PRELIMINARY ADAPTATION OF THE PSYCHOEDUCATION PORTION OF MODULAR

THERAPY FOR CHILDHOOD ANXIETY DISORDERS FOR D/dEAF AND HARD OF

HEARING CHILDREN

A Dissertation

Presented to the Faculty of

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The PGSP-Stanford Psy.D. Consortium

Palo Alto University

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Palo Alto, California

In Partial Fulfillment of the

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Requirements for the Degree of

Doctor of Psychology
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By

Audrey Cortesi

July, 2019

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PRELIMINARY ADAPTATION OF THE PSYCHOEDUCATION PORTION OF MODULAR

THERAPY FOR CHILDHOOD ANXIETY DISORDERS FOR D/dEAF AND HARD OF

HEARING CHILDREN

Audrey Cortesi
The PGSP-Stanford Psy.D. Consortium, Palo Alto University, 2019

D/deaf and hard of hearing (DHH) individuals are more vulnerable to mental health concerns

than the hearing population (e.g., Stevenson, Kreppner, Pimperton, Worsfold, & Kennedy, 2015)

and DHH children are 1.5 – 2 times more likely to experience mental health issues than hearing

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youth (Hindley, 2005). Internalizing disorders, and anxiety disorders in particular, have been
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identified as the most prevalent diagnosis among DHH youth (e.g., Hindley, Hill, McGuigan, &

Kitson, 1994). Despite high rates of mental health issues among DHH children, access to mental
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health care is severely limited due to cultural and linguistic barriers (e.g., Alexander, Ladd, &

Powell, 2012; Pollard, 1994) and further complicated by a paucity of treatments that have been

adapted for DHH populations. To address this need, this study created an adapted therapy
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resource to be used with DHH youth with anxiety. The modular direct service model entitled

Managing and Adapting Practice (MAP) was selected as the basis for adaptation due to the

increased utilization (e.g., Friedberg, 2017), efficacy (e.g., Weisz et al., 2012; Chorpita, et al.,

2017), and flexibility (e.g., facilitates linguistic and cultural adaptation) of modular approaches.

Given the known benefits of psychoeducation (Houghton & Saxon, 2007), particularly as a form

of early intervention for youth (Hirshfeld-Becker & Biederman, 2002), this study adapted steps

1–6 of the MAP practice guide, “psychoeducation” for childhood anxiety. The target population

for the adaptation was DHH children ages 7–12. An expert advisory panel, including Deaf

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community members, was created to assist with the adaptation of materials both culturally and

linguistically. The practice guide was adapted into a video format and provided in American

Sign Language (ASL) with closed captioning and English voiceover, to ensure full accessibility.

This adapted guide was designed to serve as an adjunct resource to augment treatment. Financial

and time constraints limited study scope to focus on adapting six of the 12 steps of the MAP

practice guide and precluded the evaluation of the adapted resource. Next steps include

comprehensive evaluation of the adapted resource, adaptation of the additional six steps, and

dissemination of the adapted resource to clinicians as a therapy tool.

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© Copyright 2019
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Audrey Cortesi
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All Rights Reserved
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 Preliminary Adaptation of the Psychoeducation Portion of Modular Therapy for Childhood

Anxiety Disorders for D/deaf and Hard of Hearing Children

This dissertation by Audrey Cortesi, directed and approved by the candidate’s committee, has

been accepted and approved by the Faculty of The PGSP-Stanford Psy.D. Consortium, Palo Alto

University in partial fulfillment of the requirements for the degree of

DOCTOR OF PSYCHOLOGY

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July 29, 2019
IE Risa Dickson, Ph.D.
Vice President for Academic Affairs
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Dissertation Committee:
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____________________________________
Elizabeth Reichert, Ph.D.
Chair

____________________________________
Yan Leykin, Ph.D.
Committee Member

____________________________________
Nicole Starace, Ph.D.
Committee Member

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 TABLE OF CONTENTS
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LIST OF TABLES .................................................................................................................. 9
LIST OF FIGURES ................................................................................................................ 10
CHAPTER
I. REVIEW OF THE LITERATURE ...................................................................................... 11
Introduction ............................................................................................................................ 11
Deaf Population and Mental Health Needs Among Youth ....................................................... 13
Introduction to the Population ............................................................................................ 13
Vulnerability to Mental Health Concerns............................................................................ 15

