.
ISBN 0-8058-4469-4 (alk. paper)
1. Deaf—Mental health services—United States. 2. Deafness—Social
aspects. I. Glickman, Neil S. II. Gulati, Sanjay.
RC451.4.D4 M44 2003
362.2’087’2—dc21 2002029414
CIP
ISBN 1-4106-0757-7 Master e-book ISBN
Books published by Lawrence Erlbaum Associates are printed on acid-

free paper, and their bindings are chosen for strength and durability.
Contents
List of Contributors xii
Preface ix
Prologue: My Story xxi

Jan DeVinney
1 Culturally Affirmative Mental Health Treatment 1

for Deaf People: What it Looks Like and Why
it is Essential
Neil Glickman
2 Psychiatric Care of Culturally Deaf People 33

Sanjay Gulati
3 Psychological Evaluation of Deaf Children 109

Terrell Clark
4 Culturally Affirmative Inpatient Treatment 145

With Psychologically Unsophisticated Deaf People
Neil Glickman
5 Sensory Strategies for Self-Regulation: Nonlinguistic 203

Body-Based Treatment for Deaf Psychiatric Patients
Diane Trikakis, Nancy Curci, and Helen Strom
v
vi CONTENTS
6 Culturally Affirmative Residential Treatment Services 239

for Deaf Children With Emotional and Behavioral
Disorders
Judy Vreeland and Jim Tourangeau
7 Culturally Affirmative Substance Abuse Treatment 261

for Deaf People: Approaches, Materials, and
Administrative Considerations
Debra Guthmann and Katherine A. Sandberg
8 Toward Culturally Affirmative Assessment 305

and Treatment of Deaf People With Sexual
Offending Behaviors
Susan Lemere
9 Does God have a Cochlear Implant? 327

Michael A. Harvey
Epilogue: When the Therapist Is Deaf 347

Sanjay Gulati
Appendix: Contents of the Accompanying CD 373

Skill Card Illustrator: Michael Krajnak
Author Index 417
Subject Index 423

List of Contributors
ILLUSTRATIONS:
Michael Krajnak, BA
CONTRIBUTORS
Terrell Clark, PhD

Boston Center for Deaf and Hard of Hearing Children
Nancy Day Curci, MA, OT/L
Jan DeVinney, MS
Maine Bureau of Rehabilitation Services
Deborah Guthmann, EdD
Fairview University Medical Center
Michael A. Harvey, PhD, ABPP
Private Practice, Framingham, Massachusetts
Susan Lemere, LICSW
Staffier & Associates
Katherine A. Sandberg, BS, LADC
Fairview University Medical Center
Helen Strom, OTR/L
Jim Tourangeau, MS
The Learning Center for Deaf Children
vii
viii LIST OF CONTRIBUTORS
Diane Trikakis, OTR/L

Judy Vreeland, MA
Walden School
Preface
Neil Glickman
Assumption College
Sanjay Gulati
Harvard Medical School
The American School for the Deaf
This book is concerned with the practical work of creating specialty

mental health services for deaf people. Our main focus is on those deaf
people who do not see themselves as disabled, but rather as a linguistic
and cultural minority. The literature most relevant to our enterprise is
therefore that of cross-cultural psychology rather than of disability psy-
chology (Glickman, 1996b) . We do not address the needs of late-deaf-
ened or hard-of-hearing people in any great depth, because they almost
always maintain a cultural identity as hearing people—there is as yet no
“hard-of-hearing culture.” However, many of the ideas developed here
are applicable to hard-of-hearing people and to those who became deaf
early in life and were raised “orally,” with English as their primary lan-
guage. We believe that clinicians familiar with cultural deafness are
more comfortable and more capable of working with people with every
type of hearing loss.
Our contributors do not view deafness as a disability. Therefore, they
do not explore the kind of question implicit in the disability model: how
does one adjust to and accommodate a disability. Instead, they ask how to
provide mental health treatment that is actually relevant and helpful to a
group of people who too often have been patronized or mistreated in the
“hearing” institutions—schools, social services, and health care—that
claimed to care for them.
ix
x PREFACE
The “cultural” view of deafness has been 40 years in the making,1 propelled
by the linguistic discovery that sign languages are languages (Pollard, 1992,
1996), by the general failure of oral educational methods, and by the struggle
for minority civil rights. Our contributors build on the pioneering work of a
generation of deaf and hearing clinicians and advocates. Our clinical predeces-
sors include Edna Levine and Helmer Myklebust, who published influential
early books on the “psychology of deafness” in 1960 (Vernon, 1995). The pio-
neers with deaf children were Hilde Schlesinger and Kay Meadow. Their
1972 work Sound and Sign (Schlesinger & Meadow, 1972), along with Eugene
Mindel and McCay Vernon’s 1971 work They Grow in Silence (Mindel &
Vernon, 1971) influenced a generation of mental health professionals to see
deafness differently. Dr. Schlesinger’s clinic, the University of California
Center on Deafness, gathered an extraordinary collection of researchers and
clinicians whose many achievements included a seminal book; Mental Health
Assessment of Deaf Clients: A Practical Manual, although now 15 years old, is in
no way out of date (Elliott, Glass, & Evans, 1987).
The first psychiatric inpatient facilities for deaf people were established at
Rockland Psychiatric Center in New York (key figures there were Franz
Kallman, John Rainer, and Kenneth Altschuler), and St. Elizabeth Hospital in
Washington, D.C. (Luther Robinson). McCay Vernon (Vernon, 1990) and more
recently Robert Pollard (University of Rochester Medical Center and Deaf
Wellness Center) have advanced the understanding of culturally appropriate
psychological assessment of deaf people. Excellent clinical work and research
along culturally affirmative lines now comes from a variety of centers. Lin-
guists, psycholinguists, and anthropologists have become fascinated by deaf-
ness, and their findings inspire educators and mental health clinicians.
As part of the deaf civil right revolution, deaf people themselves have
gained access to previously denied education. Influential early deaf role
models and teachers included Larry Stewart, Glenn Anderson, Allen
Sussman, and Barbara Brauer. The work of these and other leaders and spe-
cialty mental health programs is reflected in an important document, Stan-
dards of care for the delivery of mental health services to deaf and hard of hearing
persons (Myers, 1995). The growth of our subspecialty is also evident in the
establishment of Gallaudet University’s Conference on Deafness and Men-
tal Health in 1998, and in the proliferation of regional conferences and local
mental health associations, such as the Massachusetts Mental Health Pro-
viders for the Deaf and Hard of Hearing.
WHAT DO WE MEAN BY “CULTURAL AFFIRMATION?”
A culturally affirmative program provides opportunities for cultural in-

volvement and growth for the patient who desires it. Cultural affirmation
should not be mistaken for cultural promotion: It does not push a particular
1
Really, the remaking. The idea that deaf people have their own language and way of
being has been considered off and on for centuries.
PREFACE xi
cultural orientation on those who do not want it. Instead it stands in opposi-
tion to the standard medical or “pathological” model, where deafness is
seen as a disability for which deaf people are to be pitied or from which they
should be “cured.”
The relationship of the attitude of cultural affirmation to other views of
deafness can be understood through the following diagram:
Cultural Cultural Cultural Cultural Cultural
L L L L
Promotion Affirmation Sensitivity Insensitivity Rejection
Starting at the far right, cultural rejection or denial is the attitude held by
those who deny the importance of sign language or contact with deaf
adults for young deaf people, those who see deafness only as illness or an
obstacle to be overcome. The fact that one rejects the idea of Deaf culture
does not mean one cannot be a kind, well-intentioned person. But a mental
health professional with this attitude is unlikely be trusted by culturally
Deaf people. Cultural insensitivity is the position of the average mental
health program in regard to deafness—an attitude of simple ignorance,
without malice. The clients of a therapist with this attitude, for example,
might say, “I had to teach her everything about deafness.” Early in the treat-
ment, the therapist might have asked basic questions: “What’s a TTY?” or
“But why can’t you lip-read?” Cultural insensitivity is also shown when
programs attempt to serve deaf people without educating themselves
about deafness. Next, cultural sensitivity implies some knowledge of deaf
people’s special needs and abilities, such as knowing to provide an inter-
preter for a client who uses sign language. People develop cultural sensitiv-
ity through open-minded interaction with members of a community
willing to share their experience and perspective.
Skipping nowto the far left of the diagram, cultural promotion is a task for
Deaf theater and arts, for political advocates, and for bilingual schools. It is
the life project of many Deaf people. But in a mental health setting, cultural
promotion carries risks. It can be disrespectful of a client’s actual degree of
cultural identification; a client might feel more or less culturally Deaf. It can
inappropriately focus attention on the client’s identity instead of his mental
health needs. It can imply that the client is not acceptable the way he is.
When clinicians carry a political agenda of any sort, it will interfere with
their ability to listen and empathize with any particular client. Our chosen
approach, cultural affirmation, goes beyond cultural sensitivity because it in-
cludes having cultural competence, relevant self-awareness, and special
knowledge and skills (Sue, Arredondo, & McDavis, 1992). But it does not go
so far as cultural promotion because our goals are promoting clients’
health, success, and happiness, not “consciousness raising” or fostering po-
litical change. A client might discover positive aspects of Deaf identity in an
affirmative program. But we must respect our clients’ opinions and provide
them the freedom to seek their own solutions to the problems of deaf iden-
tity and politics.
xii PREFACE
Culturally affirmative mental health programs have been established

since the 1980s through Deaf community advocacy and the growing appre-
ciation on the part of mental health providers that culturally Deaf people,
like other cultural and linguistic minorities, often fare poorly in the mental
health system. Cultural affirmation differs considerably from the mini-
mum legal standard mandated by the Americans with Disabilities Act and
other laws, which require that services designed for hearing people be
made accessible to deaf people. In practice, this most often means simply
hiring a sign language interpreter for some portion of the clients’ service. Laws
do not require modifying programs in any essential way or establishing
specific Deaf-centered programs.
Every culturally affirmative program faces the challenge that what is op-
timal for one client may not be for another. Imagine three new patients ar-
riving at the Mental Health Unit for Deaf Persons at Westborough State
Hospital (Deaf Unit), in Westborough, Massachusetts. (Both editors and
several contributors are affiliated with this program.) The communication
specialist determines that the first client, who has suffered nearly complete
deprivation of language in childhood, requires communication in a pure
American Sign Language (ASL), supplemented with gesture and mime.
Thereafter, the team strives to use pure ASL with him, and arranges for him
to have special ASL tutoring. The second client communicates comfortably
in Pidgin Signed English (PSE), using a mixture of English and ASL. She
might feel confused and intimidated if everyone tried to communicate in
pure ASL. The team strives to match her need for PSE. The third client is a
nonsigning, orally deaf person. When he was referred, we explained that
our unit provides a signing milieu. He had the choice of going to a “hear-
ing” hospital, but he chose our program because he knew deafness would
be seen as normal here. For him, the team must use English primarily while
still maintaining a signing environment for others—not an easy task. The
point is that although we accept and nurture Deaf culture and ASL, we
serve each unique deaf person as best we can. Cultural affirmation is an at-
titude, not a straitjacket.
BUT IS DEAFNESS A CULTURE?
Some people take issue with the concept of a deaf culture. Certainly it is true
that signing deaf people share the majority of their values with the hearing
people of their geographic region: They watch the same television shows,
do most of the same things with friends, and want the same good jobs.
Many “culturally Deaf” people actually spend the majority of their time
with hearing people. But there is a striking discontinuity of opinion and
perspective that seems to us to justify the use of the word culture for a cer-
tain group of deaf people. Most obviously, culturally Deaf people use sign
language and experience it as a primary language. They value sign lan-
guage first and the ability to interact with nonsigners second. Most hearing
PREFACE xiii
people see things quite differently, valuing a deaf person’s ability to speak
even a little more highly than that same person’s ability to communicate
well in sign. Essentially, most hearing people are “deaf” to sign language.
Furthermore, there is a visual “way of being” that goes with not hearing. In
broad generalization, this includes being exquisitely attuned to body lan-
guage (try hiding your feelings from a deaf person), excelling at mime and
drama, and being visually perceptive. A visually perceptive hearing man,
Leonardo da Vinci, long ago noticed the eloquence and expressiveness of
deaf people’s use of their bodies and recommended that artists study them
(Rée. 1999). There are other features typical of culturally deaf Americans,
such as interpersonal directness and the striking use of humor. Suggested
readings that expand on this topic can be found at the end of chapter 2 in
this volume. Finally, and most important, Deaf people consider themselves
a cultural group. Can hearing people question them?
Deaf culture would largely disappear with the disappearance of the lan-
guage difference, although elements of it would remain as parts of the
larger culture, such as baseball signs and football huddles. When the entire
population of several towns in Martha’s Vineyard were bilingual in English
and Martha’s Vineyard Sign Language, in the 19th century, there was only a
single, bilingual culture (Groce, 1985). Similarly, if deafness is one day
“cured” through the perfection of cochlear implants and the identification
of all the genes for genetic deafness, resulting in the abortion of deaf fetuses
or genetic treatments for deafness, deaf culture will cease to exist. (The fact
that many hearing people consider such abortions acceptable whereas
most Deaf people would consider them eugenic is another discontinuity of
opinion that seems to justify the notion of Deaf culture.) Deaf culture is
unique among human cultures—it arises from a language barrier and a
physical status. It is different too in being passed on more often from peers
and nonrelated parents, rather than from the deaf child’s own parents, who
are most often hearing.
By a strict anthropological definition, deaf culture might more precisely
be described as a subculture. This small distinction seems irrelevant to our
purposes. We suggest that the skeptical reader talk with some culturally
Deaf people and decide this issue for himself.
TO WHOM DOES THIS BOOK APPLY?
Although many of the chapters in this volume describe specialized pro-

grams for signing Deaf people, cultural affirmation does not depend on the
client’s having a certain type or depth of cultural identity (Glickman,
1996a). It provides a relevant perspective, we believe, for mental health
treatment of all deaf people. The major case studies presented in the pro-
logue and in chapter 9, for example, are of a late-deafened adult and child.
There is no doubt that a large group of deaf people, the majority if one in-
cludes late-deafened people, do experience their deafness as a terrible loss
xiv PREFACE
and tragedy. This group of deaf people often has no affiliation with signing
deaf people and no desire for such an affiliation. When counseling these
deaf persons, helping them adjust to and cope with what they perceive to be
an enormous misfortune is a relevant clinical theme.
But even for these clients, a culturally affirmative mental health clinician
might work differently. A relevant parallel might be what happens when a
homosexual person seeks mental health treatment. A counselor who appre-
ciates that gay and lesbian people can lead healthy, productive lives can of-
fer a perspective that validates whatever identity and lifestyle the patient
has or develops, without prejudice or discomfort. Similarly, a counselor
who knows about deafness feels more comfortable in working with a hard-
of-hearing person, a late-deafened person, or an orally raised deaf person.
The culturally competent counselor understands the entire range of com-
munication, identity, social, and other issues that might arise peripherally
in the treatment of anyone with hearing loss, even those who are culturally
hearing. Just knowing that deafness can feel normal radically changes such
a therapist’s perspective on a client’s hearing loss. See, for example, the
work of contributor Michael Harvey in helping late-deafened people move
from seeing their hearing loss as a deficit to understanding it as a difference
to be accepted (Harvey, 1998).
The title of this book: Mental Health Care of Deaf People: A Culturally Affir-
mative Approach reflects our belief that our model has some applicability to
all deaf persons. The title is also meant to acknowledge the existence of a
cultural model of deafness, its implications for work with all deaf people,
and its growing espousal by a new international community of mental
health providers. One issue that we do not tackle is the issue of deaf people
with multiple cultural identifications. Espousing Deaf culture does not
mean someone is not also Japanese, Haitian, or native American. Refer-
ences for additional reading in this area can be found at the end of chapter 2.
Another specialized area that we leave untouched, sadly, is deaf-blindness.
WHAT’S IN THIS BOOK?
Most of this book’s chapters describe specific culturally affirmative pro-

grams, or treatment approaches for deaf clients with specific needs. All ad-
dress some dimension of the triad of attitude, knowledge, and skills that
characterizes culturally affirmative work with minority persons (Glickman,
1996b; Sue, Arredardo, & McDavis, 1992).
We open with “My Story,” a first-person account of mental health care
gone seriously awry. Jan DeVinney, a late-deafened woman who is cur-
rently the director of the Division on Deafness at the Bureau of Rehabilita-
tion Services for the state of Maine, was hospitalized for depression at the
Maine Medical Center in 1996. She eventually sued the hospital under the
Americans with Disabilities Act. Her suit was joined by state and federal
authorities, resulting in the hospital’s agreeing to institute a detailed policy
PREFACE xv
for better serving deaf people, a policy that will now serve as a national
model for hearing hospitals serving deaf people. Sanjay Gulati and Neil
Glickman served as expert witnesses in her case, which vividly illustrates
the need for specialized services for deaf people. She is the only client
whose real name and actual identifying details appear in this book; all oth-
ers have been heavily disguised.
What should a specialized program for deaf people look like? In chapter 1,
“Culturally Affirmative Mental Health Treatment for Deaf People: What it
Looks Like and Why it is Essential,” Neil Glickman distinguishes culturally af-
firmative mental health treatment from the lower standard of “accessible”
treatment. He challenges the assumption that simply providing an interpreter
creates full accessibility to mental health services for a deaf client, showing that
even having a “deafness expert” on staff does not solve the problem. He goes
on to describe what a complete culturally affirmative program looks like, us-
ing Westborough State Hospital’s Deaf Unit as the primary example.
In chapter 2, “Psychiatric Care of Culturally Deaf People,” Sanjay Gulati
provides a primer for psychiatric work with culturally deaf people. He pres-
ents essential information about deafness from the fields of linguistics, an-
thropology, and education. He describes common clinical issues and
practical aspects such as using an interpreter. He also answers the most com-
mon question that hearing psychiatrists ask: “Do deaf people hear voices?”
In chapter 3, “Psychological Evaluation of Deaf Children,” Terrell Clark,
the director of the Boston Center for Deaf and Hard of Hearing Children, at
Children’s Hospital, Boston, covers the choice and application of psycho-
logical tests for deaf children, illustrated with numerous case examples. A
4-year-old immigrant child presents with no exposure to sign language or
deaf culture. Because of her extensive knowledge and skills in working
with deaf children, Dr. Clark could evaluate this child in a manner that is
culturally affirmative because it recognized positively the capacities of the
child as a deaf person, including the potential for future involvement with
both deaf and hearing communities. As she puts it, “culturally affirmative
psychological evaluations of deaf children are performed by applying spe-
cialized skills and knowledge, appreciating the context of the individual
child, and genuinely respecting the culture, language, experiences, and val-
ues of Deaf people.” The editors regret that we were unable to persuade
Robert Pollard to take time from his many current projects to contribute a
parallel chapter concerning the evaluation of deaf adults. Fortunately, Dr.
Pollard’s work is widely available in his own writings.
Chapters 4 through 8 describe specialized areas of culturally affirmative
care. The premise of these chapters is that deaf persons in nonspecialized
programs do not receive treatment interventions designed to meet their
special needs and that nothing short of this level of adaptation and specialization
will reach them.
In chapter 4, “Culturally Affirmative Inpatient Treatment With Psycho-
logically Unsophisticated Deaf People,” Neil Glickman describes work with
xvi PREFACE
one of the most significant subpopulations among deaf persons referred for
mental health care, those often referred to as “low functioning.” He describes
how the team at Westborough State Hospital has refashioned treatment in-
terventions to work with this group, whom we prefer to call psychologically
unsophisticated. Like other chapters from Westborough, this chapter includes
the remarkable artwork of Michael Krajnak, a Deaf man who is currently
(2003) the communication specialist on the Deaf Unit. Michael creates visual
materials that help us explain difficult concepts using minimal English.
Chapter 5, “Sensory Strategies for Self-Regulation: Nonlinguistic Body-
Based Treatment for Deaf Psychiatric Patients,” concerns the role of occupa-
tional therapy at the Deaf Unit at Westborough. The authors are Diane
Trikakis, Nancy Day Curci, (present and former Deaf Unit occupational ther-
apists), and their supervisor, Helen Strom. They describe their success in
adapting Sensory Movement Interventions (SMI), a standard occupational
therapy appoach, for use with deaf clients. SMI is minimally dependent on
language. It teaches patients to soothe themselves when they are anxious or
upset and to increase their level of alertness when sluggish or depressed. The
staff of the Deaf Unit has embraced these ideas as enthusiastically as the pa-
tients, using them to improve work performance and take better care of our-
selves. We take pleasure in presenting this work to the larger mental health
and deafness community.
Chapter 6 is “Culturally Affirmative Residential Treatment Services for
Deaf Children With Emotional and Behavioral Disorders.” Walden School is a
therapeutic residential and day school within The Learning Center for Deaf
Children in Framingham, Massachusetts. TLC pioneered bilingual–bicultural
education in the United States, and Walden School shares its culturally affir-
mative viewpoint. Judy Vreeland, the director of Walden School, and Jim
Tourangeau, TLC’s dean of students, describe the many challenges to running
such a program. Their case examples illustrate such work at its best.
The Minnesota Chemical Dependency Program at Fairview University
Medical Center pioneered culturally affirmative substance abuse treat-
ment. In chapter 7, “Culturally Affirmative Substance Abuse Treatment for
Deaf People: Approaches, Materials, and Administrative Considerations,”
Debra Guthmann and Katherine Sandberg follow a representative deaf cli-
ent through their program, describing the specialized assessment and treat-
ment approaches he receives. They consider the administrative issues in
creating such a program. (Administrative issues in creating culturally affir-
mative programs are also considered in chaps. 1 and 6.) They generously
provide materials from their program for the reader’s use. Further materi-
als are available from their program, 1-800-282-3323 V/TTY.
Chapter 8, “Toward Culturally Affirmative Assessment and Treatment
of Deaf Persons With Sexual Offending Behaviors,” addresses the issue of
sexual offending among deaf clients. The author, Susan Lemere is a former
Deaf Unit social worker who specializes in both substance abuse and sexual
PREFACE xvii
offender treatment with deaf people. Difficulty with sexual boundaries can
be seen as a particularly challenging and dangerous subset of social diffi-
culties. Susan is a hearing second-language learner of sign. Her work, like
all treatment provided by hearing persons on the Deaf Unit, is done in col-
laboration with Deaf professional and paraprofessional staff. Through this
cross-cultural collaboration, we seek to bring both clinical and communica-
tion/cultural expertise. Susan’s chapter presents her and the Deaf Unit’s
fascinating new work in this area.
Michael Harvey, a psychologist who has pioneered culturally affirma-
tive work, presents a difficult case in chapter 9, “Does God Have a Cochlear
Implant?” His clients, a hearing, biracial couple struggle with whether to
seek cochlear implantation for their son, who was born hearing and became
deaf at age 6. Which identity should this child have? Who should decide? Is
he naturally deaf because he now doesn’t hear, or is he natively hearing be-
cause he was born that way? The case material is enhanced through com-
parison with racial identity issues. Dr. Harvey’s daydreams regarding his
clients’ struggle over the implant nicely illustrate the difference between
cultural affirmation and cultural promotion.
We close with a celebration of the varied voices of Deaf clinicians. In
“When the Therapist is Deaf,” Sanjay Gulati explores cultural affirmation
as explained by deaf therapists in a series of personal interviews. We hope
to leave the reader with a sense of the vitality and intelligence that empow-
ered deaf people bring to their work.
SOME NOTES ON NOMENCLATURE
The use of Deaf for culturally Deaf and deaf for audiologically deaf is now
standard in the field of deafness. Another recent solution, used by Lane et
al., is to capitalize the entire word when intending the cultural meaning:
DEAF (Lane, Hoffmeister, & Bahan, 1996). We have chosen the first option,
using the capitalized Deaf only where the cultural aspect of deafness is be-
ing specifically emphasized, and the lowercase otherwise.
Throughout the text, American Sign Language is transcribed in English
“gloss” using fully capitalization, in the manner that has become standard
in deafness. For example, STORE I GO represents the ASL sentence “I am
going to the store.” Such glosses are reductive (the three-dimensional spa-
tial nature of sign and its facial grammar and body language are reduced to
a single dimension), but serve adequately for readers familiar with ASL.
Those unfamiliar with ASL should not assume that ASL is ungrammatical
because the phrase would be ungrammatical in English. ASL’s grammar is
as strict as that of any other language, only the rules are different.
With regard to the gender of pronouns, we have chosen to avoid the
awkward constructions “he or she” and “his or her” by alternating or as-
signing gender randomly.
xviii PREFACE
Finally, because it is known as a TTY in American Sign Language, we have

