http://www.ed.gov/fund/grant/apply/nidrr/prioritybkg-mhsd.html

NIDRR Priority - Mental Health Service Delivery to Deaf,
Hard-of-Hearing, and Deaf-Blind Individuals From Diverse Racial, Ethnic,
and Linguistic Backgrounds

National Institute on Disability and Rehabilitation Research (NIDRR)
Priority-Mental Health Service Delivery Background Material.


Additional Background Material:
The United States (U.S.) Surgeon General recommended the following,
"Seek help if you have a mental health problem or think you have
symptoms of a mental disorder" (Mental Health: A Report of the Surgeon
General, U.S. Public Health Service, 1999). In the field of mental
health, "help" is based largely on the relationship between service
provider and service recipient -- and this relationship is based
primarily on communication. Even psychotropic medications are given in
conjunction with counseling, therapy, case-management, and other
communication-based services.

For individuals who are deaf, hard-of-hearing, or deaf-blind, spoken
English often is an ineffective means of communication. American Sign
Language, tactile signing, cued speech, interpreters, and assistive
listening devices are some of the methods used to augment communication.
The question is how the use of these (and other) communication
modalities affects outcomes in mental health service delivery for deaf,
hard-of-hearing, and deaf-blind individuals.

The Surgeon General also noted that individuals from racial, cultural,
and linguistic minorities in the U.S. face serious barriers to competent
mental health care, suffer a greater loss to overall health and
productivity, and bear a greater burden from unmet mental health needs.

The groups examined in the above-referenced supplement follow Federal
classifications of racial and ethnic groups in the U.S.: African
Americans, American Indians and Alaska Natives, Asian Americans and
Pacific Islanders, and Hispanic Americans. The Surgeon General reports
that, in the year 2025, about 40 percent of adults and 48 percent of
children will be from racial and ethnic minority groups(Mental Health:
Culture, Race, and Ethnicity, a Supplement to Mental Health: A Report of
the Surgeon General, U.S. Public Health Service, 2001).

The Surgeon General recommended that future studies identify effective
interventions with minority subpopulations, including persons with
co-occurring mental and physical health conditions (Mental Health:
Culture, Race, and Ethnicity, a Supplement to Mental Health: A Report of
the Surgeon General, U.S. Public Health Service, 2001). Deaf,
hard-of-hearing, and deaf-blind individuals from diverse racial, ethnic,
and linguistic backgrounds are important examples of this type of
subpopulation. For them, the burdens of unmet mental health needs are
heightened because of communication barriers. The National Center for
Health Statistics (NCHS) estimates that approximately 8.6 percent of the
national population experiences hearing loss. This includes 4.2 percent
of both the Black and Hispanic populations (Ries P.W.,Prevalence and
characteristics of persons with hearing trouble: United States, 1990-91,
National Center for Health Statistics, Vital and Health Statistics,
Series 10(188), 1994).

Furthermore, each subpopulation has rich diversity and variety.
Asian/Pacific Americans, for example, come from a multitude of countries
and speak a variety of languages (Cheng, Li-Rong Lilly, Deafness: An
Asian/Pacific Perspective, in Kathee Christensen (Ed.), Deaf Plus: A
Multicultural Perspective, San Diego, CA: Dawn Sign Press; pp. 59-93,
2000). Deaf, hard-of-hearing, and deaf-blind individuals also are
diverse in areas such as communication styles and preferences, and
language acquisition and mastery.

For example, some deaf individuals may have picked up individual words
or signs, but developed no language base. Deaf individuals with limited
or no language base have been known by a variety of terms such as "low
verbal," "low functioning," "individuals with minimal language skills,"
and (more recently) "traditionally underserved deaf persons."
Traditionally underserved deaf persons may experience additional
difficulties such as cognitive impairment, illiteracy, lack of
education, low income, and a lack of independence (Duffy, K., Clinical
Case Management with Traditionally Underserved Deaf Adults, in Irene
Leigh,Psychotherapy with Deaf Clients from Diverse Groups: Washington,
DC, Gallaudet University Press, pp. 329-349, 1999). In order to avoid
confusion with the use of the term "traditionally underserved" set forth
in Section 21 of the Rehabilitation Act of 1973, the term "individual
with minimal language skills" hereafter is used in this priority instead
of the term "traditionally underserved deaf person."

Excellence in mental health service delivery to deaf, hard-of-hearing,
and deaf-blind individuals requires effective communication and
culturally and linguistically appropriate test measurements and
treatment modalities. This is particularly true for deaf, hard of
hearing, and deaf-blind individuals from diverse racial, ethnic, and
linguistic backgrounds. Cultural influences can be seen, for example, in
the American Indian deaf community, which reportedly uses mental health
services rarely -- in part, because the process of sharing personal
information is culturally unfamiliar (Eldridge N.M., Culturally
Responsive Psychotherapy with American Indians Who Are Deaf, in Irene
Leigh (Ed.),Psychotherapy with Deaf Clients from Diverse Backgrounds,
Washington, DC: Gallaudet University Press; pg. 182, 1999).