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Dearth of Competent Providers and Appropriate Resources ................................................ 19
Current Mental Health Resources ....................................................................................... 27
PCIT for Deaf families ................................................................................................ 28
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CBT for D/deaf and hearing adults with language and learning challenges .................. 30
DBT for Deaf adults .................................................................................................... 31
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Evidence-Based Treatments for Childhood Anxiety ................................................................ 33

Modular Based Therapies .................................................................................................. 34
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Rise of Technology-Based Interventions............................................................................. 37

Deaf and Hard of Hearing Specific Instruction and Treatment ................................................. 39
Instruction of Deaf and Hard of Hearing Youth ................................................................. 39
Modifications of Treatments for Deaf and Hard of Hearing Individuals .............................. 40
Purpose of the Current Study................................................................................................... 42
II. METHODS ........................................................................................................................ 47
Overview ................................................................................................................................ 47
Procedure ................................................................................................................................ 49
Phase 1: Literature Review ................................................................................................. 49
Phase 2: Selection of MAP and Research Agreement ......................................................... 51
Phase 3: Script Development .............................................................................................. 52

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 Expert Advisory Panel – First meeting......................................................................... 55
Expert Advisory Panel – Second meeting .................................................................... 56
Phase 4: Script Creation ..................................................................................................... 57
Phase 5: Video Creation ..................................................................................................... 58
Meeting with Editor..................................................................................................... 58
Video Filming ............................................................................................................. 58
Phase 6: Video Editing ....................................................................................................... 60
III. RESULTS ......................................................................................................................... 61
Overview ................................................................................................................................ 61
Adaptations ............................................................................................................................. 61

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Broad Adaptations.............................................................................................................. 61
Visuals ........................................................................................................................ 62
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ASL............................................................................................................................. 62
Cultural ....................................................................................................................... 63
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Dialogic Teaching Style .............................................................................................. 64
Developmental and Cognitive ...................................................................................... 65
Intervention Specific Adaptations....................................................................................... 65
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Step 1: Get a Common Vocabulary.............................................................................. 66

Step 2: Explain the Three Parts to Anxiety................................................................... 68
Step 3: Examples of Thoughts ..................................................................................... 72
Step 4: Examples of Feelings ....................................................................................... 75
Step 5: Examples of Behaviors .................................................................................... 76
Step 6: Normalize the Emotion of Anxiety .................................................................. 78
IV. DISCUSSION ................................................................................................................... 81
Reflection ............................................................................................................................... 81
Process and Outcome ......................................................................................................... 81
Obstacles and Limitations ....................................................................................................... 86
Barriers .............................................................................................................................. 86

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 Limitations to Application .................................................................................................. 88
Future Directions .................................................................................................................... 94
Completion of the Full Practice Guide ................................................................................ 94
Expansion to Other Treatments and Subpopulations ........................................................... 96
REFERENCES ....................................................................................................................... 97
APPENDICES ........................................................................................................................ 120
A. MAP Practice Guide – Child Anxiety Psychoeducation ...................................................... 120
B. Video Scripts with Blocking for MAP Steps 1–6 ................................................................ 121

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 LIST OF TABLES

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1. Resources Utilized for Video Creation ................................................................................ 48

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 LIST OF FIGURES

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1. Study timeline ..................................................................................................................... 49

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 CHAPTER I

REVIEW OF THE LITERATURE

Introduction

Numerous studies have demonstrated that D/deaf and hard of hearing (DHH) individuals

have higher rates of mental health concerns as compared to their hearing counterparts (e.g.,

Stevenson, Kreppner, Pimperton, Worsfold, & Kennedy, 2015; Fellinger, Holzinger, & Pollard,

2012; Fellinger, Holzinger, Sattle, Laucht, & Goldberg, 2009), including an increased

vulnerability to anxiety disorders in DHH youth (e.g., Hindley, Hill, McGuigan, & Kitson, 1994;