chosen to retain the older term “TTY” (teletypewriter) in preference to the
newer “TDD” (teletype device for the deaf). Similarly, we have preferred
“lip-reading” in most instances to the academic word “speechreading.”
THE APPENDIX AND COMPACT DISC
The text is accompanied by a compact disc, the contents and use of which
are presented in the appendix. It contains the communication and sub-
stance abuse assessments, and the sample drug treatment tools developed
by the Minnesota Chemical Dependency Program and described in chapter
7. It also contains many of the psychosocial skill cards described in chapter
4 and others described in the Appendix. All these tools have become indis-
pensable on the Deaf Unit. We hope readers will use and adapt these mate-
rials for different settings, including work with hearing clients who have
limited verbal or conceptual abilities, and we invite readers’ feedback.
WHO ARE THE EDITORS?
Neil Glickman is cofounder and current unit clinical director of the Mental
Health Unit for Deaf Persons. The Deaf Unit is part of the Massachusetts
Department of Mental Health, and is located at Westborough State Hospi-
tal in Westborough, Massachusetts. It is the only inpatient unit of its kind in
New England. Dr. Glickman is adjunct faculty at the Institute for Social and
Rehabilitative Services at Assumption College in Worcester, Massachu-
setts. A graduate of Gallaudet University’s masters program in rehabilita-
tion counseling and the University of Massachusetts, Amherst’s program
in counseling psychology, he is a licensed psychologist and certified reha-
bilitation counselor. With Michael Harvey, PhD, he edited Culturally Affir-
mative Psychotherapy with Deaf Persons, published by Lawrence Erlbaum
Associates in 1996. Dr. Glickman is a hearing, second-language user of ASL
Sanjay Gulati is a child psychiatrist who works full time in deafness in a
variety of settings: an outpatient service (Cambridge Hospital, Cam-
bridge), on the Deaf Unit (where he is now a consultant), at a psychoedu-
cational evaluation clinic (the Boston Center for Deaf and Hard of Hearing
Children, Children’s Hospital, Boston), and at the American School for the
Deaf. In addition, he chairs the Group for the Advancement of Psychiatry’s
(GAP) Committee on Disabilities and teaches medical students, residents,
and fellows in child psychiatry at Harvard. His research interests include
the behavioral consequences of language deprivation and, with GAP, the
experiences of deaf medical students under the ADA. Dr. Gulati’s work in
deafness arose from his own experience of progressive hearing loss. After
completing his medical training in 1992, he interviewed with Hilde
Schlesinger for a position at the University of California Center on Deafness
in San Francisco. Over hot cocoa and chocolates at a local “chocolate bar”—
PREFACE xix
easily the most enjoyable interview in his life—Dr. Schlesinger explained

that “to understand deaf adults you need to understand how deaf children
develop,” and advised that he train further as a child and adolescent psy-
chiatrist instead of taking the job. He took her wise advice, completing his
training at Harvard before beginning his career in deafness.
ACKNOWLEDGMENTS
Neil Glickman thanks the staff of the Westborough State Hospital Deaf
Unit, whose creativity, talent, and dedication constantly inspire him. These
staff members include Sanjay Gulati, Bruce Hurter, and Philip Candilis,
psychiatrists; Susan Salinas, Susan Lemere, Terry Morrell, and Greg Fisher,
social workers; Diane Trikakis and Nancy Day Curci, occupational thera-
pists; Michael Krajnak and Charles Garabrant, communication specialists;
Wendy Petrarca, Susan Jones, and Russell Ross, interpreters; Joann
Cremins, Jan Nute, Greg Shuler, John Scannell, Afua Danso, Donna Peacott,
Teckler Chikomo, Jean Granger, and Rose Mascari, nurses; Omar Olazabal,
Fatima Silvestre, Debra Middleton, Sam Appiah, Bev Angeles, Deborah
Abelha, Clarence McKenzie, Laura Martin, Kwame Amoah, William Clark,
Brenda Perry, Robert Duff, Sara Dugas, Alicia Jones, and Susana Diaz, men-
tal health workers; and Stacey DeRienzo, medical records clerk.
The Deaf Unit could not survive and thrive without the active support of
Westborough State Hospital and Department of Mental Health administra-
tion including Steve Scheibel, Dan Lambert, Jyotikaben Patel, Denise
Rab-Wilson, Theodore Kirousis, Barbara Lou Fenby, Lynn Hoffman, Mary
Ellen Foti and Commissioner Mary Lou Sudders. It’s a delight to work for
an agency in which the hearing administrators “get it” when it comes to the
need for culturally affirmative mental health treatment for deaf persons.
Neil wishes to thank the clients of the Deaf Unit. It has been said that one
learns counseling from one’s clients. Neil thinks this is especially true with
culturally different clients and with clients like John, described in chapter 4,
who are “psychologically unsophisticated.”
Neil also thanks Sunjay Gularti, Michael Harvey and McCay Vernon
for their close readings of the text, and Sherry Zitter for her helpful sug-
gestions to his chapters. Michael Harvey has been a mentor and friend
for over 15 years and his influence is felt throughout this work. Neil
thanks his life partner Steven Riel for his love, encouragement, and con-
stant support.
Sanjay Gulati thanks Westborough State Hospital (medical director
Jyotikaben Patel) and Cambridge Hospital (John Wechter) for providing
writing time, Terrell Clark for ten years of teaching him about deafness, and
mentors Timothy Dugan, MD and Robert Ziegler, MD, who made his career
possible. He thanks those who read and commented on the drafts of various
chapters: psychologist and mentor Terrell Clark, PhD; psychiatrists Craig
Buchholz, MD, David Gendron, MD, and David Pepper, MD; educator and
xx PREFACE
employer Ray Stevens, PhD; Deborah Barber; and Harvard Medical School
students Chris Prichard and Shannon McDonald. He is deeply indebted,
professionally and personally, to those who have welcomed him into the
Deaf world. He thanks Neil Glickman for tolerating his Aesop’s hare style of
working, and for serving as a model of creativity and thoughtfulness. Finally,
he thanks wife and daughter, Maureen and Ilina, for so lovingly supporting
this project.
Both editors thank our gracious and intelligent editor at LEA, Susan
Milmoe, as well as other talented LEA production staff including Paul
Smolenski, Art Lizza, and Erika Kica.
REFERENCES
Elliott, H., Glass, L., & Evans, J. W. (Eds.). (1987). Mental health assessment of deaf
clients: A practical manual. London: Taylor & Francis.
Glickman, N. (1996a). The development of culturally Deaf identities. In N.
Glickman & M. Harvey (Eds.), Culturally affirmative psychotherapy with deaf
persons. Mahwah, NJ: Lawrence Erlbaum Associates.
Glickman, N. (1996b). What is culturally affirmative psychotherapy? In N.
Glickman, N., & Harvey, M. (Eds.). (1996). Culturally affirmative psychotherapy
with deaf persons. Mahwah, NJ: Lawrence Erlbaum Associates.
Groce, N. E. (1985). Everyone here spoke sign language. Cambridge, MA: Harvard
University Press.
Harvey, M. (1998). Odyssey of hearing loss: Tales of Triumph. San Diego, CA: Dawn
Sign Press.
Lane, H., Hoffmeister, R., & Bahan, B. (1996). A journey into the Deaf-world. San
Diego, CA: Dawn Sign Press.
Mindel, E. D., & Vernon, M. (1971). They grow in silence. Silver Spring, MD: Na-
tional Association for the Deaf Press.
Myers, R. (1995). Standards of care for the delivery of mental health services to deaf and
hard of hearing persons. Washington, DC: National Association of the Deaf.
Pollard, R. Q. (1992). 100 years in psychology and deafness: A centennial retro-
spective. Journal of the American Deafness & Rehabilitation Association, 26(3),
32–46.
Pollard, R. Q. (1996). Professional psychology and deaf people: The emergence
of a discipline. American Psychologist, 51(4), 389–396.
Rée, M. (1999). I see a voice: Deafness, language, and the senses: A philosophical his-
tory. New York: Metropolitan Books.
Schlesinger, H. S., & Meadow, K. P. (1972). Sound and sign: Childhood deafness and
mental health. Berkeley: California University Press.
Sue, D. W., Arredondo, P., & McDavis, R. (1992). Multicultural counseling com-
petencies and standards: A call to the profession. Journal of Counseling and
Development, 70(4), 477–486.
Vernon, M. (1990). The psychology of deafness. New York: Longman.
Vernon, M. (1995). An historical perspective on psychology and deafness.
JADARA, 29(2), 8–13.
Prologue: My Story
Jan DeVinney
Bureau of Rehabilitation Services, Augusta, Maine
It was a dark and stormy night—no, actually it was a lovely late summer
evening in 1996—when I was hospitalized on the psychiatric ward of the
Maine Medical Center in Portland, Maine. Because their services were inac-
cessible to me as a deaf person, my stay there was a nightmare. After leav-
ing, I sued the hospital under the Americans with Disabilities Act, and won
a consent decree in which the hospital agreed to make many improvements
in their services. Here is my story.
I am a late-deafened woman, a mental health professional, and the mar-
ried mother of two children. I hardly had room in my life at the time for a ca-
tastrophe. By day, I coordinated a community support program for deaf
people with major mental illnesses (Maine’s first), and attended classes to-
ward a masters degree in rehabilitation counseling. By night, I became a
carpenter, working on our home. For several weeks prior to my hospitaliza-
tion, I had been installing doors, cabinets, countertops, casings, and trim so
my family could move from the basement to the living quarters of our new
home. In between, I tried to deal with a serious problem: the recent loss of
the last of my hearing. Despite our attending family therapy, my husband
and sons were having great difficulty adapting to the increased difficulty of
communicating with me.
That summer day, my work was temporarily calm. My clients were
housed, fed, employed, and well stocked with their medications. It was Fri-
day, and a rare quiet afternoon awaited me. Over a glass of wine I had a
good talk with a friend outside, then settled down in front of the TV with
my husband. He answered the phone. Learning that one of our sons had
collapsed while watching a school football game, he dashed out. I paced
and worried, alone in the house, not knowing if our son was dead or alive.
Had I still been hearing, I would have tried to get more information, or at
least could have called a friend to hear a supportive voice. Now that I was
deaf, I felt trapped and alone.
xxi
xxii PROLOGUE
They arrived home more than an hour later. I was relieved to see my son
unhurt, but needed to know what had happened. Neither my son nor my
husband would make the effort to communicate with me. Embarrassed, or
maybe excited to call his friends and tell them the story, I remember my son
standing motionless in my bedroom, telephone in hand. I snapped inside,
snatched the telephone from his hand and screamed at him, “you see what
it’s like being totally cut off from communication!”
I was clearly responding to something larger than the evening’s events.
This was hardly the first time that my family had been unwilling or unable
to communicate with me. Four years earlier, I had experienced an episode
of Major Depression. A few months before the football game, fearing that it
was returning, I had restarted my antidepressant medications. For several
weeks, I had been eating and sleeping poorly, and had suffered from peri-
ods of confusion. I had begun to feel increasingly overwhelmed, and just
that week I had dropped my classes for the semester.
The incident with my son left me feeling that I had become incompetent
to care for my own child in a crisis. As I thought it over, a long list of the
things that I had now become unable to do scrolled before my eyes. “Face
it,” I thought, “life just isn’t worth living now that I’m deaf.” Sitting in my
workshop smoking one cigarette after another, I felt completely cut off from
my family and from the rest of the world. “I just can’t do this anymore,” I
thought. “Everyone will be better off without me. I’ve just been pretending
that my deafness is no big deal. But it’s a huge deal, a huge problem. How I
hate myself for going deaf!”
Realizing finally that I needed help, I went back in the house to the TTY,
and tried to call the crisis hotline. Although they were supposed to be deaf-
accessible, they hung up on me repeatedly. Finally, I got through to them by
using the state’s relay service. The phone counselor I talked to was clueless,
responding to my despair with the odd comment that my job seemed to be
my first priority.
I sat, crying desperately, drowning in the feeling of isolation created by
my deafness. I became more possessed by the thought of suicide. There was
some old scotch in the cupboard, and some pills in the medicine cabinet. I
could finish the job with the running blade of my table saw.
My agency had just fashioned a crisis plan for our deaf clients, which
called for emergency evaluations to take place at the Maine Medical Center
(MMC). It was clear that now I, the program coordinator, was in crisis! I
grabbed my medications, my favorite pillow, some cigarettes, and my in-
surance card, and drove to the hospital. Entering the emergency room, I
told the nurse that I was deaf and was having a nervous breakdown. The
old-fashioned phrase seemed to describe how I was feeling perfectly. She
nodded, and took my name and insurance information.
One by one, the nurse called the other patients’ names, leading them into
the emergency room. I had understandable speech, and was a good lip-
reader. I was able to make some sense of sounds through my hearing aids. I
PROLOGUE xxiii
knew people often did not realize that I was profoundly deaf, so I reminded
the nurse that I would not hear my name, and stayed close to the reception
desk. I felt exposed there amidst the Friday night hustle and bustle of the
state’s busiest emergency room. I wished I could move to a quiet corner. Af-
ter escorting a few more patients past me, the nurse walked by again with
no one in tow. “My turn?” I guessed. Annoyed, she led me to a curtained cu-
bicle in the noisy emergency room.
Hearing aids amplify everything, whether speech or background noise,
and in the noisy emergency room I could not understand anything at all. It
was after midnight. I curled up and dozed off on the bed. A doctor woke
me, and tried to question me. “I can’t hear,” I protested, but he kept on talk-
ing. “Can we move to a quieter place to talk?” I asked. “Sorry, you need to
stay here,” he replied. What was he thinking? I gave up and rambled on,
guessing at his questions.
He left and I drifted off to sleep. A nurse woke me and led me to another
room. I hoped that this would be a quiet place where lip-reading would be
easier. The new room was windowless, and had only one dim light fixture
high in the ceiling. The bed was attached to the wall with large bolts. A
screaming woman was wheeled by in five-point restraints. She was sur-
rounded by people in lab coats and police uniforms. A guard appeared out-
side my door. I noticed that the room was empty of anything sharp or loose
that might be used as a weapon.
“This must be the place for crazy people,” I thought. “I’ve become one!
How can this be happening to me?” I was struck by the irony that it was the
purpose of my job to help my eight deaf clients avoid the very situation in
which I now found myself.
At 5 a.m., a young woman appeared, a Filipino psychiatry resident with
a strong accent. Between my deafness, my mental state, and her accent, I
couldn’t understand her at all. I sobbed. I have since been asked why I did
not request a sign language interpreter at that moment. I was new to being
profoundly deaf, and had never previously needed to use an interpreter in
a medical setting. I was also used to struggling to hear, and could often
function fairly well in one on one conversations. Finally, I was depressed
and exhausted, and wanted someone to care for me rather than needing to
advocate continuously for myself.
Having professional experience on the other side of the mental status
exam, I guessed away at the psychiatrist’s questions. She took notes. When I
said I could not understand her, she moved closer, until she was literally “in
my face.” I did not feel understood or cared for by her. Unbelievably, she said
something about the possibility of “fixing” my deafness with a cochlear im-
plant, as if she were prepared to perform the surgery then and there. “Some-
one please help me,” I thought. “I can’t hear and I’m losing my mind!”
The doctor left, and two escorts appeared. We took the elevator to the 6th
floor, and passed through a locked door. I must be on P6, I realized, the
locked psychiatric ward. A kind nurse conducted another intake interview.
xxiv PROLOGUE
When I told her that I could not handle being completely deaf and that my
life did not feel worth living, she answered that it was time to stop taking
care of everyone else, and to let others take care of me. She promised that
they would help me. She noted my deafness and my use of American Sign
Language in the chart. It was 6 a.m. Outside, dawn was breaking. The nurse
led me to my room. With its large quantity of my new roommate’s personal
effects, it looked like a combination of an ordinary hospital room and a col-
lege dorm room. There was heavy metal mesh over the windows. I lay
down and slept deeply until noon.
I awoke with a start, having forgotten where I was. A nurse came in with
a pad of paper and wrote down her name. Written communication! I re-
quested a TTY to call my husband and to tell him what had happened. I
hadn’t taken the time before leaving home to leave him a note. (It turned
out that he had assumed I’d gone to a friend’s house.) Instead of a TTY, she
brought me an amplified phone. “No,” I said. “I really need a TTY.” I had
given up on amplified phones just a few months before, when the frustra-
tion of trying to hear had finally outweighed the pleasure and convenience.
Becoming unable to hear on the telephone had been a major contributor to
my social isolation, and had undoubtedly increased my risk of recurrent
depression.
The nurse came back soon with the oldest TTY I have ever seen. It was
broken. I became angry. She offered to call my husband for me. Meanwhile,
they searched the hospital again, and eventually located a more modern
TTY. But the comedy of errors was not over: The new TTY was missing its
adapter. I launched a verbal tirade about the obstacles I faced due to my
deafness, which seemed to be just as bad here—where I was supposed to be
understood and cared for—as they were outside. “The ward is not set up for
deaf patients,” they said. “It should be,” I replied. “There are laws that re-
quire it!”
Contacted by the nurses, my husband arrived. He was concerned and
bewildered, not yet realizing how serious my depression had suddenly be-
come. I told him about the TTY problem. He helped me make a fuss. First
they found an adapter that didn’t fit, then, 3 hours later, one that did. They
set up the TTY in the unit’s main conference room.
I asked my husband to call my boss, a friend, and my sister. I especially
wanted my friend to get in touch with one of my professors, Reid, and ex-
plain why I had dropped my classes. After my husband left, I retreated to
my room with a jigsaw puzzle. The ward was empty. No one had told me
what to expect from the hospital. I didn’t even know how the meals
worked. Other patients were eating in the day room. Unable to chat with
them, I got a tray of food and took it to my room, where I ate the food cold,
once more feeling desperately alone.
Although I probably needed hospitalization, I decided that I could not
stand the communication inaccessibility and insensitivity to my deafness
on P6. I requested to be released. I was a “voluntary” rather than a commit-
PROLOGUE xxv
ted patient, and had the legal right to leave. However, they explained that if
I left “against medical advice,” my insurance company wouldn’t cover my
stay. In other words, I was legally voluntary, but financially involuntary,
and had to stay.
No one had yet mentioned an interpreter. I expected one to arrive any
minute. Surely they knew that deaf people use interpreters to talk with
hearing people. A nurse came to my room to invite me to the nightly
“wrap-up” group. “Will there be an interpreter?” I asked. “No,” she re-
plied. With no way to follow the conversation, I declined to join the group.
The nurse’s invitation and my refusal were repeated like clockwork each
evening after that—they never did find an interpreter for that group.
I needed to call my son to reassure him that my hospitalization was not
his fault, and to tell him I loved him. The door of the conference room was
locked. I asked the ward receptionist to let me in, but she said that only
“my” nurse could do that. My nurse was busy with wrap-up group. I lost
my temper, and threw a pencil. Hearing patients could make and receive
telephone calls 24 hours a day, I objected, but my access to the outside world
was going to be limited to making outgoing calls only from a stupid locked
conference room! Reduced once more to tears, I ran back to my room. My
roommates watched as I lay on the bed and turned my face to the wall. I was
a prisoner. Later in my stay, they did make a schedule for me to use the con-
ference room when they didn’t need it. However, I was never able to receive
a single TTY call while on the unit.
I ate another meal alone in my room. I started a giant jigsaw puzzle of the
Golden Gate Bridge and began a journal.
No energy. Battles to do. No accessible TTY. Closed captioning on the TV? I doubt it.
Educating them. Last night the nurse told me I would learn this weekend to accept
help … Wrong! I have to care for myself as usual … I’m getting more and more iso-
lated with less and less energy to help myself, as well as less desire to try.
A nurse brought in a medication to help me sleep. I cried myself to sleep,