Even assuming that deaf, hard-of-hearing, and deaf-blind individuals
seek and receive treatment from providers familiar with their cultural
and linguistic backgrounds, psychological test measures often are
inadequate (Vernon M., An Historical Perspective on Psychology and
Deafness, Journal of the American Deafness and Rehabilitation
Association, Vol. 29(2), pg. 11, 1995). Few psychological tests and
assessment instruments have been developed specifically for the deaf
population -- and none have been developed for the Asian-American deaf
population (Wu C.L. and Grant N.C., Asian American and Deaf, in Irene
Leigh (Ed.),Psychotherapy with Deaf Clients from Diverse Backgrounds,
Washington, D.C.: Gallaudet University Press; pg. 212, 1999).

Prior work has addressed areas such as the use of interpreters in
psychotherapy, service delivery to hard-of-hearing persons, and an
emerging paradigm shift that views deaf people as culturally different
rather than as clinically pathological. However, none of these studies
specifically address individuals who are deaf, hard-of-hearing, or
deaf-blind and who may be from diverse racial, ethnic, or linguistic
backgrounds (Harvey M.,Psychotherapy with Deaf and Hard-of-Hearing
Persons: A Systemic Model, Hillsdale, NJ, Lawrence Erlbaum Associates,
Inc., 1989; Glickman N.S. and Harvey M., Eds,Culturally Affirmative
Psychotherapy with Deaf Persons, Mahwah, NJ: Lawrence Erlbaum
Associates, Inc., 1996; Trychin S.,Mental Health Practitioner's Guide:
Providing Mental Health Services to People who are Hard-of-Hearing,
International Federation of Hard-of-Hearing
People,http://www.ifhoh.org/papers/trychin2.htm).

An additional concern raised in the field is the adequacy and
acceptability of using sign language interpreters in psychotherapy
sessions with clinicians who do not know sign language. One unresolved
question is whether whether psychotherapy sessions conducted via third
parties (i.e., interpreters) provide an equal level of mental health
care for deaf people as psychotherapy sessions provided directly by
clinicians who are fluent in sign language (Lytle, Linda Risser, and
Lewis, Jeffrey W., Deaf Therapists, Deaf Clients, and the Therapeutic
Relationship, in Glickman N.S. and Harvey M., Eds, Culturally
Affirmative Psychotherapy with Deaf Persons, Mahwah, NJ: Lawrence
Erlbaum Associates, Inc., p. 264, 1996). Also at issue is whether
services provided through interpreters offer a truly effective means of
communication in the mental health treatment context (Lee, Randy and
Kearney, Mary Kate, Setting the Legal Context: What is the Meaning of
Equal Access to Mental Health Services? In Myers, R., (ed.), Standards
of Care for the Delivery of Mental Health Services to Deaf and Hard of
Hearing Persons, R.R. Myers Consulting, Mental Health/Deaf and
Hard-of-Hearing Services, 1995, distributed by the National Association
of the Deaf, 814 Thayer Avenue, Silver Spring, MD 20910-4500).

The Standards of Care cited above also address a range of other issues
related to mental health care for deaf and hard of hearing persons.
These include, for example, psychological testing, racial and ethnic
diversity, deaf-blind individuals; and deaf persons with minimal
language skills. These standards generally consist of basic
explanations, "how to" instructions, and recommendations for service
providers. As noted by many of the authors, a broader knowledge base is
needed in these and other areas in order to improve service to these
populations (Myers, R., (ed.),Standards of Care for the Delivery of
Mental Health Services to Deaf and Hard of Hearing Persons, R.R. Myers
Consulting, Mental Health/Deaf and Hard-of-Hearing Services, 1995,
distributed by the National Association of the Deaf, 814 Thayer Avenue,
Silver Spring, MD 20910-4500).

For purposes of this priority, the term "qualified interpreter" is
defined in accordance with the definition used in the Americans with
Disabilities Act: "A qualified interpreter means an interpreter who is
able to interpret effectively, accurately, and impartially both
receptively and expressively, using any necessary specialized
vocabulary" (28 CFR 36.104).

This proposed priority focuses on the mental health service delivery
system. However, the Department is considering adding an invitational
priority in the final priority that will include mental health service
delivery in the criminal justice system to deaf, hard-of-hearing, and
deaf-blind individuals from diverse racial, ethnic, and linguistic
backgrounds.