Roberts & Hindley, 1999). However, studies also show that DHH individuals have substantially

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decreased access to care due to linguistic and cultural barriers (Alexander, Ladd, & Powell,
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2012; Pollard, 1994; Glickman, 1983, 1986; Heller, 1987; Sussman, 1989). In addition to

decreased access to standard care, services that have been adapted for DHH populations are rare.
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There are only a select few mental health treatments that have been adapted for DHH individuals

to date (O’Hearn & Pollard, 2008; Glickman, 2009b; Day, Costa, Previ, & Caverly, 2018), two

of which were created for adults and are not developmentally appropriate for DHH children. Due
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to high abuse rates of DHH children (Sullivan & Knutson, 2000) and our knowledge about the

positive impacts of preventative care and early intervention (Hirshfeld-Becker & Biederman,

2002), it is imperative that mental health resources are made available and accessible for the

treatment of DHH youth. Given the increased prevalence of anxiety disorders in DHH children,

the current study focused on the treatment of anxiety in DHH youth. Cognitive Behavioral

Therapy (CBT) has been identified as the gold standard for the treatment of childhood anxiety

disorders (e.g., Higa-McMillan, Francis, Rith-Najarian, & Chorpita, 2016; Wehry, Beesdo-

Baum, Hennelly, Connolly, & Strawn, 2015). However, despite the efficacy of CBT, a

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significant portion of children with anxiety fail to achieve clinical levels of symptom reduction

(Kendall, Settipani, & Cummings, 2012). In order to address this issue and the pervasive science-

practice gap, the literature is trending toward modular approaches due to the inherent flexibility

and applicability of more transdiagnostic designs (e.g., Friedberg, 2017; Hersh, Metz, & Weisz,

2016; Kendall, Settipani, & Cummings, 2012). The rise of modular approaches offers a

promising new approach to treatment that may be particularly beneficial for culturally diverse

youth (Lyon, Lau, McCauley, Stoep, & Chorpita, 2014).

Modular designs have demonstrated efficacy in several studies (e.g., Weisz et al., 2012;

Chorpita, et al., 2017) and lend themselves well to linguistic and cultural adaptation due the

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focus on specific interventions, techniques, and independent modules rather than the more
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traditional manualized approach, which is a cohesive, intradependent treatment protocol that

cannot be separated into component parts. There is a modular direct service model known as
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Managing and Adapting Practice (MAP) that identifies and compiles the common elements of

effective mental health interventions for a multitude of treatment targets (Chorpita & Daleiden,

2014; Chorpita, Daleiden, & Collins, 2014). The MAP system (Southam-Gerow et al., 2014) and
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counterparts of MAP (e.g. Modular Approach to Therapy for Children with Anxiety, Depression,

or Conduct Problems; MATCH; Chorpita & Weisz, 2009) have been shown to be particularly

effective for diverse youth in community settings, with promising results such as superior

efficacy over Cognitive Behavioral Therapy and other evidence-based treatment (EBT) manuals

(Chorpita et al., 2017; Weisz et al., 2012). The flexibility of MAP allows for considerable

cultural adaptation and integration of local cultural knowledge, without sacrificing fidelity to the

empirically supported interventions (Lyon et al., 2014). Presently, this effective treatment model

is not adapted for DHH youth, who are in great need of treatment that is both empirically

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informed and culturally tailored. For a population with such a high rate of psychiatric concerns,

increased access to a promising treatment such as MAP could be highly beneficial.

Given the demonstrated effectiveness of MAP and the ease at which it can be tailored,

adaptation for DHH community appears to be the natural next step to increase treatment access

for this population. Due to the barriers that make it challenging for DHH individuals to access

these services as they exist currently, linguistic and cultural adaptations were needed to ensure

accessibility as well as appropriateness of the interventions. Potential adaptations include: (a)

interpretation into American Sign Language (ASL; Glickman, 2017; O’Hearn & Pollard, 2008;

Day et al., 2018), (b) information presented in video format (O’Hearn & Pollard, 2008; Day et

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al., 2018), (c) increased utilization of visual aids (Glickman, 2017; O’Hearn & Pollard, 2008),
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(d) simplification of English terminology (O’Hearn & Pollard, 2008; Glickman, 2009b), (e) use

of dialogic as opposed to didactic teaching style (O’Hearn & Pollard, 2008; Glickman, 2009b),
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or (f) integration of culturally appropriate stories and metaphors (Glickman, 2017; O’Hearn &

Pollard, 2008; Day et al., 2018). Adaptation of MAP interventions specifically for DHH youth

could not only add to the current literature base but could also expand treatment access for the
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DHH population in an empirically supported, culturally relevant way.