and awoke the next morning still feeling exhausted. I found my breakfast
tray and set off for my room. This time I was stopped and told to join the
other patients in the day room. “I can’t hear anyone, and don’t want to
watch how easy communication is for hearing people!” I answered. I ate,
cried, worked on my puzzle, which seemed to be missing a few pieces, and
wrote furiously in my new journal. At least the blank pages seemed to un-
derstand. The journal helped me then, and it helped me again later, when I
needed to remember the details of my hospitalization for my lawsuit.
To my surprise, my professor Reid showed up! I had only wanted to send
him a message. I was embarrassed at first, then genuinely happy to see him.
Lacking a private place to talk, we set up chairs in the hallway. This conver-
sation was the only actual therapy I got in the hospital. Reid does not sign.
He knew me and was patient, but it still wasn’t easy to communicate. At
xxvi PROLOGUE
one point, when he raised his voice above the din, another patient promptly
joined the conversation. Reid sent her away politely but firmly. I told Reid
how things were for me. I explained that at school I had always worn armor,
striving to show myself as perfectly capable. I wanted to be seen as having
had gone deaf and “risen above it” by attending classes with interpreters.
Inside, however, I had slowly become a depressed and beaten creature.
Reid was compassionate, and gave me some straightforward advice that
started me on the long road back to the world of the fully alive.
After 2 days, I was allowed to go outside three times a day for “fresh air
passes” lasting 15 minutes. I could smoke again! At the end of my second
fresh air pass, I took a different elevator back up to the ward, and ended up at
the far end of a hallway. I rang the doorbell several times, but nothing hap-
pened. I was afraid that my 15 minutes would run out and I would lose my
new privilege. A janitor came by and pointed at a speaker mounted on the
ceiling. Apparently, they were talking to me by intercom from inside the
ward, having forgotten that I was deaf! That night, after my third fresh air pass,
there was yet another incident. No one had told me that when returning to
the ward at night I should check with security at the front desk. I breezed past
the desk, nodding, and was startled a moment later when the two security of-
ficers stopped me from behind, demanding to know what my business was.
Other patients talked and learned the ropes from one other, but made little
effort to communicate with me. I reached out to only one, a man whose room
was across the hall. Like me, he was a mental health professional. I tried to
ask him how it felt being a patient instead of a professional. He answered me
in a few sentences, none of which I understood. I did the old head nod and
smile, then walked away as fast as I could. I avoided him the rest of the time
since he was one of those people I could not understand at all.
Monday finally arrived. I looked forward to meeting my doctors, creat-
ing a treatment plan, and—I hoped—beginning my recovery. Despite all
my complaints over the weekend, there was no interpreter for this crucial
meeting. Once more, I guessed my way through an interview. The team as-
signed me to various therapy groups. I demanded, none too politely, that
they provide interpreters. At an occupational therapy group the leader sim-
ply told me I didn’t need an interpreter. I bit my tongue, saving my energy
for other battles. While the group members discussed their goals, I sat like
an idiot, with no idea what was going on. After the introductions, I worked
on a simple craft project. They were condescending. “Such nice work,” they
said, “How well you work independently … so creative. You should take
up a hobby working with your hands.” I seethed, but didn’t have the en-
ergy to lash out. Was it my deafness or my depression that made it impossi-
ble for them to imagine that I had just designed and built my own home,
and was every bit as educated as they?
My outbursts got me assigned to an anger management group. But there
was no interpreter! I told them plainly that for me, sitting around role play-
ing aggressive, assertive, and passive behavior was “bullshit.” “I am angry
PROLOGUE xxvii
because my civil rights as a disabled person are being violated!” I ex-

plained. They responded with a homework assignment: some exercises to
help me learn to accept what I could not change.
One evening a woman walked in and signed, “Hi.” Excited and relieved,
I signed while speaking, “You must be the interpreter.” She repeated my
sign. “That’s how you sign interpreter?” From my next question, she
learned the sign for “psychiatrist.” Disturbed, I inquired about her training
and learned that she was a hospital volunteer who had taken some sign lan-
guage classes. She was the hospital’s answer to all my requests for an inter-
preter! Mental health interpreting is among the most demanding type of
interpreting, and they had sent me someone unable to sign! I asked her to go
back and tell them that she was not competent to interpret. If I complained
myself, I feared the staff would just see more evidence that I was a difficult
patient. The woman offered to call her sign language teacher—a Deaf man
whom I happened to know quite well—to interpret for me. I asked her how
one deaf person could possibly interpret for another. “Oh yeah,” she re-
plied. MMC did eventually provide some interpreting time, but their staff
never really “got it.” They seemed unable to get their brains around the fact
that I could speak but could not hear.
I needed advocacy support. I knew the state’s Director of Deaf Services
for the Department of Mental Health, and asked my husband to call her. She
was unable to get back to me due to the TTY set-up, which did not permit
me to take incoming calls. I asked for the hospital’s ADA coordinator. No
one knew who that was, or whether they even had one. One nurse thought I
wanted the American Dental Association. When I yelled about violation of
my civil rights, one staff member said, “Civil rights? You’re white!”
One day, I noticed a card taped to a lamp near the medication desk. I be-
came excited as I read, “Advocate for the Deaf.” “Help is on the way!” I
thought. The phone number was long distance. The way the TTY was con-
nected, I didn’t know how to make a long distance call. No one could tell me
where the card had come from, or whether someone had already spoken
with the advocate. It turned out that they had tried to get her help with ar-
ranging interpreting. I never did meet her while hospitalized, but we met
much later, and we are now close friends.
Even when I did have an interpreter, I often found the treatment I re-
ceived on P6 inadequate. In a medication education group, for example, I
volunteered that it could be dangerous to suddenly stop taking an SSRI (Se-
lective Serotonin Re-uptake Inhibitor) antidepressant. I had stopped taking
mine just before being hospitalized because of insomnia and night sweats,
which I suspected were medication side effects. The group leader contra-
dicted me, incorrectly stating that SSRI’s did not cause night sweats, and
suggested that I might be experiencing menopause. I certainly wanted to
hear that at the ripe old age of 40!
By my third day in the hospital, I finally figured out that patients were
expected to request their own medications every day. I didn’t even know
xxviii PROLOGUE
the medication schedule. Since this procedure was used to see if patients
were competent to manage their medications, they must have concluded
that I was not.
I took to shouting my litany of civil rights violations to everyone within
earshot, until I realized I really was beginning to sound crazy. Through my
journal writing I gradually realized that I needed to take time to grieve my
hearing loss. Losing my hearing had affected every facet of my life. As a
late-deafened person, I did not have the sense of identity that members of
the Deaf community feel. I also realized that being angry with staff was out-
ward-directed, and therefore easy and safe. The grieving that I needed to do
was internal and therefore terrifying. Far from being a safe and supportive
place to grieve and heal, the hospital had worsened my problems through
their staff members’ denial, ignorance, and minimization. I grieve their
hurtful reactions to this day.
The treatment team on P6 diagnosed me with an Adjustment Disorder.
They believed that I had become acutely suicidal in an overreaction to my
son’s collapse at the football game. They overlooked my progressive deaf-
ness, my history of a depressive episode, and the other stresses in my life.
They did see that the communication barrier in my family had contributed
to my reaction. They addressed this issue by inviting my husband and teen-
age sons for family meetings, for which they provided an interpreter. (Evi-
dently they thought that I needed an interpreter to communicate with my
family, but not with them!) My kids heard again what they had already
heard in family counseling the previous year: the importance of using sign
language at home and including me in conversations. After two of these
family sessions and a 4-hour pass to go home, my managed care company
refused to cover a longer stay. Their decision was based on my diagnosis of
Adjustment Disorder, which is less serious than Major Depression because
it does not necessarily require medication treatment and does not carry a
high risk of suicide. I was discharged, supposedly cured.
The day after my discharge I suffered the worst anxiety I have felt in my
entire life. I was scared of being alone, still depressed, and still a danger to
myself. I didn’t know where I would find help. They told me to find a thera-
pist who could sign—something they hadn’t thought important in the hos-
pital. I was supposed to call the hospital social worker the next morning,
but had never talked to this person and had no idea how to contact him by
telephone, much less by TTY. I also needed to find a psychiatrist for antide-
pressants, but had not been told how to do so.
My husband called the hospital for me. He was able to obtain a prescrip-
tion for an antianxiety medication, which helped. He found out that there
was a 4-month wait for a psychiatrist there. Would I be alive in 4 months?
He called back, and pleaded with them to find someone sooner. The next
day they called to suggest a psychiatrist new to the state. Unfortunately, he
was a close friend of MMC’s chief of psychiatry. I had no choice but to work
with him. This man knew nothing about deafness or acquired deafness. I al-
PROLOGUE xxix
ways felt guarded talking with him about my hospitalization (and later
about the lawsuit) for fear he would terminate me due to his conflict of in-
terest. But he did know his medications. In a long intake interview, I told
him which medications had worked for me in the past. He readily restarted
them. After a few weeks of adjusting the dose, my depression finally began
to lift. For therapy, I went back to a therapist whom I had seen off and on in
the past, although she did not sign and was therefore no longer an easy per-
son for me to work with.
Although I felt better and had my life somewhat back in order, I was un-
able let go of the anger—the boiling rage—that I continued to feel toward
MMC. I had gone there expecting understanding and expert care. Instead, I
had found the barriers around my deafness multiplied, and I had experi-
enced condescension and stigma. The professionals had been ignorant of
deafness. When I had complained, they had labeled me a crazy mental pa-
tient. I had been forced to advocate for myself continuously, at a time when I
felt weakest and least able to advocate. I had not received any useful treat-
ment there. To add insult to injury, I had been misdiagnosed, resulting in a
premature discharge that left me at continued risk to myself. Later, when I
was independently evaluated as part of my lawsuit, three professionals de-
termined that in addition to having had a major depression, I had devel-
oped posttraumatic stress disorder as a result of my hospitalization.
I remain astonished by the degree of the hospital’s minimization of the
problems I faced due to my acquired deafness. I myself had minimized the
impact of my deafness for years. In fact, I have learned since that as many as
80% of people who become deaf become clinically depressed, a higher per-
centage than that for any other acquired disability, including blindness,
paraplegia, and even quadriplegia. The loss of communication, that which
makes us human, is simply devastating. (Deaf people who grow up sign-
ing, of course, feel normal because they have communication.)
If I could not get basic accommodations, I wondered, how could other
deaf people get them, those who could not speak, who could not rely on
written communication, who did not know their rights? How many deaf
people had the hospital discriminated against in the 23 years since the Re-
habilitation Act of 1973, or in the 6 years since the even stronger Americans
with Disabilities Act (ADA)? Many of my clients might need hospitaliza-
tion; they would probably receive even worse treatment than I had.
At work, I began to feel I needed to protect my clients from the professional
“hearing world.” When my beeper went off, I would hit the ceiling, having lost
my confidence that I could handle the next crisis. In the end, I never returned
full time to my previous position, and I eventually changed from clinical to ad-
ministrative work. I was permanently scarred by my experience.
As I looked back and worried that my clients would go through what I
had, the idea that I should do something about it took hold in my mind. A
month after discharge, I began investigating the possibility of a lawsuit. I
wanted to force MMC to admit their ignorance regarding deaf people and
xxx PROLOGUE
change their policies. I also wanted an apology for how I had been treated.
The first discrimination lawyer contacted turned me down with a form
letter. I wondered if he might have thought that working with a deaf per-
son would require interpreters and be expensive,1 or if he didn’t want to
deal with a mental health issue. After that, a friend, Jon Connick, the direc-
tor of the Maine Center on Deafness, referred me to a lawyer who sat on
his board of directors.
My husband and I met with Deirdre Smith the following week. She
signed while speaking and was easy for me to understand. She seemed in-
terested in my case, and requested permission to review my hospital re-
cords. The records supported what I had told her: Three days without an
interpreter, the ridiculously unqualified “interpreter,” and the TTY locked
inaccessibly in the conference room. There was clear evidence of my com-
plaints and my requests—“patient is demanding an interpreter … patient
continues to complain about lack of civil rights here on the unit … patient
demanding use of TTY … patient upset over inability to find a quiet place to
meet with staff and visitors”—but no sense that these requests might be
valid. One nurse thought that I had become enraged due to a “breach of
confidentiality.” I still have no idea what she meant. Reading my records
was a powerful experience. I had felt minimized while there, but to see it in
black and white, how they had discounted everything I said and blamed
me for my reactions to their actions, was almost too much. I saw the check-
lists that each nursing shift had completed. Almost every one recorded that
I had been “angry,” “anxious,” “argumentative,” or “agitated.” According
to the chart, I was a woman overwhelmed with the “interior decorating of
her home,” “the stress of her job at the deaf program,” and “her son getting
hurt.” There was no mention of the other stresses in my life, and, most im-
portant, no empathic understanding of the isolation or the trauma of my
progressive deafness. They had completely missed the point. “No wonder
there was no follow-up treatment,” I thought. “No wonder there were no
medications.”
According to Deirdre, it would be difficult to prove malpractice, but it
should be possible to show that the hospital had failed to comply with three
laws: the Rehabilitation Act of 1973, the Americans with Disabilities Act
(ADA), and the Maine Human Rights Act. We gave her a $750 retainer for
costs associated with the case. She would be paid further by contingency fee,
one third of anything we won. I learned that one could not sue for monetary
damages under the ADA, that there was a $10,000 limit for damages under
the Rehabilitation Act, and that anything I did win would be taxed. But I
wasn’t after money. I hoped to end the case with the satisfaction of knowing
that MMC was wrong and have a few thousand dollars in my pocket. I
1
Editors’ note: This type of corrosive uncertainty about whether or not one is being
discriminated against is one of the most challenging aspects of life for any member of a
minority group.
PROLOGUE xxxi
wanted the hospital to comply with the laws. Most of all, I wanted to ensure
that what had happened to me would never happen to another deaf person.
Our first legal action was filing a formal complaint with the Maine Human
Rights Commission to sue under the Maine Human Rights Act. (We were be-
ginning with a state case and could sue only under this state statute.) In Au-
gust, 1997, the National Association of the Deaf (NAD) joined my lawsuit as
co-counsel, adding a lawyer, Marc Charmantz, and creating a team.
I was offered a new job with the Maine Department of Mental Health,
Mental Retardation and Substance Abuse Services (DMHMRSAS) in the
Office of Deaf Services. Before starting I took a month off, during which I
slept, did jigsaw puzzles, and tried to stay optimistic. I stuck with my new
outpatient depression treatment: antidepressants every day, therapist once
a week, and psychiatrist once a month.
One day I asked my lawyer what my lawsuit might be worth in mone-
tary terms. “Probably between two and three hundred thousand dollars,”
she replied. I was stunned. I had not begun the lawsuit to win money. How-
ever, the thought of paying off my mortgage, of not having to worry about
my sons’ college education, or of having a little extra for special things, was
very exciting. So exciting, in fact, that I immediately charged a family vaca-
tion to Mexico, two rooms worth of new furniture, and a handful of “small
ticket” items. This turned out to be a big mistake. A warning to the reader:
Never bank on litigation!
After 6 months, we received our “right to sue” letter, and things sped up.
We discussed expert witnesses. We subpoenaed 10 years worth of doctors’
and therapists’ records. A sad thing happened: My therapist told me she
could no longer work with me due to a conflict of interest. She had seen me
through my first major depressive episode. She knew my battles and my
victories, but could no longer stay by my side. I was devastated.
In seeking a new therapist, I faced a dilemma common among deaf peo-
ple, particularly those in the mental health field. I needed a therapist who
could sign, or a skilled, nonsigning therapist whom I could see with an in-
terpreter. But the few signing therapists and all the local interpreters were
friends or colleagues. I eventually decided that I would not feel comfortable
working with any interpreter, despite their code of ethics. I therefore chose
a signing colleague, someone with whom I shared clients. Jana signed flu-
ently and knew about late-deafness. I didn’t need to teach her. She guided
me through the next year of hell. Without her, I don’t know how I would
have kept going.
Three months later, the United States Department of Justice (DOJ), ex-
pressed interest in joining my lawsuit. They wanted a test case for Title III of
the ADA, regarding compliance in emergency and medical settings. I was
very nervous during my interview with their attorney, Jim Moore, a tall and
serious, but pleasant man whom we met in an office straight out of “L.A.
Law.” He listened to my story and reviewed my records. I was thrilled
when he filed for the DOJ to intervene as co-plaintiff. It felt like validation
xxxii PROLOGUE
that MMC had in fact broken the law. My lawsuit was now entitled Janet
DeVinney and the United States of America v. Maine Medical Center. Big stuff, it
made the nightly news in Portland and newspapers around the state.
The process of “discovery” came next. I learned more about myself than I
cared to know. MMC insisted on referring to me as a hard-of-hearing
woman. They wanted to show that I did not need interpreters for therapy.
Not until they received the records from my otolaryngologist did they fi-
nally concede that, with a 105 decibel (dB) bilateral hearing loss, I was in
fact deaf; 90dB is the usual cutoff for profound deafness. I had the right to
interpreters and TTYs in the hospital.
During November and December 1997, my life was not my own. Fortu-
nately, my supervisor felt that I could achieve as much through the lawsuit
as at the office, and let me take the time I needed for endless meetings and
evaluations. My 3 days of deposition were conveniently scheduled on the 2
days before Thanksgiving and the day before Christmas Eve. MMC’s law-
yer grilled me, reviewing my therapists’ records, my doctors’ records, and
my hospitalization, asking about my marriage, my kids, my knowledge of
the policies of other hospitals with regard to deaf and hard of hearing peo-
ple … on and on. It was awful. I broke down at one point. I felt as if I were
the one on trial. I had to remind myself that it wasn’t my fault how I had
been treated.
My old hospital journal saw me through the deposition, as it had now
been 14 months since my hospitalization. In it, I had documented every de-
tail of my experience, so it was not too hard to memorize chronologically
the important events of those 5 days. I still got thrown by a few questions of
the “are you sure it was Monday afternoon, not Monday before lunch?”
kind, but was much more secure than I would have been without it. Deirdre
and Jim coached me to answer the questions I was unsure of with, “I really
can’t recall,” or “to the best of my knowledge … ” I was supposed to answer
each question with a simple yes or no, which wasn’t easy when I wanted to
add details or was feeling defensive. Unlike what I had seen in TV deposi-
tions, my lawyers could not object when something was going wrong, or
when the opposing lawyer was too hard on me. I had to answer the ques-
tions, regardless. Lawyers are not supposed to press a witness too hard dur-
ing the discovery phase, in which they are establishing facts that may come
up later in a trial, but I felt very pressed.
My lawyers deposed the psychiatrist who had overseen my care, the chief
psychiatrist, and the vice president of nursing. The vice president was asked
to explain the institution’s procedures for accommodating deaf and hard of
hearing patients. Her responses were illuminating—aside from some old
policies somewhere in their handbook, she made it clear that no one at MMC
had any idea what to do when a deaf patient arrived on their doorstep.
The two psychiatrists’ depositions were also interesting in that they still
really didn’t get it. They persisted in the assumption that I could under-
stand what was said to me and what was going on around me. They
PROLOGUE xxxiii
claimed to be unaware of my inability to participate in groups without an