Deaf Population and Mental Health Needs Among Youth

Introduction to the Population

According to the National Institute on Deafness and Other Communication Disorders

(NIDCD), approximately two to three of every 1,000 children born in the United States have a

detectable level of hearing loss in one or both ears. Furthermore, for individuals in the United

States who are age 12 and older, nearly one in five (48.1 million) have either unilateral or

bilateral hearing loss (Lin, Niparko, & Ferrucci, 2011). This significant percentage of Americans

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comprises a unique subset of the population that is highly diverse (Byrne, 1998) across several

domains including but not limited to: level of hearing, age of onset, cause, utilization of assistive

technology, communication modality, and cultural identification.

In terms of cultural identification, according to the National Association of the Deaf

(NAD), individuals who identify themselves as Deaf with a capitalized “D” are culturally Deaf,

meaning they are part of Deaf culture and share American Sign Language (ASL) as their

common language (NAD, 2018). The Laurent Clerc National Deaf Education Center at Gallaudet

University states, “American Deaf culture centers on the use of ASL and identification and unity

with other people who are Deaf.” (Gallaudet University, 2015). Reagan (1995) discussed the

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potential lack of understanding and appreciation for Deaf culture as he explained,
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The world of the Deaf remains a … hidden one for the vast majority of the hearing
population. Indeed, for most hearing people deafness is understood solely as a disabling
condition that involves an inability – specifically, the inability to function audiologically
as do “normal” people. However, for many Deaf people, deafness is defined not so much
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in terms of audiological issues, but rather, with respect to linguistic, social, and cultural
issues.

Benedict and Legg (2014) described the experience of being part of Deaf culture and a member
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of the Deaf community as a sense of belonging or a feeling of “home.” They discussed that there

is shared worldview experienced by many Deaf people that is celebrated within the community.

“Deaf people describe a sense of connection and a shared understanding of what it means to be a

deaf person that is felt almost immediately upon meeting another person who is deaf.” (Benedict

& Legg, 2014). The term “Deaf” is specifically differentiated from the label of “deaf” with a

lowercase “d.” The identification of deaf refers to “the audiological condition of not hearing”

(Padden & Humphries, 1988, p. 2) and to a group of individuals who “do not have access to the

knowledge, beliefs, and practices that make up the culture of Deaf people” (Padden &

Humphries, 1988, p. 2). Additionally, the NAD (2018) also specifies a third term, “hard of

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hearing”. This term can be used to denote a person: 1) with a mild to moderate hearing loss, 2)

an individual who has chosen not to identify with the culturally Deaf community, or 3) both.

Individuals who are hard of hearing can join and participate in the Deaf community or they can

choose not to be associated with this cultural affiliation (NAD, 2018). Notably, the NAD

recognizes these three terms “Deaf”, “deaf”, and “hard of hearing” as most commonly accepted

and recommends the use of these terms instead of “deaf and dumb”, “deaf-mute”, and “hearing-

impaired” due to the associated negative connotations (NAD, 2018). As such, Deaf, deaf, and

hard of hearing (DHH) individuals will be referred to collectively as “DHH” hence forth in this

study. The term “D/deaf” will also be used to encapsulate all D/deaf individuals, culturally Deaf

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and non-culturally deaf.
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With regard to diversity in communication methods, DHH individuals also have a variety

of communication modalities available to them. Typically, their communication modality is

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selected in early childhood to facilitate language development and communication with primary

caregivers (Gravel and O’Gara, 2003). Gravel and O’Gara (2003) discuss the various

communication options available to DHH children that vary from spoken to signed modalities as
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well as combinations of the two such as spoken language with visual cues or signs. Within the

Deaf community, ASL is highly preferred and is utilized as the primary form of communication.

Additionally, DHH individuals vary linguistically in their proficiency with English (O’Hearn &

Pollard, 2008; Bochner & Walter, 2005; Bryne, 1998), which can impact their experience with

the majority hearing culture.

Vulnerability to Mental Health Concerns

It is important to note that this unique, diverse portion of the population is more

susceptible to mental health concerns than the average hearing individual (person with fully

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intact hearing). Deaf individuals have more mental health issues than their hearing counterparts

(e.g., Stevenson, Kreppner, Pimperton, Worsfold, & Kennedy, 2015; Fellinger, Holzinger, &

Pollard, 2012; Fellinger et al., 2009) across developmental stages. This is evidenced by estimates

that the vulnerability to mental health issues of deaf children is increased 1.5 - 2 times more than

that of hearing children (Hindley, 2005), deaf adolescents have a higher prevalence of

psychopathology (van Gent, Goedhart, Hindley, & Treffers, 2007), and deaf adult respondents

exhibit more symptoms of mental health problems than hearing respondents on a symptom

checklist (Kvam, Loeb, & Tambs, 2006).

The deaf population’s increased vulnerability to mental health problems may be due to

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minority and disabled status. Deaf individuals are a minority in a majority-hearing world,
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especially for those who identify as culturally Deaf (Padden, 1980; Padden & Humphries, 1988)

and communicate with American Sign Language (ASL). Not only are deaf individuals
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outnumbered in public sectors, they are also typically a minority in their own homes with 90% of

deaf children being born to hearing parents (NIDCD, 2016). Many hearing parents do not plan to

have a deaf child; thus, discovering and adapting to their child’s deafness can be a challenging
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adjustment. Many hearing parents do not know ASL and either do not wish to learn or struggle to

acquire fluency. A study conducted in the United Kingdom in 2005 found that the majority of

deaf children were likely to exhibit spoken language delays (Hindley, 2005). Additionally,

Hindley (2005) found that it was probable that the children who did utilize sign language in the

study as their primary mode of communication were not having their developmental needs met

by the signing competency of the adults and peers in their environment. Moreover, Hindley

asserted that the early language deprivation often experienced by deaf individuals in hearing

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households is a key risk factor for developmental delays, which in turn, can influence future

mental functioning and mental health.

Furthermore, D/deaf individuals are also considered to be of disabled status by majority

hearing culture. Individuals with disabilities face more practical and social problems than

nondisabled individuals, potentially predisposing them to an increased risk of developing mental

health concerns (Kvam, Loeb, & Tambs, 2006). Disabled status also predisposes DHH

individuals to become victims of abuse. The vulnerability to abuse is especially significant when

childhood maltreatment is considered, due to the immense impact abuse at a young age can have

on mental health functioning. Sullivan and Knutson (2000) found a 31% prevalence rate of

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childhood maltreatment for individuals with disabilities as compared to a 9% prevalence rate for
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nondisabled children, resulting in children with disabilities being 3.4 times more likely to be

abused. This study also found evidence that deaf children are twice as likely to be neglected or
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emotionally abused and four times as likely to experience physical abuse than children with no

disability (Sullivan & Knutson, 2000). A recent study indicated that DHH individuals reported

significantly increased rates of childhood maltreatment, lifetime trauma, and PTSD symptoms as
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compared to hearing participants. Notably, the risk of experiencing traumatic events increased

with the severity of the deafness (Schenkel et al., 2013). Furthermore, studies show that children

with disabilities have an increased vulnerability to suffer from multiple types of childhood

maltreatment, are more likely to be victimized earlier in their youth, and are at a higher risk for

experiencing maltreatment in the home or in a specialized school setting (Kazak & Marvin,

1984; Sullivan & Knutson, 2000; Turner, Vanderminden, Finkelhor, Hamby, & Shattuck, 2011).

This broad, increased susceptibility to various types of childhood maltreatment and settings may

align with the evidence supporting the notion that deaf individuals are more likely to have

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suicidal ideation and suicide attempts than hearing individuals (Black & Glickman, 2006;

Durland, 2004; Samar et al., 2007).