interpreter, about the TTY issue, and about several other battles. It was very
difficult listening to them explain my hospitalization as being due to noth-
ing more than my son’s fainting. They would have learned differently had
the lawsuit continued and some nursing staff had been deposed. I did not
feel that my lawyers pressed the witnesses as hard as MMC’s lawyers had
pressed me.
In addition to my own providers, we needed “expert witnesses” to tes-
tify that I was, in fact, depressed and deaf, and that I needed accommoda-
tions. My lawyer wanted me to fly to New York City, take a cab into
Manhattan, hop on a bus to New Jersey, take a bus and a cab back to New
York, and then fly home. I had left New York 17 years before precisely be-
cause it had too many people moving too quickly for me. How could I navi-
gate now, deaf and depressed? Fortunately they understood, and came up
with a simpler plan. My husband and I drove to Connecticut for a psychiat-
ric evaluation, which was held in our hotel room. The communication ex-
pert flew to Maine and saw me at home. This 5-hour evaluation measured
my comprehension of spoken and signed communication and my knowl-
edge of English and ASL.
The DOJ flew me to San Diego for a second psychiatric evaluation, which
lasted a full day. My husband came along, and we had a wonderful time.
We had married in California, and had lived there for 4 years, long ago—
this was our first time returning as a couple. It was pleasant to leave Maine
on a cold, December morning and arrive in warm, sunny southern Califor-
nia later the same day. I met two well-known experts in deafness and
late-deafness, people whose work I had studied and quoted in graduate
school. After returning, I had a second communication evaluation, in New
Hampshire, and was finally done.
Despite my curiosity, and willingness to pay for the write-ups, I was only
provided the results of one of these evaluations. Looking back, this should
have been an early hint that my lawsuit had outgrown me, and that I was
becoming a “case” to the lawyers rather than a person.
In January of 1998, the DOJ gave the hospital a list of their expectations for
policy, practice, and procedural changes. The hospital’s response was a joke.
They claimed that they “always” accommodated deaf and hard of hearing
patients fully. The DOJ countered with the first draft of a “consent decree,” an
agreement by the hospital to make changes in its policies. The thought of
having a consent decree with my name on it felt great. The four lawyers
worked on the details over the next 4 months. At first, they would send me a
draft of every little change, until I finally asked them to just figure it out them-
selves and then show it to me. I didn’t find the legal language battles enjoy-
able. Seeing how the lawyers were piling up billable hours bothered me even
more. Each time they did request my input, I had just 24 hours to respond. It
was intimidating. The NAD and the DOJ wanted their consent decree, their
model policy for the nation to see and use. My lawyer wanted the case settled
xxxiv PROLOGUE
as soon as possible, as it was becoming very expensive for her firm—without

a trial, there would be only a small monetary gain. Who was watching out for
me? It felt as if the lawyers had taken my lawsuit away from me.
In April of 1998, I was given the choice of settling for my name on the
consent decree and a small amount of money, or going to trial, with the pos-
sibility of either greater gain or greater losses. As usual, I had 24 hours to de-
cide. I wanted the settlement amount spelled out in the consent decree, so
people would know I had not benefitted financially from the lawsuit. I also
wanted an apology from MMC, or at least an admission of wrongdoing.
They refused both. I said I wanted to go to trial.
Suddenly, my lawyers became doubtful about the strength of my case.
They worried that we could lose a court battle. Maybe I had no longer been
sufficiently depressed by the time I was seen in San Diego, or maybe my
lip-reading skills were too good and would hurt my case. If I lost, I would
be responsible for the costs of the trial for all the lawyers involved. I would
lose my home, which I had dreamed of designing and building since I was
building tree forts. My home was my safe place to run from the world. My
garden had kept me going through my depression. Planting hundreds of
flower bulbs had been my way of saying that I planned to be there the next
spring. I had walked outside every day that winter, awaiting the first signs
of life under the Maine snow and ice. I could not risk losing my home, and
saw no choice but to settle.
Through this whole ordeal, my husband had tried in his own way to be
supportive. When I cried that I just couldn’t go on with it, he would say, “so
drop the lawsuit.” I did often think of just walking away from the whole
thing. But then I would ask myself, “In 5 years, how will you feel if you
don’t follow through with it?” and keep on going. It hasn’t been 5 years yet,
so I still can’t answer whether it was worth it. I wish someone else had done
this long ago, that the test case didn’t have to have been me. At times, I think
I should have pushed on with a trial. Then I try to remember the shape I was
in at the time, and that the hospital could have argued that nothing negative
happened to me as a result of my hospitalization. After all, I was still mar-
ried, I was closer to finishing my master’s degree, and I had a better job.
They could claim to have cured me. My own strength of character could
have been used against me.
Jana, my new therapist helped me with my depression, with the trau-
matic experience of being hospitalized, and with the new awful feeling of
having chosen to “settle.” The tension from the lawsuit showed itself when
I briefly became angrier and again felt suicidal. I asked my lawyer if any-
thing happened to me, would my family still get the money. It was a stupid
thing to do, raising a red flag like that. I was told I would be rehospitalized if
I didn’t “contract for safety.”
So, in April 1998, I accepted the settlement that the lawyers had ar-
ranged. I got my name on the consent decree and enough money, after
taxes, to pay off the credit card bills I had run up when I thought I was about
PROLOGUE xxxv
to strike it rich. Hearing that the hospital had an annual operating budget of
300 million dollars, I wanted some of it. I wanted that 2 or 3 hundred thou-
sand dollars that I had been told my case was worth. I wanted an apology. I
wished I had something more to show for my efforts. The consent decree
was celebrated with a press conference, to which, somehow, the lawyers
did not invite me. Nevertheless, I was a media star for a day. I was inter-
viewed by three television stations and the Portland newspaper. The hospi-
tal made a big deal out of not having to apologize to me because they “had
done nothing wrong.” But of course the 38 pages of changes they were now
agreeing made it clear that they had. Among other things, they agreed to:
• ascertain at intake whether a patient is deaf,

• promptly provide a qualified sign-language interpreter and/or other
communication aids for their full range of medical services,
• provide television closed captioning,
• request interpreters within 1 hour of an unscheduled emergency visit,
• provide these communication services for deaf family members,
friends, and companions of MMC patients,
• provide amplified telephones, TTY pay phones, TTY room phones,
and dedicated incoming lines,
• add closed captioning to all TV advertisements related to MMC,
• obtain pictograph forms and flash cards for patients who are not liter-
ate,
• post signs throughout the hospital advertising the availability of in-
terpreters and other accommodations,
• sponsor an annual grand rounds presentation pertaining to deaf is-
sues during Deaf Awareness Week,
• produce or purchase a video on accommodating deaf/hard-of-
hearing patients,
• mandate and provide in-service training for all employees, starting
with ER staff,
• create deaf/hard of hearing patient satisfaction surveys,
• supply compliance reports to DOJ, NAD, my attorney, and me,
• hire an “ADA Communication Services Coordinator,”
• reach out to the local Deaf community, explaining the services pro-
vided by MMC,
• survey deaf patients regarding their degree of satisfaction with the
hospital’s services,
• make payments to me, my lawyer, NAD and DOJ.
When it was all over, I took 10 weeks off. I honestly can’t say what I did
during that time, but I was able to complete my therapy and discontinue
medications, so some kind of healing must have taken place. Many hearing
people called or wrote to congratulate me on winning my suit. It was 3
months before a deaf person congratulated or thanked me. Someone said it
xxxvi PROLOGUE
was not a Deaf thing to do, which I don’t understand. However, I do hear
stories from deaf people about how much better things are at the hospital
now, particularly in regard to interpreters, TTYs, and the checklist now
used to help patients request the accommodations they need. In the first
year under the consent decree, the amount of interpreting performed at
MMC more than doubled. Knowing that helps a lot.
Based on my experience, I can give this advice: If you want to pursue a
suit, do it to change things, not for money. You only hear about huge mone-
tary settlements in the news because, like airplane crashes, they are so rare.
Airplanes land safely and lawsuits are settled without going to trial every
day of the week. Be realistic about what your suit might accomplish. A law-
suit requires time, hard work, tears, invasion of privacy, and the risk of fi-
nancial ruin—it’s not much like television. Anyone going through a lawsuit
needs support throughout the process, from friends, family, and competent
professionals. It is unfortunate that in our society, lawsuits are sometimes
the only way to stand up and change things.
I admit that I’m still angry about the whole thing. I find it painful to think
back on my hospitalization and lawsuit. I put off writing this chapter for
months. Finally, I had a 3-day weekend, cried, slept, poured a glass of wine,
and got it all down. I encourage you to read the consent decree itself, and to
use it as a model for hospitals in your own state, or a warning to them. The
more good that comes out of my bad experiences, the better.
1
Culturally Affirmative Mental Health
Treatment for Deaf People: What it Looks
Like and Why it is Essential
Neil Glickman
Assumption College
PERSONAL INTRODUCTION: CROSS-CULTURAL LEGITIMACY
I am a psychologist who administers an inpatient psychiatric unit for deaf

people. I’ve made a career of touting culturally affirmative mental health
treatment for deaf people. I am constantly thinking about the cross-cultural
dynamics between deaf and hearing people, and I have done everything in
my power to shape my program so that it lives up to the ideals I advocate.
But I face an obstacle in talking about this issue, at least with a deaf audi-
ence: I am hearing. Over the years, deaf people have challenged me with
questions like these:
What makes you an expert on deaf people, or even on psychotherapy with

deaf people? You’ve written some articles and edited a book? Hearing peo-
ple have been writing about deaf people for years, usually presenting us as
incompetent and inadequate. You run a mental health program for deaf
people? Almost all mental health programs for deaf people are run by
hearing people. Most of them are grossly insensitive to our viewpoints. If
your program is so ‘culturally affirmative,’ why isn’t it run by a deaf per-
son? If you are so pro-deaf, why do you sign in Pidgin Sign English? Why
are most of your staff hearing? Who are you, as a hearing person, to even
suggest what ‘culturally affirmative’ mental health treatment is? You can’t
see your hearing biases. You are still a hearing person exercising authority
over deaf people.
These questions challenge my “cross-cultural legitimacy” (Pollard,

1996), the degree to which a culturally different community accepts one as a
1
2 GLICKMAN
helper. For example, if you don’t sign at all, promote oral education of deaf
children, and encourage hearing parents to seek cochlear implants for their
deaf children, you will not have cross-cultural legitimacy with the Deaf
community. They will not accept you as a helper. Indeed, they may even see
you as an enemy.
You can’t give yourself legitimacy to work with a community to which
you do not belong. All the academic credentials in the world mean nothing.
The community decides whether you are trustworthy and whether you un-
derstand them. Establishing cross-cultural legitimacy is the greatest chal-
lenge any hearing clinician faces in working with deaf people. Consider the
challenge for me as a hearing program administrator: I must hire, promote,
discipline, and terminate staff as well as establish policies that are clinically
sound, fiscally prudent, responsive to constraints on available resources,
and acceptable to the Deaf community. Yet if a mental health program seeks
to serve a minority community, it must achieve cross-cultural legitimacy or
the intended clientele will reject it.
In addition to the notion of legitimacy, cross-cultural theory gives us the
concept of “ally.” German Christians who hid Jews during the Nazi era
were their allies. White abolitionists who fought to end slavery, and the
White civil rights workers who fought to end segregation were allies of Af-
rican American people. Members of PFLAG (Parents and Friends of Les-
bians and Gays) are allies of gay men and lesbian women.
My response to questions about my legitimacy is that, while I do have a
position of authority with regard to some deaf people, I strive to live, not as
an expert, but as an ally. I accept that the final judges of my cross-cultural le-
gitimacy will be deaf people. I present a model of culturally affirmative in-
patient treatment of deaf persons in that spirit. I hope that both deaf and
hearing people use it, critique it, and improve on it.
WHY IS CULTURALLY AFFIRMATIVE MENTAL HEALTH

TREATMENT NECESSARY?
If you are hearing and if you are awake, if you seriously attend to what deaf
people say, then you know that the mental health problems that some deaf
people develop can not be separated from the abusive ways they have been
treated by hearing people. Some of these abusive responses to deaf people
include:
• Controlling deaf schools and other programs that serve deaf people.
• Forbidding sign language in deaf schools and programs, and corrupt-
ing sign language into unnatural imitations of English.
• Focusing obsessively on speech and speech reading to the exclusion
of academic subjects.
• Imposing hearing aids on students who do not want them.
• Forcing surgical procedures on deaf children who cannot consent.
1. CULTURALLY AFFIRMATIVE TREATMENT 3
• Mainstreaming deaf children, resulting in isolation from peers and

deaf adults.
• Delaying 20 years from the recognition of sign languages as true lan-
guages to accepting them broadly for instructing deaf children
(1960–1980).
• Drawing erroneous and damning conclusions from inappropriate
psychological testing.
• Diagnosing deaf people as mentally retarded, autistic, or schizo-
phrenic, and allowing them to languish in institutions.
• Holding a medical conception of what it means to be deaf—deafness
as a pathology, a handicap, and a tragedy—and therefore believing
that deaf people need to be “fixed.”
• Believing that deaf people are disabled not just in being unable to
hear, but intellectually, emotionally, and morally.
• Promoting the idea of the psychology of deafness, that deaf people are
unintelligent, egocentric, concrete, irresponsible, impulsive, imma-
ture, paranoid, and so on.
• Actively discriminating against deaf people in hiring and promotions.
• Showing paternalism, pity, and contempt toward deaf people.
• Excluding of the Deaf community from decision making on key mat-
ters, such as educational policies and medical procedures that pertain
to deaf people.
But the absolute core of oppression of deaf people, as I have come to un-
derstand from their stories, is:
• Disempowering them around communication, resulting in commu-

nication isolation.
Hearing mental health professionals who do not have full knowledge

of the deaf experience, self-awareness, and an appropriate set of skills
may actually repeat these forms of oppression in their treatment. This is
well illustrated in the story of Janet DeVinney, whose experience opened
this book. Ms. DeVinney was working toward a graduate degree in
psychosocial rehabilitation, and needed a brief inpatient treatment for de-
pression. As a mental health professional herself, she knew the mental
health system and her rights as a deaf person under the Americans with
Disability Act (ADA) and other laws. She had strong signing skills. As a
late-deafened person, she also had fluent English and comprehensible
speech. She was in a strong position to advocate for herself. Some mid-
dle-class or well-educated deaf people like Ms. DeVinney would not want
to be treated in a specialized deaf program such as ours, however much
they want and need sign language for treatment. Some might have con-
cerns about confidentiality. Ms. DeVinney, for example, might have wor-
ried about being hospitalized with her own clients. Others might worry
4 GLICKMAN
about finding peers at their level of functioning. Ms. DeVinney, however,

was not offered a choice. She was hospitalized in a hearing facility that
was completely unprepared to help her.
Ms. DeVinney’s depression, as she saw it, was largely due to the pain of
struggling with hearing people, including her own family, around commu-
nication. Her communication isolation was repeated in the treatment set-
ting. How could she articulate her experience to people who were repeating
the same mistreatment that brought her to that point? To add insult to in-
jury, her providers saw her depression and anger as something purely in-
ternal, and denied their part in it. Rather than responsibly attempting to
make their treatment environment more accessible, they did things like re-
ferring her to an anger management group without an interpreter. They en-
couraged her to assert herself, but treated her as unreasonable when she
asserted her need for an interpreter. In the end, she got qualified interpret-
ing for exactly three therapy sessions. The treatment environment retrauma-
tized her; she was later diagnosed with Posttraumatic Stress Disorder
caused by her hospital experiences.
Ms. DeVinney’s experience of psychiatric inpatient treatment is typical
for deaf people admitted to hearing units. I know this because I take refer-
rals from them. Many deaf people have a more difficult time than Ms.
DeVinney because they lack the education and intellectual sophistication to
advocate for themselves or because they are more seriously mentally ill.
Ms. DeVinney was not linguistically impaired or psychotic. She was not
given psychological testing that drew incorrect conclusions drawn about
her mental capacity and diagnosis. She had strong “premorbid” function-
ing, and no history of the developmental and behavioral difficulties com-
mon in most of our patients. For a deaf person presenting for help in a
hearing psychiatric facility, she presented a “best case scenario.”
Consider, for instance, the case of a 30-year-old man I call Ed, who was
transferred to our unit from a hearing psychiatric unit. Ed had grown up in
a third world country. Because no one in his life had used a formal sign lan-
guage, he had no language system of any sort. He communicated entirely
through gesture and “home signs.” (Fortunately, this situation is now
rarely seen in the United States.) Ed had enormous deficits in developmen-
tal skills. His ability to manage his emotions in almost any social situation
was poor. He was a large man. To get what he wanted, he would gesture
dramatically, vocalize loudly, and raise his fists.
Sometime in Ed’s past (no records are available, and he certainly
couldn’t tell us), a doctor prescribed Haldol, presumably believing him to
be psychotic. His family dutifully continued it for years. When he arrived
in this country, the prescription was renewed. Ed experienced painful
muscle cramps as a side effect of Haldol, and often refused it. His family
began crushing it and hiding it in his food. He became “paranoid,” refus-
ing to eat unless he saw the food being prepared. He became angry with
his parents and sometimes threatened them. Finally, they called the police
who, with a force of some six men, subdued him and brought him to a
hearing hospital, a facility renowned for medical excellence. There he was
strapped in restraints for days because he was big and scary and nobody
could communicate him. While in restraints, he was given an injection
of—Haldol.
We were apprehensive about Ed being transferred to our unit, but our
fears were unjustified. We were not put off by his lack of formal language
skills, as we were used to finding creative ways to communicate with our
clients. Our deaf staff members in particular were remarkable in their abil-
ity to communicate with Ed through gesture and drawing. Simply being on
our unit, where people seriously attempted to communicate with him, Ed’s
behavior improved dramatically. It quickly became clear that he was not
psychotic but did have Obsessive-Compulsive Disorder (OCD). He spent 3
or 4 hours a day in the bathroom washing his hands and face. We stopped
the Haldol, started teaching him sign, started him at the sheltered work-
shop, and eventually got through his “paranoia” and convinced him to try
an appropriate medication for his OCD.
The experiences of most deaf people in hearing psychiatric facilities lie
somewhere between those of Ms. DeVinney and Ed. Most facilities will at-
tempt to provide some interpreting services, perhaps for meetings with the
psychiatrist or social worker, but the larger treatment milieu, including
group therapy and interactions with nursing staff, will remain inaccessible.
They will own one TTY (teletypewriter) and may even be able to locate it
when needed. One or two of their staff may know some sign (although this
becomes more a curse than a blessing if these staff are elevated into “deaf-
ness experts”). Their clinicians will likely have no knowledge of the biologi-
cal, developmental, social, and cultural implications of deafness, no sense
of what is normal for deaf people, and no appreciation of their biases as
hearing people. Misdiagnosis will be common. The deaf patient will have
no deaf peers, and staff may have no sense of the difficulty in integrating
deaf persons in hearing groups, even when an interpreter is present. The re-
sulting experience for the deaf person is isolation and frustration at best,
misdiagnosis, mistreatment, and retraumatization at worst.
Oppression can occur in our facility too. An example is illustrative:
When regular staff are out sick at Westborough State Hospital, staff from
other units may be assigned to “float,” or cover for them. Many of the
nurses and mental health workers who float to our unit would rather not be
there. They are uncomfortable working with deaf patients, and often even
more uncomfortable working with deaf staff. The nurse is always in charge
of the milieu, even when she is supervising regular staff who know the pa-
tients better than she does, and who can communicate with them. One day
a nurse I’ll call Julie floated down to our unit. Our staff know how she feels
about being assigned to us: She grumbles that she hates it. Julie only looks
at our deaf staff when ordering them to do something. She refuses inter-
preters, saying that “deaf people understand me fine.”
6 GLICKMAN
One evening, a patient was feeling agitated. Julie told her, in spoken
English, “go to your room or the quiet room.” Later this client assaulted
someone and had to be physically restrained. Two deaf mental health
workers (MHWs) were working that shift, including one of the most com-
petent staff members on our unit, a leader who sits on our executive com-
mittee. Julie felt he was buckling the restraint belt too slowly, and
motioned for him to leave the room. She wanted a hearing float to take
over. There was an interpreter present, and the MHW signed that he knew
what he was doing. He had performed this procedure many times. She
motioned again for him to leave the room, telling the interpreter, “I know
what he wants but he is too slow and is wasting my time.” Julie then had
the other deaf mental health worker, a woman, leave the room too. Her ra-
tionale was that there were enough male staff there. So the two deaf staff
members, the only people present who actually knew the person being re-
strained and could communicate directly with her, were ordered out
while hearing floats took over.
The only person the deaf mental health workers could turn to that eve-
ning was the nursing supervisor. But the nursing supervisor that evening
was also infamous among our deaf staff. She too complained about the has-
sles of dealing with deaf people. When she came down to “trip” the unit,
she would ignore deaf staff and ask hearing staff how things were. She re-
fused to write or to sign. The deaf staff rightly perceived that she valued in-
put from the hearing people but not from them. Needless to say, the
offended deaf mental health workers did not choose to complain to her.
Julie firmly believed that in an emergency hearing people should run
the show. When we addressed this with her, she argued that her primary
concern was safety. She felt that the situation had been unsafe because
deaf staff could not communicate quickly with hearing nonsigners. (No-
tice how she blamed the deaf people for the communication problem.) We
had heard this argument when we first hired deaf people. We heard it
again when our deaf staff sought opportunities for overtime on the hear-
ing units. Now we were hearing that they were not safe to manage a crisis
on their own unit. We told her that 15 years of experience showed there
was no truth to her claim. Deaf and hearing people can work together
smoothly, even in emergencies. In fact it is more unsafe having no deaf
people there. At the very least Julie was rude, insensitive, and unprofes-
sional. The nursing supervisor supported Julie’s actions that evening. She
could not fathom how Julie’s behavior reflected prejudice. She told me I
was prejudiced against hearing people.
The deaf mental health workers involved in this incident were trauma-
tized by it. Really, they were retraumatized. They had experienced hearing
people discounting, undermining, rejecting, or ignoring them all their
lives. Now it had happened even in a “safe” place. The psychological fall-
out of this incident was enormous. Our staff spent days processing it and
recovering from it. Julie and her supervisor couldn’t even see the problem.
How could a deaf person stay sane and healthy in an environment that was
so ignorant and invalidating?
Sadly, all this occurred in an environment supposedly designed to be
culturally affirmative. But at least on our unit, abuses could be named and
challenged. The unit leadership were able to validate the deaf staff mem-
bers’ perception of oppression, and we fought for them. Deaf staff could
talk safely about their experience. Without this, the deaf staff would have
sat with their rage. They might even have been written up for having ob-
jected to leaving the room, or fired for insubordination. This is normal, daily
reality for deaf people. Unless the environment is specially attuned, new
abuses will always occur. Deaf people will be enraged and silenced. They
will not be as productive in their work and their patients will suffer.
Why are culturally affirmative mental health programs essential for deaf
people? The answer goes well beyond the most obvious issue: the need for a
signing environment. It goes beyond the need for deaf role models and for
staff, deaf and hearing, who are sensitive to the deaf experience. It goes be-
yond the fact that working with deaf people requires special knowledge
and skills as well as thinking about what it means, culturally and histori-
cally, to be hearing and deaf. We need to create culturally affirmative men-
tal health programs so that the treatment setting does not repeat the same
offenses that contributed to the deaf person’s problems.
Can a hearing person understand what it means to go through life and be
excluded from almost every conversation? What if, like many deaf chil-
dren, he doesn’t have the language to make sense of these experiences?
And what if, in each new situation, people assume he is not competent?
People deny his potential to learn and become skilled. They don’t value his
opinions. Each time he meets a new hearing person, he feels blamed, mis-
understood, pitied, left out, and criticized by people who believe they are
objective, fair, wise, and helpful. All of this gets re-enacted in each new set-
ting, including in each new treatment setting, as Ms. DeVinney’s experi-
ence in our preface showed. So the deaf person, now in a psychiatric crisis,
has to explain to yet another hearing person, who is behaving in exactly the
same ignorant, uninformed and biased way, why he is angry or depressed
or confused. Deaf people can’t begin to piece this all together, to give the
right name to their experience, in an environment that repeats and then ob-
scures the same trauma. They can’t develop trust, the foundation of mental
health treatment, in an environment where people don’t speak their lan-
guage, don’t understand their world, don’t validate their experiences, and
don’t know that they don’t know.
ACCESSIBILITY VERSUS CULTURAL AFFIRMATION
I want to clarify the difference between accessible treatment, which is required

by laws like the Americans with Disabilities Act, and culturally affirmative
treatment, which is a higher standard not required by law. The ADA states
8 GLICKMAN
that “no qualified individual with a disability shall, by reason of such disabil-
ity, be excluded from participation in or be denied the benefits of the services,
programs or activities of a public entity, or be subjected to discrimination by
any such entity.” The ADA prescribes “qualified interpreters and other effec-
tive methods of making aurally delivered materials available to individuals
with hearing impairments” as the standard for providing “auxiliary aids and
services.” (Americans with Disabilities Act, 1990). The key word here is effec-
tive. The provision of qualified interpreters is suggested as one way of insur-
ing effective communication with deaf persons. Thus, the ADA does not
require that services be designed by and for deaf persons, only that effective
means of communication be used to create inclusion.
The vast majority of mental health services targeted at deaf people strive
for accessibility, not cultural affirmation. That is, they strive for the mini-
mum standard required by law. If we examine the consent decree that re-
sulted from Jan DeVinney’s lawsuit against Maine Medical Center (MMC),
for example, we see that Maine Medical Center agreed to an impressive
number of steps designed to make its services accessible. (See pp. xxxv in
the Prologue of this volume for some examples.)
MMC did not offer or agree to create services specifically tailored for deaf
people. Although the implementation of “reasonable accommodation” is a
significant victory for deaf people, this strategy has a number of limita-
tions, especially in mental health programs, and especially when the clien-
tele are less educated, illiterate, or psychologically unsophisticated. Ideally,
deaf people should have a choice of specialized and accessible mental
health services. Some deaf people prefer to be served in an accessible hear-
ing setting. They might associate mostly with hearing people. They may
have concerns about lack of confidentiality in Deaf programs. They might
not want to be in the same treatment program as the “lower-functioning”
deaf people that are more likely to be served in some identifiable Deaf pro-
grams. On the other hand, many high-functioning Deaf people also request
treatment in our facility because the presence of a signing environment
trumps any other concerns.
Most often, mental health programs attempt to ensure effective commu-
nication and thus create accessibility for deaf people through one or two
methods. The first method is to hire sign language interpreters. The second
method is to hire a “deafness expert.” Each method meets the letter of the
law but fails to create genuine inclusion. Let’s examine them both.
DOES HIRING INTERPRETERS CREATE PROGRAM

ACCESSIBILITY?
The provision of an interpreter (even a qualified, certified interpreter) with-

out other modifications to the communication dynamics, creates an “illusion
of inclusion.” This is true even when all parties are fluent users of some lan-
guage and fully understand the role of interpreters. In mental health settings,
it is often the case that the deaf consumer may not be a fluent user of sign, and
it is very possible that deaf and hearing alike do not understand how to use
an interpreter. But those are only two small issues. Interpreters work best in
situations when people of two language groups have nearly equal power
and linguistic competence and can both understand and attend to the com-
munication process. This occurs, for instance, in international politics or
business. In the typical situation where a sign language interpreter is used, a
lone deaf person sits in a sea of hearing people who are oblivious to the com-
munication, language and power dynamics that are occurring.
Consider what usually happens in such a meeting. Everyone talks at
once. People interrupt each other, make asides, use slang and idiomatic lan-
guage difficult to translate, and make references to a body of cultural infor-
mation shared by the dominant group. People refer to a television show, a
song, or a movie that hasn’t been captioned. People make jokes that are nei-
ther funny nor sensible in translation. They use professional jargon and ac-
ronyms. They laugh and tease. They use sarcasm and irony. The interpreter
tries to keep up, sometimes with information he himself may not under-
stand. The participants may become irritated if the interpreter attempts to
slow the conversation or asks people to take turns talking.
Or, consider what happens when a hearing clinician interviews a deaf
client who happens to be psychologically unsophisticated or cognitively
and linguistically limited. The hearing clinician uses words or ideas that the
deaf person doesn’t understand. A psychiatrist may ask, “Is there any his-
tory of mental illness in your family?” The deaf person doesn’t understand
the abstract concept of mental illness and has little knowledge of family his-
tory, never having had good communication within the family. An internist
might need to review a list of 25 diseases, and is accustomed to getting a
quick yes or no response. The interpreter can fingerspell the disease names,
knowing full well that the patient doesn’t know most of these “big words,”
or explain to the doctor that they will have to go one by one, slowly, explain-
ing each disease to the patient. In the first case, true communication doesn’t
occur. In the second, the doctor, whose time is tightly scheduled, becomes
frustrated and impatient. A psychologist might ask a patient the meaning
of an English proverb, not appreciating how idioms and proverbs are lan-
guage bound. The psychologist continues, “Do you hear voices?” and the
patient responds, “No, I’m deaf.” “Do you hear voices inside your head
when no one is around? Do you hear things that other people do not hear?”
The interpreter translates this, but the deaf patient is confused. How could
he hear things that hearing people do not hear?
Many deaf persons seen in mental health settings do not have intact sign
or spoken-language systems. Hearing clinicians working with deaf people
for the first time generally have no reference for what it means to be an adult
who never acquired a full language. They can’t relate or make sense of this
except perhaps to draw erroneous conclusions about mental retardation, a
mood disorder, or psychosis. The language-impaired client signs with a
10 GLICKMAN
limited vocabulary and disorganized grammar, posing enormous inter-

preting challenges. The task of assessing for a thought disorder in a lan-
guage-impaired deaf person is beyond the competency of any clinician not
specially trained. The interpreter cannot draw conclusions for the clinician
about the presence of a thought disorder (although the clinician may ask
the interpreter to do so). The presence of an interpreter simply cannot com-
pensate for the clinician’s lack of experience and normative frame.
Typically, clinicians in this situation feel deskilled and look desperately to
the interpreter to take away the language problem and explain what is hap-
pening both linguistically and psychiatrically (Schlesinger, 1972).
Interpreters are the only people present in these situations who actu-
ally know what information isn’t getting communicated. They are the
only people present who appreciate the vast gaps in world knowledge
and conceptual frameworks that separate the hearing majority from
many deaf patients. They can’t possibly overcome these vast gaps in expe-
rience and perspectives simply by interpreting, yet everyone expects that
they can and will. A bold interpreter may attempt to interrupt to explain a
communication difficulty. People may attempt for a moment to slow
down, but the problems reappears soon as they fall back into their habit-
ual style of communicating. The deaf people don’t know what they are
missing and blame the interpreter when they don’t get all the information.
In addition, given the time lag between spoken and interpreted com-
ments, it takes an enormously assertive and empowered deaf person to in-
terrupt and get a word in edgewise. If the hearing person has high status
and the deaf person has low status, it is a rare deaf person who can in any
way attempt to manage communication. Deaf people are quite expert at
pretending to understand, and hearing people, uncomfortable with the
communication problems, are usually all too willing to accept the deaf
person’s “empty nod” at face value.
What’s the experience of a linguistically competent signing deaf partici-
pant in an important meeting with hearing colleagues? This person proba-
bly had to fight to get an interpreter present. She is already aware that her
hearing colleagues are annoyed at having their usual pattern of communi-
cation disrupted. This is especially true if there are issues around paying
the interpreter, or if the meeting was scheduled around the interpreter’s
availability. She may have gotten messages like, “you lip-read fine,” or “I’ll
tell you what’s going on later,” or “this isn’t important. I’ll let you know
when something important happens.” She may be thankful and relieved to
have an interpreter present, but also self-conscious about it. She may be
grateful for even partial inclusion. Given these dynamics, she is hardly in a
position to complain that she is unable to participate fully.
The deaf participant is supposed to be appreciative, and given the alter-
native of no accessibility, may in fact feel appreciative. But the same experi-
ence of communication isolation, of getting bits and pieces of the
conversation, of not truly understanding what is meant, may well occur
even with the interpreter present. How can the deaf person object that she is
still being excluded without risking alienating her hearing colleagues? Af-
ter all, they’ve provided an interpreter. Boy, she is pushy! What else could
she want?
In these situations, it is a gross illusion to imagine that provision of an in-
terpreter has solved the communication problem and created communica-
tion inclusion for the deaf person. What is often repeated in situations
where an interpreter is present is, in fact, the same old trauma of disempow-
erment around communication and communication isolation. Only now it
is subtler and much harder to acknowledge. “You got an interpreter. So
what’s your problem?”
These are all problems that occur when the interpreter is actually pres-
ent. When a deaf person is hospitalized, there is no interpreter present most
of the time. There may be one for a scheduled meeting with a psychiatrist
but not for community meeting, medication education with the nurse, or
communicating with other patients over meals. When hospitals call me to
transfer a deaf patient who was admitted to their setting, I hear over and
over that they could not obtain interpreters even for their “important” meet-
ings. The deaf patient may have waited days for one scheduled meeting
with an interpreter. In Massachusetts at the time of this writing, the Depart-
ment of Public Health’s strategy for accessing substance-abuse services for
deaf people relies on a few interpreters to cover the entire state. The DPH
withdrew support for creating special expertise to serve deaf people in
specified substance-abuse programs and instead declared that by hiring in-
terpreters they were meeting their legal responsibilities to create accessible
treatment. The predictable result has been limited interpreter availability
and programs that are “clueless” when confronted with a deaf consumer.
This was before a state budget crisis resulted in cutbacks even to these inad-
equate services.
DOES TRAINING OR HIRING A “DEAFNESS EXPERT”

CREATE ACCESSIBILITY?
A “deafness expert” is born when a mental health program discovers the

need to serve deaf people, which it meets by hiring a single signing clinician
or by sending a staff person for sign language training. Expecting anyone,
after just a few months of classes, to serve deaf clients is unfair to the “ex-
pert” and profoundly insulting to the clients. One would like to imagine
that administrators would not be so insensitive to the language needs of
non-English speaking hearing clients, but in fact this type of mistreatment
of minority language groups happens routinely. Hearing people typically
underestimate what is involved in learning to sign. Programs with a union-
ized labor force can face additional obstacles if the union opposes hiring
staff with specialized skills because they would like their members to have
the right to learn new skills on the job. Similarly, administrators may be re-
12 GLICKMAN
luctant to pay higher salaries to recruit staff with specialized language

skills. The idea that people will learn language skills on the job has probably
destroyed more efforts to serve linguistic minorities, including deaf people,
than any other.
Unless the program already has a large deaf caseload, it will prefer hiring
a “flexible” clinician who can work with deaf and hearing people. This in-
evitably means a hearing person. The administrator who does the hiring is
typically ignorant about sign language and Deaf culture and therefore un-
qualified to judge an applicant’s cultural sensitivity and signing skill. So
anyone who claims to be skilled can be hired. This person then will be ex-
pected to handle any and all deaf clients for the agency.
I know these issues from inside, having worked myself as a “deafness ex-
pert” in a vocational rehabilitation agency and several outpatient mental
health centers. My signing skills have gotten me jobs, and gave me an edge in
applying to a competitive doctoral program. They have helped me to get on
insurance panels in my private practice. Hearing people who claim to be able
to sign often experience these kinds of financial and material privileges. In-
deed, while reading a book that purports to help mental health clinicians
break into closed insurance panels, I came across the following advice:
The skill most frequently needed is the ability to conduct therapy in a foreign
language or in sign language. Although facility in a foreign language is not a
skill that is easily acquired, if the therapist already has this skill it should be
exploited. One language that some feel is relatively easily learned is sign lan-
guage. And sign language is frequently needed by managed care companies.
Should the reader wish to develop a skill in sign language, it could well open
some doors. But before undertaking such an effort, the best policy would be to
check first with the managed care companies the reader wishes to join to en-
sure that this effort would pay off in acceptance on the preferred provider
panel. (Poynter, 1994)
Besides presenting the erroneous impression that sign language is “rela-

tively easily learned,” the attitude reflected here helps us understand why
deaf people may distrust hearing mental health providers—it centers on the
financial needs of the therapist, not on the needs of clients. At our hospital,
we got approval to pay more for entry-level direct care positions on our unit
because we needed bilingual skills. Once we advertised our higher-paying
positions, there was a flurry of interest among hearing direct-care workers
seeking promotion. Over the years, I’ve had many hearing people anxious
for a promotion request a position on our unit, promising they will learn sign
language. I’ve had union stewards argue with me that their hearing constitu-
ents should have the opportunity for these promotions. My response is al-
ways the same: First learn sign language, then come and talk to me. Nearly
all of the time, these people have no real interest in learning ASL or working
with deaf people. This quickly becomes apparent when they are asked to
work to demonstrate their commitment.
When a mental health agency discovers the need to serve deaf people, it
usually looks for a quick, painless way to do so. Hiring someone who signs
or having a staff member learn some sign language may be the first thing
the program’s administrators think of. Unfortunately, they do not realize
what is involved in learning ASL, or understand that they are working in a
cross-cultural context, requiring cross-cultural legitimacy with the Deaf
community. On the other hand, they do understand perfectly well that if
they hired a deaf person, more would be required of them than they might
wish to contend with. For instance, they’d have to think about accommoda-
tions for that person, and who knows where that might lead? Indeed, I’ve
seen hearing administrators in a vocational rehabilitation agency, whose
professional belief system was centered on the importance of hiring “hand-
icapped” people, balk at the prospect of hiring a deaf counselor, even when
the counselor’s case load was to be composed entirely of deaf people! I’ve
seen a hearing person, after just one sign language class, instantly become
an agency’s “deafness expert.” This is what the mandate for ensuring effec-
tive communication may look like in practice.
Pity the poor “deafness expert.” He is expected to serve deaf people of
every age, and to be skilled in the treatment of every psychiatric condition.
The deafness expert is expected to communicate easily with every deaf per-
son referred. In addition, because of the lack of a continuum of culturally
appropriate mental health and substance-abuse care for deaf people, an
outpatient deafness expert might be expected to serve clients who need a
more intense level of care, or who need a different kind of treatment, such as
addiction work or a sexual offender group. No hearing clinician working
with English speaking clients faces similar expectations of being all things
to all people. These expectations can’t be met. Like the sign language inter-
preter who can’t overcome the confused communication dynamics of a
fast-paced meeting, the deafness expert is set up to fail. Yet he may be reluc-
tant to admit that he cannot communicate well with all his deaf clients be-
cause he was hired with the expectation that he would. He may have
difficulty acknowledging that after three sign language classes and 1½
years of agency-funded training, he is still a beginner. His supervisors may
not want to hear that ASL is every bit as challenging to learn as any other
language—it’s not something one just “picks up.” The deafness expert may
have difficulty justifying an expense like an interpreter for family therapy
sessions. The clinic thought they had created accessibility by hiring the
deafness expert. Now they learn they have additional expenses and modifi-
cations beyond that. And they certainly don’t want to hear that the deafness
expert needs the assistance of a Certified Deaf Interpreter (CDI) in addition
to a sign language interpreter to communicate with some of his clients.
A seasoned clinician who has authority within a mental health setting
and who has a great deal of clinical experience with deaf people might be
able to explain these issues and dynamics to her administration and get
support. A new clinician hired into an agency that has no previous experi-
14 GLICKMAN
ence working with deaf people probably cannot. Instead, the clinician is
likely to try to please everyone, with predictably poor results.
If the agency found it easier to hire a hearing person who signs than to ac-
commodate a deaf person, there may have been deaf candidates who didn’t
get the job. Then instead of creating access, the program has just begun by
directly offending the local Deaf community, making it very difficult for
their newly hired clinician to establish cross-cultural legitimacy.
When a mental health program is serious about creating accessibility and
is informed about what this truly involves, it may be able to serve some deaf
consumers, especially those who are educated, who are assertive about their
rights, and who affiliate comfortably with hearing people. But mental health
settings that want to serve the entire Deaf community must have a higher
standard than mere accessibility, whatever may be required by law. Mental
health programs are designed to heal. Healing requires honestly grappling
with the power and communication dynamics between deaf and hearing
people, and having special knowledge and skills. To be truly effective, these
programs need to be designed “from the ground up” by and for deaf people.
THE MENTAL HEALTH UNIT FOR DEAF PERSONS