Given the overall increased vulnerability for DHH individuals, it is important to consider the

impact of psychopathology on developing DHH youth. Interestingly, there is very limited

research on prevalence rates of specific mental health disorders in DHH youth in the United

States. However, studies conducted in the Netherlands, Germany, and the United Kingdom have

identified anxiety disorders as the most prevalent mental health issue in DHH youth. More

research is necessary to determine the reason for this increased prevalence in DHH children.

Some potential hypotheses include: perceiving the world as more frightening due to language

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difficulties, the attitudes of hearing individuals, and adjusting to the hearing world (Li & Prevatt,
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2010); experiencing social situations as more “emotionally confus[ing]” and anxiety-provoking

(Li & Prevatt, 2010); difficulties with expressive speech affecting social development, in turn
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negatively impacting friendships and resulting in associations with increased anxiety (Azab,

Kamel, & Abdelrhman, 2015); social difficulties and isolation (Batten, Oakes, & Alexander,

2013); and symptoms going unrecognized due to communication barriers and lack of awareness
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(van Eldik, 2005; Roberts & Hindley, 1999).

The literature regarding childhood anxiety disorders in hearing children denotes that anxiety

disorders are highly common (e.g., Lønfeldt, Silverman, Esbjørn, 2017; Higa-McMillan, Francis,

Rith-Najarian, & Chorpita, 2016; Cartwright-Hatton, McNicol, Doubleday, 2006) and require

treatment due to the significant negative impacts of anxiety symptoms on youth (e.g., Wu et al.,

2016; Langley et al., 2014). Since childhood anxiety can have such detrimental effects on

hearing youth, it would seem to follow that the impacts may be even more significant for DHH

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children, given their increased vulnerability. Therefore, similar care should be taken to address

the mental health needs of DHH children with anxiety.

Although anxiety disorders are often cited as the most prevalent psychiatric diagnosis in

DHH youth (e.g., Hindley, Hill, McGuigan, & Kitson, 1994; Roberts & Hindley, 1999), there is

some discrepancy in the literature pointing more broadly to internalizing disorders as a primary

concern. For instance, some studies have identified depression (e.g., Fellinger, Holzinger, Sattel,

Laught, & Goldberg, 2009), depression and anxiety (e.g., van Eldik, 2005; Konuk, Erdogan,

Atik, Ugur, & Simsekyilmaz, 2006), or anxiety and mood disorders (e.g., van Gent, Goedhart,

Hindley, & Treffers, 2007) as most prevalent among this population. In contrast, other studies

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point to both internalizing and externalizing disorders (e.g., van Eldik, Treffers, Veerman, &
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Verhulst, 2004) as well as ADHD conduct, autism-spectrum, and bipolar disorders (e.g.,

Landsberger, Diaz, Spring, Sheward, & Sculley, 2014). However, these disorders are often
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prevalent in the general child population and therefore, it is difficult to clearly determine the

most prevalent disorder in the DHH youth population. Rationale for the discrepancies in the

literature may be due to differing study locations, methodology, and the immense diversity
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within the DHH population (i.e., level of hearing, age of onset, cause, utilization of assistive

technology, communication modality, cultural identification, etc.). More generally, these

discrepancies and the limited findings in the United States highlight the need for more rigorous

research and study in this area.

Dearth of Competent Providers and Appropriate Resources

Despite the ample evidence that deaf individuals have an increased vulnerability and

higher rates of mental health problems, access to the mental health service system is remarkably

limited for DHH individuals (Pollard, 1994). A primary impediment is a significant language

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barrier that exists due to the lack of ASL-fluent providers and the limited availability of quality

interpreting services. The dearth of qualified interpreters may be due to the demanding nature of

interpretation for mental health settings. This requires interpreters who are: (a) certified to

interpret, (b) knowledgeable about mental health terminology, and (c) willing to interpret and

capable of processing the emotional material to which they are exposed in therapeutic settings

(Cornes & Napier, 2005). It is important to note that ASL is a fully formed language with a

unique structure and grammar system independent from English (e.g., NIDCD, 2017; Pfau &