AT WESTBOROUGH STATE HOSPITAL
The Mental Health Unit for Deaf Persons (“Deaf Unit” for short) is a 10-bed
acute-care psychiatric unit in Westborough, Massachusetts. It was estab-
lished in 1987 on the recommendation of a task force involving mental
health clinicians and Deaf community activists. In Massachusetts, it did not
take a lawsuit to create this program. The unit was established at a time
when a receptive, liberal governor responded to political mobilization in
both the provider and consumer communities. The unit was created along
with the Massachusetts Commission for the Deaf and Hard of Hearing, the
expansion of programs for independent living skills centers, and the cre-
ation of telephone relay services. The Deaf Unit is the only program of its
kind in New England. It serves adolescents and adults, mainly from Massa-
chusetts, but occasionally from neighboring states. The Deaf Unit is de-
signed as a treatment center for acute psychiatric illness, not a “warehouse”
for those with chronic mental illness. I was one of two co-directors of the
unit from 1987 to 1989 (Sherry Zitter, LICSW was the other), and I returned
as unit director in 1996.
The Deaf Unit is housed in a state psychiatric hospital, and is adminis-
tered by the hospital, a facility that had no previous experience serving deaf
people. The hospital administration in turn reports to the administration of
the local catchment area of the Department of Mental Health. Thus, al-
though the Unit serves only deaf people, it is dependent on the good will
and financial support of many hearing administrators who have no partic-
ular expertise in working with deaf people. Although officially chartered as
a culturally affirmative mental health program, the Deaf Unit still has to ex-
ist in the real world, subject to ever-changing fiscal and political realities.
From a culturally Deaf perspective, there is much to criticize about our

program. Four of the five unit directors to date have been hearing. Deaf
people have never made up more than one third of the staff. We have hired
staff at times who had no signing abilities. We have had some staff who are
insensitive to the deaf experience. Partly, this is because Westborough State
Hospital is a unionized, civil service work environment in which we do not
always have full control over hiring and promotion. Like the hospital and
area administrators, the union leaders have varied in their sensitivity to the
needs of deaf patients and staff. Nor can we always find staff who are quali-
fied in their respective disciplines as well as in ASL or, even better, qualified
and deaf. Readers should not imagine that the barriers to creating cultur-
ally affirmative programming in our setting are any fewer than elsewhere.
But as a program that seeks explicitly to be culturally affirmative, and that
is formally chartered to be culturally affirmative, we do 7 things consistent
with our culturally affirmative mission:
1. Culturally Affirmative Programs Serve Only Deaf People,

Usually From a Large Geographic Area
The Deaf Unit, although housed in a hearing psychiatric hospital and ad-
ministered by a mental health agency with no particular expertise in deaf-
ness, serves only deaf people. Because signing deaf people are a
low-incidence population, we necessarily serve a wide geographic area.
Thus, our unit is a statewide program with capacity to serve clients from
outside Massachusetts when beds are available. We also are unique in Mas-
sachusetts in serving both adolescents (14 years of age and older) and
adults on the same unit. This has both advantages and disadvantages, but
because the state chose to support only one specialized unit, we were
granted permission to mix these age groups.
When our unit opened, we made an enormous effort not to hire existing
hospital staff into our program. This was challenging because, in order to
recruit signing staff, we offered better pay for direct-service positions than
the rest of the hospital. Fortunately, the main union steward at that time
was a person of unusual awareness and cultural sensitivity, and she sup-
ported our efforts to find staff who were competent signers. We got the staff
we wanted, and we established the precedent of requiring sign language
skills for most positions. We also alienated much of the existing hospital
staff. To make matters worse, we then refused to send our patients to the
hospital day-treatment programs, developing our own day-treatment
groups instead. We told everyone that we wanted to be autonomous.
Again, we got what we wanted, but at the cost of some bitterness and re-
sentment. In later years, we have put energy into “mending fences.”
Only after creating a distinct physical space and an autonomous treat-
ment program did we begin seeking opportunities for our patients to join in
hospital-wide events and activities, like swimming and hospital parties.
Now, our patients work successfully in the hospital’s vocational workshop
16 GLICKMAN
and snack bar. They also attend AA meetings with their hearing peers. We
are looking at ways to make the whole hospital deaf friendly, including the
ultimate goal of hiring deaf people to work in hearing parts of the hospital.
If I had to do it again, I would do it exactly the same way. I would cre-
ate a deaf space first, then seek out opportunities for mainstreaming.
Some initial alienation from the larger community was probably un-
avoidable. Developmentally, it was essential to establish autonomy before wel-
coming the option of limited integration. I’m aware of other deaf inpatient
programs that never overcame the demand of unions, civil service, and
management to hire and promote existing hospital employees for new
deaf services. This is a fatal error because once the mainstreaming model
is established, it perpetuates itself, and the deaf voice that is needed to
change it can never materialize.
Our decision to provide our own day-treatment programming, and in-
deed to provide a distinct deaf-treatment milieu, strikes some people as
regressive. People often respond in the same way to deaf schools. They
feel that mainstreaming, whether in education or in mental health treat-
ment, creates inclusion and that segregation results in the ghetto-ization
of deaf people. I know there are parts of the United States where mental
health administrators will not even consider separate programming for
this reason.
It can be very difficult to persuade these hearing administrators that
their feelings about integration are culturally hearing viewpoints that are not
respectful of the experience and world view of most people born deaf. Separate deaf
programs may be controversial for hearing people, but they are rarely so for
signing deaf people. Mainstreaming, as deaf people commonly note, more
often leads to isolation than inclusion. This is reflected powerfully in one
ASL sign for “mainstreaming” in which, instead of the fingers from both
hands folding together and blending, the five fingers of one hand “over-
power” one finger from the other hand.
In the pages that follow, I spell out the tremendous clinical advantages
to creating separate deaf mental health programs. Consider a few points:
How many deaf staff will typically choose to work in a hearing programs
that strives only for accessibility? How well can the mentoring and train-
ing of deaf professionals occur in such a setting? Who decides whether
these programs address the needs and experience of deaf patients ade-
quately? Do these programs speak honestly to the daily realities of deaf
people’s lives?
The Deaf Unit was created at a brief period in time when there was a
widespread statewide vision in Massachusetts of the need for specialized
deaf services. There are specialized deaf schools, mental health and sub-
stance abuse programs, and other services throughout the country. They
exist wherever the Deaf community has been strong enough to force hear-
ing decision-makers to stop assuming they know what is best for “the deaf”
but rather to open their minds and listen to deaf people.
2. Culturally Affirmative Programs Strive to Hire Large Numbers

of Competent Deaf Staff at all Levels of the Organization
Nothing creates a deaf program like deaf staff. In trying to create a signing en-
vironment, respectful and empowering of deaf people, there is simply no sub-
stitute for hiring large numbers of deaf people. Needless to say, they should be
employed at all levels, from administrative leadership to direct care.
However, this is more easily said than done. There are many obstacles to
hiring a large number of deaf staff, not the least of which is the difficulty
finding people with the necessary credentials and skills. Deaf people face
barriers in higher education that limit the number of qualified job appli-
cants. This situation is improving, but for it to improve further there need to
be more opportunities for deaf people to get professional training and
mentoring. It is also necessary for young deaf people to have the chance to
work at direct care so they can gain experience and make informed deci-
sions about further training. Deaf programs can provide these opportuni-
ties, which in turn creates a larger group of qualified deaf candidates for
advanced professional roles.
Robert Pollard is a leader in training deaf psychologists, having created a
rich mentoring experience for deaf psychology interns at the University of
Rochester Medical Center in New York (Pollard, 1992, 1996). He argued
that hearing people who work with deaf people in mental health have an ethical obli-
gation to seek out ways to mentor deaf people into professional roles. His program
trains deaf psychologists to work with both deaf and hearing people. When
deaf staff are working regularly with hearing clients, we will have reached
the goal of true accessibility and integration.
Because most hearing people think of deafness as a disability rather than
a cultural difference, they don’t easily see the advantage of hiring deaf peo-
ple. Ignorance about sign language (“it’s easy to learn”) and about what is
necessary for serving deaf patients (“just provide an interpreter”) gets in
the way. Hearing people are forever raising concerns about safety in hiring
deaf people. An administration that may go along with hiring a few deaf
staff may resist hiring a large mass of deaf staff. The idea of creating a
deaf-majority program can frighten and intimidate hearing people. They
will object fast and furiously. They will argue that hearing candidates have
more experience. Of course they have more experience when the whole
world is open to them for training and work opportunities! These hearing
objectors typically don’t appreciate the difference between a second lan-
guage Pidgin Sign English user and a native ASL user, nor do they appreci-
ate the other assets that deaf people can bring to a program to balance their
relative lack of experience. The skills that deaf staff at the Deaf Unit have
brought to managing crises have so impressed everyone that now hearing
staff complain about safety when there are no deaf people present.
In working with hospital and union leadership to elicit support for spe-
cialized programming, it is helpful to have articulate deaf people making
18 GLICKMAN
their own case. For hearing people who have never interacted as a peer with
a signing deaf person, this alone can be a powerful experience. Most hear-
ing people don’t want to appear prejudiced. Often, they need help under-
standing how the ideas they’ve learned about what deaf people allegedly
can’t do are prejudice.
In our facility, key hiring decisions are made collaboratively by disci-
pline heads (the directors of nursing, psychology, social work, etc) and the
unit director. The discipline heads vary in their sensitivity to the needs of
deaf people. A unit director like myself needs to nurture his alliances with
them, educating them about deaf people while respecting their compe-
tency in their own fields. As with the unions, when an alliance is made, the
right people are usually hired. When the discipline heads and the unit di-
rector don’t agree, a split in leadership occurs that is destructive to the
unit’s functioning. Somewhere in an organization there needs to be an em-
powered leader championing the cause of culturally affirmative treatment
and developing the necessary organizational alliances and processes.
As the percentage of deaf staff in a program increases, the dynamics be-
tween deaf and hearing persons change. Deaf staff start speaking out about
poor communication and cultural insensitivity. Hearing staff find they
must sign all the time. They can’t get away with “forgetting to sign” or with
“lazy signing.” A mood shift occurs with deaf patients and staff taking in-
creasing ownership of the program, seeing it as something they are in-
vested in, as opposed to just a job. When visitors come to our unit, patients
compete to determine who will give the tour. This is their program. The
therapeutic value of this feeling is priceless.
As the deaf presence in an organization increases, there may be hearing
staff members who cannot tolerate having empowered deaf colleagues. But
for the most part, morale rises and the program becomes a more exciting
place to work. Staff sense that something important and special is develop-
ing. The hearing people find themselves changing. In a deaf-centered envi-
ronment, they find they need to develop new skills and sensitivities, and
they have to learn to share power.
As the Deaf Unit, with its critical mass of deaf staff, became an established
part of Westborough State Hospital, the attitudes in the larger hospital com-
munity changed too. Deaf people are now found all around the hospital.
Many hearing staff have begun to appreciate the language and cultural com-
petency that deaf staff bring. The union stewards now have deaf constituents
they must represent. Because there are many models of effective communi-
cators present, hearing people begin to appreciate what they don’t know and
can’t do. Administrators now show pride in our special program. But with-
out the ongoing, serious commitment to hiring large numbers of deaf staff,
hearing ignorance about deaf people would certainly have dominated. It is
unfortunate that hearing people generally have to be pushed, often kicking
and screaming, into creating a deaf-centered program, but such is the reac-
tion of the majority to the empowerment of a minority.
3. Culturally Affirmative Programs Need Genuine

Communication Excellence
The communication challenges involved in working with mentally ill

deaf people are daunting. To begin with, there is enormous variation in
the skill with which deaf people communicate in sign and spoken lan-
guages. Although this is not readily apparent to a nonnative sign user,
many of the patients in programs like ours are sign language impaired.
They have limited sign vocabulary. They use ASL grammatical features
inconsistently or poorly. They omit references to subject and object and do
not sequence times logically. They mix standard signs, initialized English
signs, home signs, gestures, and local slang. They do not know how to
adapt their communication style to audience and setting. Their baseline
sign communication is impoverished, and their spoken and written lan-
guage skills are even more so. All this is before perhaps acquiring a
thought disorder that further distorts language patterns. Communicating
well with these persons requires sign communication skills that go be-
yond the sign language skill of second-language sign learners, whether
hearing or deaf. The nuances, of course, are visible only to those with an
exceptional level of ASL sophistication.
I remember an instance when all of our Deaf Unit staff, including several
native signers, were having difficulty understanding a new patient. We
were discussing this when an employee with 3 weeks of sign language
training announced confidently that he had no trouble communicating
with this patient. This reminded me of the proverb, “a little learning is a
dangerous thing.”
In addition to two full time interpreters, our Deaf Unit employs a com-
munication specialist. When the unit first opened in 1987, the two hearing
unit directors were able to argue that we needed a deaf communication spe-
cialist to give the unit cross-cultural legitimacy, facilitating our hiring of
other deaf staff. The communication specialist is a linguistically trained,
college educated, native user of ASL. Hearing staff with decent Pidgin Sign
English skills commonly misjudge their communication abilities. So do
deaf staff who may think they use ASL when they don’t, or who may think
they can match a patient’s communication style when they can’t. Just as
hearing speakers of English may speak in a confused, rambling way, so deaf
signers can sign in a confused, rambling way. When people are not commu-
nicating clearly, but think they are, there needs to be a credible expert who
can point this out, and to model genuine communication excellence. Lan-
guage skills bear heavily on diagnosis and treatment. Mental health pro-
grams for deaf people can’t afford to be sloppy in this crucial area.
On our unit, the communication specialist has many other roles too:
• training both hearing and deaf staff in American Sign Language

through a series of regular classes,
20 GLICKMAN
• performing communication evaluations of patients, which advise

the treatment team of the most effective communication mode for
each one,
• working when needed as a certified deaf interpreter (CDI),1
• advocating for culturally affirmative policies and procedures,
• supporting patient education in special circumstances, such as foren-
sic evaluations, when a patient needs to learn basic legal concepts,
• creating visual therapy tools.
Our current communication specialist, Michael Krajnak, is artistically

talented, and has developed visually oriented therapy tools. He created
most of the illustrations in this text and in the accompanying compact disc.
There is a therapeutic role for the communication specialist too. The fol-
lowing is an example:
Apatient had an extensive history of childhood abuse and neglect. As a re-
sult, she had developed some serious interpersonal problems. She was
chronically angry, demanding, critical, and blaming of other people. She saw
every instance in which she didn’t immediately get what she wanted as fur-
ther victimization. She had become grossly entitled, expecting her every
wish to be promptly addressed, crying discrimination and prejudice when-
ever that didn’t happen. She accepted no responsibility for changing herself.
Although she had begun as a victim, this patient had now become a vic-
timizer. Within a very short time on the Deaf Unit, the entire staff, deaf and
hearing, were fed up with her. Few wanted to help her. This, of course, rein-
forced her sense of herself as a victim.
One day, this patient cornered a nurse and threatened to assault her be-
cause the nurse had set some limits on her screaming. She gestured angrily,
swore, and raised her fist, then moved to attack the nurse. Staff intervened
and physically restrained the patient. The patient could not see how her be-
havior justified her being restrained. Our staff had tried to show her that
she was creating the circumstances of her own rejection by others. We tried
to show her that she was turning even natural allies like mental health staff
against her. When we confronted her about her raised fist, threatening
signs, and angry looks, she replied that she wasn’t threatening. She was just
expressing her feelings in a culturally Deaf way.
Fortunately, our communication specialist, whose culturally Deaf “cre-
dentials” were beyond dispute, could challenge her. He told her this was
baloney, and he demonstrated for her how a culturally deaf person would
show anger. No hearing person, no matter how skilled a signer, could have done
that. No hearing person would have been credible in her eyes. She needed
to hear from a culturally competent deaf person that she had become her
1
A CDI re-interprets ASL into visual-gestural language. Sometimes a CDI might work
as “relay interpreter” along with an ordinary sign language interpreter (who would
voice for hearing people and sign for the CDI). At other times the CDI might simply ob-
serve the communication flow and assist when asked, or interrupt when needed.
own worst enemy. Because the message came from him, this patient was
able to understand better how her behavior was perceived by others.
This kind of treatment problem occurs frequently in work with Deaf
people. We need credible experts to reach deaf patients who are confusing
bad behavior with Deaf culture. We also need credible deaf experts to help
patients trust us and not see us as the enemy, just oppressing them as many
of the other hearing people in their lives have.
A “good hearing signer” will often not have the language skills to work
well with many deaf patients. Even some “good deaf signers” do not have
these skills. Because it is difficult to find both exceptional communication so-
phistication and exceptional clinical skill in any one person, we often do
“cotherapy,” with the signing clinician working alongside a native ASL user.
Often our communication specialist works in this role of cotherapist, not
leading the therapy but ensuring a standard of communication excellence.
These cotherapy teams, often composed of deaf and hearing colleagues,
have other therapeutic uses. They establish a model of deaf and hearing
people working as equals and they interrupt the deaf-hearing transference
patterns that, when they can’t be interpreted or understood, interfere with
the treatment. For instance, some deaf patients have enormous rage toward
hearing people that they project onto their hearing therapist. Other deaf pa-
tients think hearing people are smarter and better, so that deaf staff must be
incompetent. With psychologically sophisticated deaf patients, one can dis-
cuss these dynamics and try to help them develop insight. One can use the
therapeutic relationship to help the deaf patient “work through” these is-
sues. But this is not a realistic strategy with many of our psychologically un-
sophisticated patients (see chap. 4, this volume). A deaf/hearing cotherapy
often diffuses these cross-cultural transference projections and helps en-
sure both effective communication and staying in a problem-solving, skill-
building treatment mode. They also provide actors for the important thera-
peutic technique of role playing.
4. Culturally Deaf Programs Create an Affirmative Physical