Quer, 2010; Gravel & O’Gara, 2003). ASL is a visual-spatial modality as opposed to English

which is vocal-auditory, which results in significant differences between the languages (Wilcox,

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2000). Compared to English, grammar in ASL utilizes highly disparate modalities, including
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facial expressions (e.g., eyebrows go up for a “Yes/No” question), specific mouth movements

(e.g., mouth forms a “mm” configuration to indicate an action that done in a relaxed, regular
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manner), and spatial relationships (e.g., utilization of signing space, the space in front of the

signer’s body, to establish the location of objects in relation to the signer or describe a past

conversation by role-shifting between individuals) (Pfau & Quer, 2010; Wilcox, 2000; Wilbur &
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Patschke, 1998). ASL is not simply “English on the hands” and as such, there are English words

for which there are no ASL signs and signs for which there are no specific word equivalents. In

fact, Liddell (2003) stated, “In reality, since ASL and English are two entirely different

languages with completely different grammars, it would be highly unusual for an ASL sentence

ever to have exactly the same grammatical structure as an English sentence.” (p. 1-2).

Furthermore, ASL interpreters are not only navigating a complex linguistic divide, but they are

also tasked with addressing cultural discrepancies between Deaf and hearing culture (Cornes &

Napier, 2005). Such complexity can make interpretation a very challenging task, especially

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within the specialized field of healthcare, and may contribute to the shortage of qualified

interpreters.

Notably, it is beneficial for mental health providers to have the ability to communicate

directly with their deaf patients rather than utilizing interpreting services. Interpreting for deaf

patients can pose potential threats to the therapeutic alliance as well as introduce linguistic and

role challenges (Cornes & Napier, 2005). A study by Brunson and Lawrence conducted in 2002

found that not only can interpretation have a meaningful impact on the therapeutic alliance, but

the interpreter’s mood can affect the mood of the deaf client. Brunson and Lawrence (2002)

showed that “despondent interpreter mood caused significant negative mood changes in the deaf

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participant even when the therapist mood was neutral/cheerful” (p. 576). Although interpreters
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are impartial and have neutral impacts in other settings, therapy appears to be particularly

influenced by the interpreter’s own affective state. Brunson and Lawrence emphasized that
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therapists should conceptualize the interpreter as “dynamic member of a triadic therapeutic

process” as well as be cognizant of how the deaf client may or may not be affected by the

interpreter’s mood. Yet another notable consideration is that interpreters commonly socialize
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within the Deaf community on a regular basis (Mathos, Kilbourne, Myers, & Post, 2009) and

therefore, confidentiality may feel less guaranteed and concerning for Deaf clients (Mathos et al.,

2009; Connolly, Rose, & Austen, 2006). To illustrate this concept, imagine a Deaf woman has a

psychotherapy session with the use of an interpreter in which she tearfully discusses a traumatic

experience. Later that day, she sees the same interpreter at a social gathering (e.g., baby shower)

or later that week, she observes the interpreter working with her neighbor to interpret for a job

interview. One can imagine that, despite ethical and legal mandates for confidentiality (including

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the interpreter Code of Ethics; Cornes & Napier, 2005), she may feel uncomfortable or not

completely assured that details of her session will not be divulged.

Moreover, when there are a lack of competent interpreters, the resultant poor

communication in combination with lack of Deaf cultural awareness among healthcare staff can

lead to negative subjective experiences and significant declines in healthcare quality for deaf

individuals (Alexander, Ladd, & Powell, 2012). A study conducted in 2004 by the Royal

National Institute for the Deaf in London found that 77% of British Sign Language (BSL) users

experienced difficulty communicating with hospital personnel. Consequently, 33% of those deaf

patients were left with uncertainties about their medications or took the incorrect dosage.

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Additionally, studies show that D/deaf individuals demonstrate lower health literacy rates as
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compared to their hearing counterparts (e.g., Smith & Samar, 2016; Kushalnagar et al., 2015;

McKee et al., 2015). Health literacy is defined by the Institute of Medicine as “the degree to
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which individuals have the capacity to obtain, process, and understand basic health information

and services needed to make appropriate health decisions” (Nielsen-Bohlman, Panzer, & Kindig,

2004). Therefore, communication difficulties with healthcare staff may be further hindered by
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reduced health literacy and understanding of the terminology being used to communicate,

regardless of clarity of communication or access to the language through ASL.