Environment
On the Deaf Unit, we provide TTYs with dedicated phone lines for staff and
patients. The doorbell, telephone, and fire alarm are hooked to flashing
lights. Patients’ bedrooms have extra light switches outside that are flicked
instead of knocking. The walls are decorated with the work of deaf artists
like Chuck Baird and with images of famous deaf people—a statue of Alice
Cogswell wrapped in a Deaf Power banner, a portrait of Laurent Clerc. Staff
and patients have decorated further by donating their own drawings,
paintings, and tapestries. A bulletin board has Deaf community news and a
running sign language game. There are Deaf community newspapers and
magazines on the tables. ASL handshapes and signs are stenciled on the
walls. A staff picture board connects our faces to our names and roles. There
22 GLICKMAN
are visual displays concerning health topics such as diabetes, healthy eat-
ing, and the dangers of cigarette smoking. Railings and a contrasting blue
wall stripe help guide visually impaired deaf patients.
In the typical “accessible” hearing facility, modification of the physical
environment is limited to purchasing one TTY. Because these programs
don’t regularly serve deaf people, most staff will be unfamiliar with how to
operate it. I remember “interpreting” (see discussion of communication
policy below) a phone conversation for a deaf colleague with a hearing pro-
fessional in another agency that claimed to be accessible to deaf people. The
deaf colleague suggested that the person use his TTY so they could talk di-
rectly instead of having me interpret. The caller asked us to wait while he
rummaged through a closet. After several minutes he located his TTY, and
my colleague got on ours, allowing me to watch the conversation. Once on
the TTY, it was clear that the caller knew nothing about TTY conversational
etiquette. My deaf colleague and I burst into hysterics when, fumbling for a
way to signal that he was done typing, the caller typed “over,” as if he were
using a 2-way radio, instead of “GA” for “go ahead.”
Having a TTY does not make a program accessible by phone even when
staff do know where to find it and how to use it. Having a TTY without a
dedicated phone line for it leaves the unsolved problem of how a deaf pa-
tient receives an incoming call without depending on hearing persons as in-
termediaries. Recall from the prologue of this volume that Ms. DeVinney’s
TTY was at first locked in a conference room where only “her nurse” could
get it for her.
5. Deaf People Manage the Communication Dynamics
Communication is an emotionally loaded issue for deaf people. If commu-

nication isolation represents the typical experience of deaf people in a
“hearing world,” then culturally affirmative treatment environments offer
an opportunity for healing and empowerment through the means with
which communication is managed. When we opened the Deaf Unit in 1987,
we naïvely imagined we would create a fully signing environment. Every-
one would sign in ASL all the time. A much more realistic goal, we soon
came to realize, was a bilingual environment where ASL and English were
respected and used as languages of equal merit. Until Deaf programs are
able to hire only staff who sign fluently, the practical administrative con-
cern is how to manage a bilingual (in some cases, multilingual) environ-
ment between groups of historically unequal power. This translates into
how to empower deaf people to manage the communication dynamics.
Perhaps the key area that distinguishes a culturally affirmative program
is our conscious, intentional focus on communication dynamics. We do not as-
sume that effective communication is occurring because an interpreter is
present or because some of us sign. Instead, we not only ask the deaf staff to
evaluate the communication, we actually ask them to direct it.
Our Deaf Unit has carefully thought out communication policies and
procedures, which we continuously revise. We expect our staff to follow
these policies as a condition of employment. Our most important policy
is that deaf people manage how we communicate at mixed deaf/hearing meet-
ings. The deaf people present decide whether hearing people should
sign for themselves or use an interpreter. Our group conversations are
routinely interrupted when communication breaks down. These inter-
ruptions, although bothersome, are actually a sign we are doing well, be-
cause they reflect the fact that our deaf staff feel empowered to challenge
poor communication dynamics. By contrast, in the typical “accessible”
program, the lone deaf person will offer an “empty nod” and not truly
participate.
Our late-deafened consultant psychiatrist, Sanjay Gulati, a confessed
practitioner of the empty nod, comments:
It’s hard to describe the feeling of relief and comfort involved in joining a
meeting at Westborough. I know that if I didn’t understand something, I can
say so, and the meeting will pause respectfully while I catch up. The partici-
pants will then become more attentive to communication, instead of dismiss-
ive or confused as would happen elsewhere.
Our deaf staff introduced the practice of using a “communication ball”

in interpreted meetings to mark who is speaking and ensure only one per-
son speaks at a time. The person wishing to speak raises his or her hand,
and waits for the ball before speaking. This practice ensures that each par-
ticipant has the group’s full attention for every comment. In particular, the
interpreter(s) can keep up without difficulty. It is remarkable how enthusi-
astically our patients embraced this practice. Even when everyone in a
group signs, we often still use a communication ball (a Koosh™ ball works
well) because it fosters carefulness about communication that is in dra-
matic contrast to what deaf people typically experience.
We don’t assume that deaf people are necessarily good signers. Deaf pa-
tients can and do request the assistance of an interpreter or the communica-
tion specialist even if their therapist signs, even if their therapist signs and
is deaf. Indeed, our deaf staff often seek the assistance of the communica-
tion specialist. They find it a relief to be able to acknowledge that they also
need help in communicating well with some of our patients.
On our unit the deaf staff, empowered to set the communication rules,
set up guidelines that not every deaf person would agree with. In other set-
tings, such as some schools, deaf staff prefer that people sign for themselves
at all times. That’s fine also. The point is that the deaf staff do the deciding.
Sometimes patients are also empowered to make these decisions. For in-
stance, a patient is invited to a treatment team meeting, and the hearing
staff ask the patient whether they should sign for themselves or use the in-
terpreter. We do this not merely out of politeness but because we recognize
that there are powerful elements of healing embedded in the issue of the
24 GLICKMAN
management of communication. Needless to say, these kinds of subtleties

are well beyond the conceptual framework of staff in a hearing program
that is proud merely to have secured an hour of interpreting.
Our communication policies address other important issues. One issue
is who is authorized to interpret. The usual practice in programs without
expertise in working with deaf people is that whoever signs is asked to in-
terpret. On our unit, only the interpreters and the communication specialist
can interpret. Others can “help with communication,” a practice that gives
us flexibility while respecting the expertise involved in communication
and the distinct role of the interpreter.
Our communication guidelines do not mandate rigid political correct-
ness. We haven’t outlawed, for instance, speaking while signing (“simulta-
neous communication”), or using Signed English, or writing. At times, staff
do whatever it takes to communicate. Creativity and flexibility are the
norm. In hearing programs, by contrast, communication is taken for
granted, and few hearing staff have the skills of adapting communication
when there is no common language.
6. A Culturally Affirmative Program Works Mindfully

with Deaf/Hearing Cross-Cultural Transference,
Countertransference as well as Cultural Biases
Most clinicians understand the Freudian concepts of transference and

countertransference. People transfer onto new people the internalized image
they have developed about primary caregivers. A person with a harsh, re-
jecting father might be inclined to perceive male authority figures as harsh
and rejecting. If a child is physically or sexually abused by a primary care-
taker, that child will likely have difficulty trusting others because of the
transferential expectation that others will behave in the same way as the
abusing caretaker.
Cross-cultural transference dynamics between hearing and deaf people
occur both between staff and patients and among staff members. They oc-
cur between a hearing supervisor and a deaf supervisee and between a
hearing program administrator and the client community. They occur re-
gardless of whether the people involved are aware of them.
Transference occurs with groups as well as with individuals. Black peo-
ple may project onto individual White people their internalized image of
White people as a group. Black people may develop stereotypes about
White people (and vice-versa) based on early life experiences with White
people or group ideology. An individual White person with good inten-
tions may still be experienced by an individual Black person, because of ra-
cial transference, as hostile. Similarly, individual deaf people who have come
to expect hearing people to behave in certain oppressive, prejudicial ways
may transfer this expectation onto new hearing people, such as a well-
meaning therapist.
As a hearing director of a deaf mental health program, I’ve at times be-

come the object of deaf people’s transferential feelings about hearing people.
At times, deaf patients and staff transfer onto me expectations that I act like a
“great White father,” magically solving all their problems. I’m supposed to
create a perfect treatment and work environment. Of course, I too want to
create this perfect environment, and like many hearing professionals who
work with deaf people, I have had rescue and savior fantasies about my role
with the Deaf community. Thus transference works both ways. A typical
“savior” projects feelings of weakness onto others, and then insists on help-
ing them rather than acknowledging his own weaknesses. The naive hearing
person’s eagerness to help can easily be a reflection of a deeper need to con-
trol or to create relationships in which the helper is defined as healthy, altruis-
tic, and morally correct. Hearing people may need deaf people to need them,
and deaf people may need hearing people to save them, unhealthy dynamics
that can corrupt supervisory as well as psychotherapeutic relationships if the
people involved are not aware of them. My illusions about my supposed “be-
neficence,” however, are also confronted by deaf people’s transferential rage.
When I fail to live up to their expectations to be the perfectly beneficent res-
cuer, I can become the most evil oppressor. This might occur with a patient
when the treatment team sets some behavioral limits. I’m the “boss” of the
Deaf Unit, so I’m the ultimate person to blame for this “unfair” treatment. It
might occur with staff when I hold them accountable for work performance
or don’t hire or promote a candidate that other staff preferred. In the unfortu-
nate instances when we have had to terminate the employment of a deaf staff
member, it can be easy for that staff person and his or her friends to interpret
this as oppression.
In addition to unconscious transference dynamics, cross-cultural super-
vision is vulnerable to more overt biases and prejudices. Cross-cultural su-
pervision is especially tricky when the supervisor is from the dominant
group and the supervisee from the minority group. A recent text on clinical
supervision (Bernard & Goodyear, 1998) brought much needed attention to
racial, gender, sexual orientation, and power issues as they can play out in
supervision. Shulman (Shulman, 1982) presented a model of supervision as
the skill of balancing support for staff with the demand that they do their
jobs. The support function involves teaching, mentoring, and developing
the supervisee’s skills. The demand function involves holding staff ac-
countable to work performance standards. Supervisors err when they pro-
vide too much demand and not enough support (the harsh, critical
supervisor whom staff resent) or too much support and not enough de-
mand (the nice supervisor who can’t get people to do their work).
In a hearing supervisor–deaf supervisee context, the hearing supervisor
who is culturally unaware may show prejudicial biases against deaf people.
These biases might place undue emphasis on a supervisee’s speech and Eng-
lish skills, such when someone remarks, intending a compliment, “you
speak so well.” I once observed an audiologist telling our culturally Deaf
26 GLICKMAN
communication specialist about the “exciting” advances in cochlear implant

technology, assuming, as hearing people typically do, that he was as excited
as she. He played along with her, pretending to be enthusiastic, and the two
of us had a good laugh about it later. Hearing people might also show biases
in their assumptions about what a deaf employee can and cannot do. Because
it is uncomfortable for hearing people to deal with the communication barri-
ers and because they have been socialized into understanding deafness as a
disability, the bias may be reflected in ignoring, avoiding or discounting the
deaf employee. Julie, the nurse I described earlier, showed this kind of bias,
as did the nursing supervisor who defended her. So have other supervisors
who, because they can’t understand sign, can’t appreciate the skillful inter-
ventions deaf staff perform with patients.
Majority clinicians who have not been cross-culturally trained inevita-
bly repeat the offenses historically inflicted on the minority group. I see this
even in some of the hearing staff on our unit, who should know better. They
will talk without signing in the presence of deaf patients and staff. They will
argue that they are being discriminated against when deaf people don’t
speak or when qualified deaf people are given leadership roles. They will
try to take over situations where deaf people are involved. They will expect
deaf people to speak and assume they can lip-read or could hear “if they re-
ally wanted to.” They will attend to and favor the hearing people in a given
situation. They will assume deaf people are incapable. They will disregard
the communication rules set up by their deaf colleagues and assume deaf
people must accommodate to them and not they to deaf people.
Hearing supervisors who have been newly introduced to Deaf culture
and don’t want to appear oppressive, or who are in an “immersion” stage of
identity development (Glickman, 1993a) in which they automatically see
deaf people as experts on serving deaf people, may make the opposite kind
of mistake. They may be reluctant to confront the deaf employee about
work performance problems. When the deaf employee cries “prejudice”
and “discrimination,” these supervisors become self-doubting. This can
also be the experience of well-meaning teachers and college professors who
are working with a deaf student who is not doing the required academic
work and who is vocal about perceived discrimination. Some minority per-
sons abuse the ideas of prejudice and discrimination when they are held ac-
countable to work or academic performance standards. The cross-
culturally unskilled supervisor or teacher can easily become disempow-
ered when this occurs.
From a psychodynamic standpoint, these cross-cultural transferential
and counter-transferential expectations create opportunities for growth
and “working through” of past abuses. When hearing clinicians are aware
of the cross-cultural dynamics and don’t act according to expectations, deaf
people have opportunities to see hearing people, and themselves, in new
ways. Receiving affirmation and support from an “oppressor” can be more
powerful than receiving it from within your own community. A heterosex-
ual male colleague of mine told me the story of a lesbian client who pre-
ferred to work in psychotherapy with an “enlightened” heterosexual male.
“It’s easy to find a lesbian therapist who will affirm my identity,” she told
him, “but if I want to work through my issues with my father, I need to talk
to a straight man.”
On the other hand, if hearing people confirm expectations that they are
insensitive, controlling, and patronizing, deaf people will respond with an-
ger, depression, and with more militant behavior. If deaf people working
and receiving treatment in a mental health treatment setting experience dis-
empowerment and communication isolation yet again, this may cause
some degree of retraumatization. Similarly, if the heterosexual male thera-
pist shows the same homophobic attitudes as the lesbian client’s father, the
opportunity for growth is lost. The client may become rooted even more
deeply in rage and despair.
In a mental health environment that works with minority people, one
needs to have staff who “get it,” who understand nondefensively about op-
pression and prejudice. The more such people are present, the more deaf
patients and staff will assert themselves, placing their experiences with
hearing people on the table. Sometimes this is rocky. Arguments and
cross-cultural misunderstandings occur. Power struggles happen. One can
no more avoid these issues in a cross-cultural treatment setting than one
can avoid transference issues in psychotherapy. The healing occurs when
the cross-cultural transference issues are handled well.
An example: A deaf mental health worker worked overtime on the eve-
ning shift. There he observed a hearing nurse, a beginning signer with only
three months’ experience on the unit, verbally direct an agitated deaf patient
to his room for a time out. He approached the patient to try to de-escalate the
situation, but the nurse gestured him back. She believed the patient should
be left alone in time out until he calmed down. The deaf mental health
worker complied, angrily. The next day he complained that the hearing
nurse had made the patient worse by expecting him to read her lips, that the
patient hadn’t appeared threatening to him, and that the nurse had insulted
him by having him back off as if he had no expertise. From his deaf point of
view, she had acted oppressively toward both the patient and him.
The nurse had a different perspective. She explained that the mental
health worker hadn’t been there during the previous half hour when she
was alone, trying to de-escalate the patient. She said that she has a good
rapport with this patient, something others knew to be true, and that even
without knowledge of sign language, she knew what a raised fist and an an-
gry expression meant. She felt that the mental health worker had inter-
vened inappropriately. “You don’t try to reason with a threatening, explo-
sive individual,” she said. “Instead, you move them to a time out until they
are calm enough to reason with.”
These two talented and valued staff members were now adversaries.
Each asked me to discipline the other. I needed to help them understand the
28 GLICKMAN
incident as normal and expected conflict in a cross-cultural situation. First, I

brought them together, with an interpreter, and helped them to hear each
other. Each had good points. The nurse was correct in saying that the deaf
mental health worker had missed the patient’s threatening behavior, and
should have been out on the floor earlier, not in the nurses’ station. She was
also right that we do not reason with people who are out of control. The
mental health worker was right in saying he could understand the patient
better than she and that her attempts to communicate might have made
matters worse. She explained that when she had gestured for the mental
health worker to move back she had merely intended that he leave the pa-
tient in his bedroom until he was calmer. She had still wanted him involved,
but hadn’t had the sign language skills to explain her reasoning. He had
seen her as not respecting his skills and felt deeply offended. After the inci-
dent, he had left her a blunt note, which she took as insubordinate and hos-
tile. But he was merely being direct in the way that deaf people often are; he
thought he was engaging her in a process of problem solving.
I told them that conflict like this always happens in a cross-cultural situa-
tion, and I helped them to see what had happened as not personal, but cul-
tural. This neutral explanation lessened their animosity and put them back
in a collaborative relationship with each other … until the next conflict,
which we knew must happen. Part of the program manager’s job is to help
staff see themselves in cross-cultural context. This will not happen, of
course, if administrators are working from the medical-pathological model
of deafness. It will certainly not happen, with either staff or patients, if the
program staff are not even aware that deaf/hearing conflicts are as compli-
cated as those between any other majority and minority groups.
7. A Culturally Affirmative Program Approaches Psychotherapy

Differently
This is a controversial topic: Must the psychotherapy method itself be ad-

justed for work with deaf people? To argue that deaf persons do better with
a particular kind of treatment may evoke the days when deaf people were
thought to be concrete thinkers who would be poor candidates for insight
oriented therapy, and needed behavioral treatment. Discussing tailoring
psychotherapy to Deaf culture may strike some as paternalistic or even rac-
ist. Yet in the literature on cross-cultural therapy, there is a tradition of
thinking about counseling and psychotherapy in relationship to class, eth-
nicity, and culture. Whenever one talks about a group of people, say deaf
people, one risks stereotyping and one neglects the issue of individual dif-
ferences among that group of people. No generalization about deaf people
and psychotherapy will be universally true, no matter how sensitive and
informed it may be.
Allen Sussman, the pioneering Deaf psychologist at Gallaudet Univer-
sity, has been in the forefront criticizing hearing clinicians who jump to con-
clusions about the alleged limitations of deaf people. He rightly pointed out
that these hearing clinicians often lack the communication skills and cul-
tural sensitivity to make judgments about deaf people (Sussman, 1998;
Sussman & Brauer, 1999). He and others argued that one cannot generalize
about deaf people who show the same range of intelligence, verbal skills,
and psychological sophistication as hearing people.
This is certainly true. Yet it is also well established in the literature on psy-
chotherapy with culturally different minorities to discuss the issue of match
between psychotherapeutic method and culture. Ivey, D’Andrea, Ivey, and
Simek-Morgan’s textbook on theories of counseling and psychotherapy us-
ing a multicultural perspective is filled with examples of how culturally
skilled psychotherapists adjust counseling methods to fit particular cultural
groups (Ivey, D’Andrea, Ivey, & Simek-Morgan, 2002). A few examples: For
some cultural groups, an action-oriented problem-solving approach reso-
nates better than an introspective one. Rules about eye contact, greetings,
and other rituals, social distance, appropriate self-disclosure, use of time,
and boundaries regarding personal involvement with clients vary consider-
ably. Different cultural groups have different “indigenous” modes of helping
and healing that can be drawn on in psychotherapy. Different groups have
different culturally relevant stories and metaphors to draw on. Definitions of
family and individual boundaries within families vary considerably. Reli-
gious traditions can be both resources for helping and barriers to helping.
There are many ways that culturally skilled counselors adjust counseling ap-
proaches with members of different communities and, done skillfully, this
does not lead to stereotyping but to a richer counseling experience.
I’ve addressed this question in detail elsewhere (Glickman, 1993b) but
anyone who doubts that cultural variables impact on counseling with deaf
people should consider some sample relevant questions:
• Do culturally Deaf people use different norms regarding eye contact,

touching, pointing, appropriate social distances, and conversational
etiquette?
• Do hearing and Deaf people interpret facial expressions and other
forms of nonverbal communication differently?
• Do different languages influence not just the content that is discussed
but the manner in which concepts are conceptualized and the style of
conversational discourse?
• Does Deaf culture influence norms for emotional self-expression and
self-disclosure?
• Do deaf and hearing people use physical space, including lighting
and seating arrangements, differently?
• Do culturally Deaf people hold any different values from culturally
hearing people?
• Do deaf people have common experiences with the notion of “help-
ing” that may influence their perceptions of professional helpers?
30 GLICKMAN
• Are there particular stories or metaphors that resonate with culturally

Deaf people and therefore may be resources in counseling?
• What resources for helping and healing may be available in the Deaf
community and culture?
The issue of adapting treatment is even more clear when working with
the subset of deaf people we most frequently see in inpatient settings. In
chapter 4, I describe these “psychologically unsophisticated” persons and
present a model of treatment designed to engage and resonate with them.
In non-specialized hearing programs, these questions about adapting
treatment will not even be asked. These programs seek to mainstream deaf
people, usually by including an interpreter. A feature of culturally affirma-
tive mental health programs, as I mentioned earlier, is the provision of deaf-
only treatment groups. Even if people believe fervently in mainstreaming
as a positive social value, the fact remains that sending many deaf people
into hearing treatment settings often fails. Wishing mainstreaming to work
will not make it work. Yet the reasons why mainstreaming often fails are not
apparent to hearing clinicians who do not use ASL, do not appreciate
Deaf/hearing cultural difference, and do not appreciate the biases and
transference responses they bring to this work.
CONCLUSIONS: CROSS-CULTURAL LEGITIMACY
Many hearing people have the experience that when they first begin to
learn sign, deaf people are welcoming and encouraging. However, if they
develop pretensions of “helping the deaf,” the same deaf people are far less
warm. Deaf people, like all oppressed minorities, have good reasons to be
cautious and even hostile when unqualified hearing people gain positions
of responsibility in the Deaf world.
Still, a large number of hearing people truly want to do this right. These
people invest enormous time and energy into learning ASL and establish-
ing relationships with deaf people. They strive to be sensitive to and sup-
portive of Deaf culture, sometimes so much so that they may even
romanticize the Deaf community and overlook the limitations of individ-
ual deaf people. They embrace the notion that deaf and hearing people can
work together as equals and agree with the agenda of empowering deaf
people to make this possible. They constantly ask themselves the question,
“what right do I have to work with deaf people?” And when a deaf person
challenges their legitimacy, they take the challenge seriously.
These process needs cannot be avoided. If you are going to work
cross-culturally or with disadvantaged people, and you are not one of
them, the minority culture people will not usually accept you unless you’ve
done your homework to demonstrate that you are an ally. To work with mi-
nority people well, majority people have to change. We need special knowl-
edge and skills. We need to understand the advantages and biases that go
along with being in the hearing majority. If we work at it long enough and
well enough, we begin to establish cross-cultural legitimacy.
Not all hearing people survive the process of cross-cultural encounter
with deaf people. Some hearing people “burn out” on working with deaf
people. We feel unappreciated. We begin to agree that maybe we shouldn’t
be here. We began working with deaf people with naïve fantasies of being a
rescuer and liberator only to discover that many deaf people don’t want our
help or value our contributions. This too is part of the process.
I think it should be recognized that although deaf people face enormous
discrimination and prejudice in the workplace, even in deaf schools and
other deaf programs, the opposite phenomenon also occurs. Deaf pro-
grams can be so hungry to hire deaf people that they hire unqualified deaf
people. And although unqualified hearing people do poor work, the wrong
deaf person can be even more destructive because he is presumed to be
competent, knowledgeable, and sensitive by virtue of being deaf. These
people can claim to have special skills they in fact don’t have, and when
challenged to perform better can hide behind their deafness. Ultimately, the
Deaf community is not well served by having inadequately skilled deaf
people with destructive attitudes hired for positions of authority or service.
There are days when I ask myself why I continue to do this work. I’m es-
pecially prone to question myself after being the recipient yet again of a
deaf person’s transferential rage at the hearing world. Like many hearing
people, I got into this work as a way to work through my own identity is-
sues. Twenty years later, I hope I stay in the field for the right reasons: the
sincere belief that, although hearing, I have something valuable to offer.
Hearing people can establish cross-cultural legitimacy and can become
real allies for deaf people. But hearing people who do this work need to de-
velop cross-cultural competencies like language skills as well as the skills of
valuing and working within world views that are different than our own.
The core issue between deaf and hearing people is now, and has always
been, one of power. Can we move from being experts on deaf people to al-
lies of deaf people? We can—many of us have—but not without a lot of
painful soul searching, and not without giving up some power.
The first barrier to establishing culturally affirmative mental health
programs is to understand how much more there is to this work than just
providing an interpreter. Second is the energetic advocacy needed to
make things happen. Social relations between Deaf and hearing people
are every bit as complex as those between any minority and majority
group. The treatment issues, need for cultural self-awareness, fund of
knowledge, and specialized skills are every bit as challenging. Perhaps
what makes this work even more difficult is that, unlike with racial and
ethnic minorities, the majority persons often don’t even understand they
are working cross-culturally. They work automatically from a medical–
pathological and disability model, which is itself a part of the oppression
that deaf people face. They don’t realize that they are looking at deafness
32 GLICKMAN
with an ideological bias that prevents them from fully comprehending the
mental health treatment issues.
If hearing people want to work with deaf people, we don’t need to
change them. We need to change ourselves, beginning with how we think
about what it means to be hearing or deaf. Then we need to learn how to
have a new kind of relationship with deaf people based on equality, mutu-
ality, and collaboration. Finally, we need to ground our means of helping,
our techniques and therapeutic approaches, in positive aspects of the deaf
experience. This new kind of relationship and work with deaf people is
what we mean by culturally affirmative treatment.
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Appendix I:
Communication Assessment PART I
Family Communication Background Date ___ ___ / 1 3

6 /___ ID: ___ ___ ___ ___ 7 ___ 15 ___ ___ ___ ___ Patient
Name: ____________________________ Form Code: 5 Age:
______________16 Onset of Deafness: _____ years of age
_______
Explanation of visual or other impairments which may affect

communication:
284 17 18
Family Communication Background: see code below =1

Blank = 2
Family
Member Age Hearing Status ASL PSE MCE Oral Write Notes Home
Signs Gestures Other
Father 19 20 21 22 23 24 25 26 27 28 29
Mother 30 31 32 33 34 35 36 37 38 39 40
Sibling 1 41 42 43 44 45 46 47 48 49 50 51
Sibling 2 52 53 54 55 56 57 58 59 60 61 62
Sibling 3 63 64 65 66 67 68 69 70 71 72 73
Comments: Hearing Status Code: 1 = no hearing loss; 2 =

mild loss (20–45); 3 = moderate loss (45–70); 4 = severe
loss (70–90); 5 = profound/deaf (90 bd and up); 6 = heard
of hearing PART II Blanks / Card 2
Client’s Communication with Persons of Various
Hearing and Signing Abilities Record the appropriate code

for Place and Type Place Code: 1 = No people 2 = A few
people 3 = A lot of people Type Code: 1 = Little or none of
the time 2 = Some of the time 3 = Most or all of the time
PLACE Deaf People Signing Hearing People Non-Signing

Hearing People
School/Work 18 19 20
Sports Clubs 21 22 23
Social Activities 24 25 26
Community 27 28 29
Church 30 31 32
Bars 33 34 35
Deaf Club 36 37 38
Medical 39 40 41
Business 42 43 44
TYPE Deaf People Signing Hearing People Non-Signing Hearing

People
Greetings 45 46 47
Directions 48 49 50
Conversations
(surface) 51 52 53
Conversations
(in-depth) 54 55 56
Questions 57 58 59 1 17
MODE: What is the most common mode of communication that

you use when you are with: Deaf people? 60 Mode Code:
Signing hearing people? 61 1 = ASL Non-signing hearing
people? 62 2 = English 3 = Other signs 4 = Gestures 5 =
Oral 6 = Speech reading 7 = Finger spelling 8 = Writing 9 =
Interpreter PART III
Client’s use of Interpreters and Adaptive Devices Blanks

CARD 3 Use of Sign Language Interpreters: (1) (2)
Have you used an interpreter before? YES NO 18
Do you know the role of an interpreter? YES NO 19
Do you know your role with an interpreter? YES NO 20
Are you comfortable using an interpreter? YES NO 21
Do you know how to get an interpreter? YES NO 22
Comments: 1 17 Use of Adaptive Devices: (1) (2)
Do you have or use a TDD/TTY? YES NO 23
Do you have or use a hearing aid? YES NO 24
Do you have or use a TV decoder? YES NO 25
Do you have or use signaling devices? YES NO 26

Do you have or use a telephone amplifier? YES NO 27
Do you have or use a hearing dog? YES NO 28
Do you have or use an assistive listening
device? Or system (ALD/ALS)? YES NO 29
Comments: Part IV CARD 3 (Cont)
Clients’ Skills in Aspects of Expressive and Receptive Sign

Language This is a rating of the various elements of the
client’s expressive and receptive sign language skills.
Indicate your rating of each of the skill elements using
the rating scale below. Rating Scale: 1 = lack of skill 2 =
poor level skill 3 = fair level skill 4 = moderate level
skill 5 = high level skill 6 = not observed
EXPRESSIVE
Sign Production 30
Fluency 31
Expresses complete thought 32
Provides details 33
Follows main topic 34
Knows manual alphabet 35
Finger spelling 36
Uses classifiers 37
Yes/No Questions 38
Why Questions 39
Use of space (absent/referent) 40
Incorporation (time/numbers) 41
Free expression 42
Use of voice 43
Facial expression agrees 44

Negative head shake 45
Affirmative head nod 46
RECEPTIVE
Understanding 47
Fluency 48
Yes/No Questions 49
Why Questions 50
Incorporation (time/numbers) 51
Requests clarification 52
Responds appropriately 53
Directions 54
Comments: PART V
Assessment Summary
Summary of Communication Assessment Interview
Recommendations for Treatment Staff
Appendix II SUBSTANCE USE ASSESSMENT SCREENING TOOL
Client Name: __________________________________ Date:

______________
Assessor:
__________________________________________________________
Referred by: ___________ Agency: _________________ Phone:

_____________
Reason for Referral:
Background Information
Date of Birth: __________ Age: __________ Gender: M / F
Marital Status: ________ Living Arrangement:

_________________________
School Status: _________ Employment Status:
__________________________
Family Incidence of alcohol / drug problems? YES / NO
If yes, identify members:
Other background information: 291
Treatment History
Admissions for Detox:
Place: ___________________________________________ Dates:

___________
Place: ___________________________________________ Dates:

___________
Admissions for Treatment:
Place: __________________ Inpatient / Outpatient Dates:

___________

___________

___________
Longest period of sobriety after treatment:

______________________________
Most recent period of sobriety:

________________________________________
Problems Related to Chemical Use
Physical Problems:
____ Hangovers ____ Tolerance ____ Withdrawal
____ Blackouts ____ Accidents / injuries ____ Passing out
____ Fights ____ Injecting drugs ____ Medicating pain
Comments:
Financial Problems:
____ Unpaid bills ____ Borrowing money ____ Outstanding
loans
____ Legal fines ____ Stealing ____ Dealing
____ Lifestyle change ____ Insufficient income ____ Pawning

items
Comments:
Family Problems:
____ Arguments / fights ____ Abuse ____ Broken promises
____ Absence from home ____ Loss of trust

____ Concerns about use
____ Use by other members ____ Hiding drugs in home ____

Custody issues
Comments:
Legal Problems
____ Arrests ____ Near arrests ____ DWI / DUI
____ Gang involvement ____ Court appearances ____ Parole
____ Restraining order ____ Domestic violence ____ Probation
Comments:
Job / School Problems:
____ Poor performance ____ Lateness ____ Absences
____ Problems with supervisor ____ Fired / suspended ____

Disciplined
____ Problems with peers ____ Using at work / school
Comments:
Social Problems:
____ Loss of friends ____ Change of friends ____ Friends use
____ Socialization around use ____ Negative reputation ____

Gambling
____ Friends older / younger
Comments:
Emotional Problems:
____ Used to feel normal ____ Mood swings ____ Self harm
____ Suicidal thoughts / behavior ____ Anger problems ____

Depression
____ Use to medicate emotional pain
Comments:
Chemical Use Information:
____ Unplanned use ____ Binge use ____ Hidden use
____ Using more than planned ____ Solo use ____ Daily use
____ Attempts to control use ____ Relapse ____ Preoccupation
____ Protecting supply ____ Poly drug use
Comments:
Identify chemicals used. For each chemical, identify age of

first use and
present pattern of use.
____ Alcohol ____ Marijuana ____ Cocaine
____ Crack ____ Inhalants ____ Sedatives
____ Hallucinogens ____ Amphetamines ____ Opiates
____ Others: ____ Others: ____ Others:
Use information:
Diagnostic Features: Please check all that apply.
___ TOLERANCE need for increased amount of substance to

achieve intoxication or markedly diminished effect with
continued use of the same amount.
___ WITHDRAWAL characteristic syndrome or same or closely

related substance taken to relieve or avoid withdrawal
symptoms.
___ SUBSTANCE taken in larger amounts or over longer period

than intended.
___ PERSISTENT desire or unsuccessful efforts to cut down

or control use.
___ TIME spent in activities necessary to obtain substance

or recover from its use.
___ SOCIAL, OCCUPATIONAL, RECREATIONAL activities given up

or reduced because of use.
___ CONTINUED use despite knowledge of physical or

psychological problems caused or exacerbated by the use.
Interview Findings and Comments:
Appendix III DRUG CHART SAMPLE STEP ONE SAMPLE ASSIGNMENT

STEP TWO SAMPLE ASSIGNMENT STEP THREE SAMPLE ASSIGNMENT
SAMPLE BEHAVIOR CONTRACT FAMILY WEEK ASSIGNMENT
296 DRUG CHART ASSIGNMENT
SAMPLE
Do all work in the order written. Get staff to sign before

doing the next part. Staff Initials / Date
1. Name all drugs you have used. __________________
2. Tell the last time you used. What? When? How much?
__________________
3. When I am high or drunk, bad things happen.
These things are called consequences. __________________
Draw 7 pictures of body consequences __________________
Draw 7 pictures of money consequences __________________
Draw 7 pictures of family consequences __________________
Draw 7 pictures of legal consequences __________________
Draw 7 pictures of job/school consequences

__________________
Draw 7 pictures of social consequences __________________
4. Present your work in a group __________________
Drug chart is due on: September 18 STEP ONE ASSIGNMENT
SAMPLE
Step One tells us: We admitted we were powerless over drugs

and alcohol and that our lives had become unmanageable.
Do work in the order written. Get staff to sign before

1. Watch ASL videotape on Step One __________________
2. Draw 10 pictures of unmanageable from
drug/alcohol use. __________________
3. Draw 10 pictures of powerlessness with drugs
and alcohol. __________________
Draw 1 picture of how powerlessness feels.

__________________
4. Draw 8 examples of how my drug/alcohol use has
caused problems for other people. __________________
5. Draw/write examples of how using alcohol/drug has
caused problems for me. __________________
6. 2 1 : 1’s with peers __________________
7. 2 1 : 1’s with staff __________________
8. Present Step One work in group. __________________
Step One is due on September 25 STEP TWO ASSIGNMENT
SAMPLE
Step Two tells us: Came to believe that a Power greater

than ourselves could restore us to sanity.

1. Meet with the Chaplain for Step Two prep
__________________
2. Watch ASL videotape on Step Two __________________
3. Draw 10 pictures of time people helped you

__________________
4. Tell 15 ways you are similar to your peers in
treatment __________________
5. Draw 10 places you can go to get support in recovery

__________________
6. List 10 people who can help you stay sober

__________________
7. Tell 15 things you like about yourself

__________________
8. 2 1 : 1’s with peers __________________
9. 2 1 : 1’s with staff __________________
Present Step Two in group __________________
Step Two is due on October 3 STEP THREE ASSIGNMENT
SAMPLE
Step Three tells us: Made a decision to turn our will and
our lives over to the care of God as we understood Him.

doing the next task. Staff Initials / Date
1. Meet with Chaplain for Step Three prep

__________________
2. Watch ASL videotape on Step Three __________________
3. Draw or write about who is your Higher Power

__________________
4. Tell how you communicate with your Higher Power

__________________
5. From the Serenity Prayer draw or write about things I

cannot change and things I can change __________________
6. Tell 10 things you are willing to give up for your

sobriety __________________
7. Why is trust important in your recovery?

__________________
8. If you choose to trust people in recovery, how can it

help you? __________________
9. 2 1 : 1’s with peers __________________
10. 2 1 : 1’s with staff __________________
Present Step Three in group __________________
Step Three is due on October 10 BEHAVIOR CONTRACT
SAMPLE
Your behavior has become a concern on the unit. The purpose

of this contract is to help you change your behavior. If
you have any questions about this contract, please ask a
staff member.
Specific Behavior Concerns:
1. Not completing work on time. Drug Chart and Step One

assignments were both late.
2. Not asking for an extension on assignments.
3. Late for groups.
Expected Changes:
1. Complete all assignments on time.
2. If you need extra time to complete your work, ask staff

for an extension before your work is due.
3. Come to all groups on time.
Client signature _____________________________________
Staff signature _____________________________________

Date __________ FAMILY WEEK ASSIGNMENT
Please complete this assignment before Family Week starts.

Bring your work
with you to all family groups.
What secrets related to using alcohol and drugs do you need

to tell your
family?
What behaviors do you use with your family to get what you
want. Be
specific.
What feelings do you have about your deafness that you have
not talked
about with your family?
What feelings about your deafness do you cover up by using

alcohol or
other drugs?
8 Toward Culturally Affirmative
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Mental Health Care of Deaf People

A Culturally Affirmative Approach

LAWRENCE ERLBAUM ASSOCIATES, PUBLISHERS

Senior Consulting Editor: Susan Milmoe

Most illustrations on CD provided by Michael Krajnak.

This book was typeset in 10/12 pt. Palatino

Copyright © 2003 by Lawrence Erlbaum Associates, Inc.

Lawrence Erlbaum Associates, Inc., Publishers

Library of Congress Cataloging-in-Publication Data

Mental health care of deaf people : a culturally affirmative approach /

ISBN 1-4106-0757-7 Master e-book ISBN

Books published by Lawrence Erlbaum Associates are printed on acid-

List of Contributors xii

Prologue: My Story xxi

1 Culturally Affirmative Mental Health Treatment 1

2 Psychiatric Care of Culturally Deaf People 33

3 Psychological Evaluation of Deaf Children 109

4 Culturally Affirmative Inpatient Treatment 145

5 Sensory Strategies for Self-Regulation: Nonlinguistic 203

6 Culturally Affirmative Residential Treatment Services 239

7 Culturally Affirmative Substance Abuse Treatment 261

8 Toward Culturally Affirmative Assessment 305

9 Does God have a Cochlear Implant? 327

Epilogue: When the Therapist Is Deaf 347

Appendix: Contents of the Accompanying CD 373

Author Index 417

Subject Index 423

Terrell Clark, PhD

Diane Trikakis, OTR/L

This book is concerned with the practical work of creating specialty

WHAT DO WE MEAN BY “CULTURAL AFFIRMATION?”

A culturally affirmative program provides opportunities for cultural in-

Culturally affirmative mental health programs have been established

BUT IS DEAFNESS A CULTURE?

TO WHOM DOES THIS BOOK APPLY?

Although many of the chapters in this volume describe specialized pro-

WHAT’S IN THIS BOOK?

Most of this book’s chapters describe specific culturally affirmative pro-

SOME NOTES ON NOMENCLATURE

Finally, because it is known as a TTY in American Sign Language, we have

THE APPENDIX AND COMPACT DISC

WHO ARE THE EDITORS?

easily the most enjoyable interview in his life—Dr. Schlesinger explained

A nurse brought in a medication to help me sleep. I cried myself to sleep,

because my civil rights as a disabled person are being violated!” I ex-

claimed to be unaware of my inability to participate in groups without an

as soon as possible, as it was becoming very expensive for her firm—without

• ascertain at intake whether a patient is deaf,

PERSONAL INTRODUCTION: CROSS-CULTURAL LEGITIMACY

I am a psychologist who administers an inpatient psychiatric unit for deaf

What makes you an expert on deaf people, or even on psychotherapy with

These questions challenge my “cross-cultural legitimacy” (Pollard,

WHY IS CULTURALLY AFFIRMATIVE MENTAL HEALTH

• Mainstreaming deaf children, resulting in isolation from peers and

• Disempowering them around communication, resulting in commu-

Hearing mental health professionals who do not have full knowledge

about finding peers at their level of functioning. Ms. DeVinney, however,

ACCESSIBILITY VERSUS CULTURAL AFFIRMATION

I want to clarify the difference between accessible treatment, which is required

DOES HIRING INTERPRETERS CREATE PROGRAM