This inefficiency in communication can be dangerous for deaf clients in medical settings

as well as within the mental health care system. Deaf individuals vary greatly in their

understanding of English mental health terms, with some terms only being recognized by 22% of

a Deaf sample (Steinberg, Sullivan, and Loew, 1998). Additionally, Steinberg, Sullivan, and

Loew (1998) found that Deaf individuals endorsed their Deaf friends as the most frequent source

(61%) for their knowledge of mental health terminology. Therefore, even if the interpreter is

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highly qualified and delivers an accurate interpretation, the Deaf individual may have a different

understanding of the terminology. For example, Steinberg, Sullivan, and Loew found that even a

term as integral to mental health as “therapist” was recognized in English by only 44% of Deaf

participants.

When a provider is not fluent in ASL, the D/deaf individual may rely on less effective

communication strategies such as speechreading (lipreading) or exchanging handwritten notes.

Only approximately 30% of English is accessible through speechreading (Dowell et al., 1982).

One study indicated that when individuals are asked to lipread select sentences without the larger

context of a conversation and rely solely on visual information (i.e., no auditory cues) lipreading

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word-recognition scores were accurate only 12.4% of the time (Altieri, Pisoni, & Townsend,
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2011). Such inexactitude requires a deaf patient to mentally fill in and fabricate the majority of

the conversation, which can lead to grave errors and misconceptions. Similarly, utilizing
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handwritten notes to communicate is incomparable to a typical spoken consultation. Not only is

note writing highly time-consuming, comprehension may be compromised by the decreased

literacy levels typically found within the Deaf community, with the average deaf high school
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graduate reading at a fourth-grade level (Holt, 1993). This may be due to limited access to

linguistically appropriate, quality education for deaf children, which in turn, affects the Deaf

community’s knowledge of the utility of mental health services as well as how to access such

services.

There is a sufficient body of research to suggest that deaf children’s reading scores fall

significantly behind those of their hearing peers (e.g., Kyle, Campbell, & MacSweeney, 2016; Qi

& Mitchell, 2012; Kyle & Harris, 2010; Kyle & Harris, 2006). Kyle, Campbell, and

MacSweeney (2016) discussed that even for deaf children whose intelligence scores fell in the

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 normative range, their reading outcomes were below those of their hearing counterparts.

Longitudinal studies have shown that deaf children develop reading skills at a slower rate due to

making significantly less progress over the course of an academic year as compared to hearing

children (Kyle & Harris, 2010). Therefore, this overall decrease in reading skills further limits

deaf individuals’ access to care through note writing as well as written handouts and forms.

Healthcare providers and clinicians need to be particularly aware of how decreased literacy rates

can affect the accessibility of informational handouts and treatment forms/worksheets.

Overall, the factors of speechreading, note writing, interpretation challenges, or cultural

miscommunications may hinder communication in various ways. Less effective communication

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can mean decreased quality of care for DHH individuals (Alexander, Ladd, & Powell, 2012).
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This reduction in quality may be particularly salient in therapeutic and mental health settings.

Mental health care relies on psychotherapy as a commonly used form of treatment.

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Psychotherapy, majorly comprised of talk therapy (American Psychological Association, 2016),

is inherently dependent upon effective communication (Ruesch, 1963). Communication is the

medium through which the intervention is delivered and received, and communication is the
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intervention itself. When compared to medical professions in which medications, instruments,

and surgeries typically serve as the main form of treatment, it is apparent that psychotherapeutic

interventions are significantly more dependent upon effective communication between the

provider and the client. Thus, communication barriers should be reduced when providing care,

especially mental health care, to DHH individuals.

Another substantial obstacle to accessing mental health services is the lack of culturally

affirmative treatments for the deaf. The literature highlights the importance and efficacy of

culturally adapting treatment for minority groups (e.g., Rathod et al., 2018; Smith, Rodríguez, &

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