An Invisible Intersection: Mental Healthcare for the Deaf Community
The 2011 Census of India (1,2), tells us that the country has roughly 1.2 million people with disability in hearing, and 1.6 million people with disability in speech, with considerable overlap. According to The Rights of Persons with Disabilities Act, 2016,(3) hearing disability includes the deaf and hard-of-hearing. This article attempts to throw light on the lack of availability and accessibility of mental healthcare for this population (hereafter, “the Deaf community”).
The Mental Healthcare Act 2017(4) upholds the right of every person to access mental healthcare without any discrimination based on disability. Yet, with only 250 certified sign language interpreters and 9000 psychiatrists(5), and no clear data on the number of counselors, such care is barely accessible for the Deaf community.
During our conversations with professionals(6,7,8,9) who work with the Deaf community, and with mental health professionals and institutions, we rarely came across any MH practitioners equipped to communicate with the Deaf community, beyond informal career or marriage counseling, and mentoring.
Worldwide, there is significant research done by psychologists that addresses ways of providing psychotherapy for Deaf clients and the role of interpreters in Deaf counseling, and emphasizes the importance of these MH caregivers knowing Deaf culture. There are also organizations that offer counseling for the Deaf community, including some governments, like the Government of Wisconsin. The National Deaf Services, part of the NHS in the UK,(10) is committed to providing MH services to the Deaf and their family members, and promoting respect for Deaf culture and sign language.
However, no such facilities are available in India, where the stigma associated with both mental health and disability causes their intersection to remain largely neglected. Even the law governing mental health and disability is silent about the mental health needs of the Deaf community. Besides, the general tendency is to assume that the Deaf have the same requirements and manifest MH issues in the same way as hearing individuals, and thus need no specialized services other than the support of assistance (live captioning, sign language interpretation, and so on). However, our research indicates that such assumptions may not always be valid. To work effectively as an MH professional in this area calls for a greater understanding of Deaf culture – which includes social, historical, psychological, rehabilitative, linguistic and cultural representation. Such professionals need to work, first, on their own biases with regard to the Deaf community. Our research also suggests that people who can hear and speak often believe Deaf persons have qualities which mark them out as different in other ways, like being particularly virtuous, or constantly grieving over their hearing disability.
Mental health problems in the Deaf community are similar to those experienced by other minority communities: some of the major concerns are substance dependency, suicidality, trauma related to intimate partner violence, abuse by known and unknown persons, unemployment or underemployment, isolation and segregation, low self-esteem, fear of the external environment.(11) We perceived a deep absence of empowerment, and concomitant loss of autonomy, for the Deaf community in India. Interpreters for Deaf people are often family members, which can make it difficult for the Deaf to communicate freely with MH professionals about their sources and feelings of distress – may in fact intensify distress. Having MH professionals from the Deaf community also becomes challenging, as professional boundaries may become difficult to maintain.
Recommendations: mental healthcare support for the Deaf community
Developing a mental health affirmative ecosystem for the Deaf community calls for a two-fold strategy: working on MH awareness for Deaf persons, on the one hand; inculcating awareness of Deaf culture amongst MH professionals, on the other. The former arm of such a strategy would involve enabling education for Deaf persons on aspects of mental health, while striving to remove the associated taboo. Given how “dumb” and “mute” have been used as belittling expressions, the Deaf may already be dealing with deep experiences of stigma. It would be necessary, also, to equip family members, teachers and interpreters with a basic knowledge and understanding of MH, and to set up peer support and emotional first aid mechanisms – for which it would be crucial to emphasize, with respect to confidentiality and other ethical considerations, the differences between regular conversation and counseling.
The second part of the strategy points to the need to create a Deaf Affirmative Counseling Practices course for MH professionals so that they acquire a better understanding of the Deaf world. The content of such a course could include the basics of the language and communication, building cultural competence, addressing personal biases, and aspects of working with interpreters.(12,13)
A better MH ecosystem that makes counseling more accessible for the Deaf community might comprise the following measures:
Establishing alternative schools of counseling or psychotherapy that are more visually-oriented could be useful. Besides art therapy, mindfulness techniques based on the use of the other senses, and alternate mediums such as chat-based apps might prove particularly helpful. Having members of the Deaf community pilot and design specific interventions might well enhance the efficacy of such therapies.
Designing psychological assessment scales: As highlighted earlier, the experience of mental disorders for Deaf persons may differ widely from those of other people, and thus it is imperative to construct better informed psychometric scales that can be employed to run clinical examinations for appropriate treatment plans.
Special training for sign language interpreters: It would be beneficial to have persons with sign language literacy and with knowledge of the ethics of the counseling relationship to assist Deaf people during their sessions. If an interpreter is used, their being trained in aspects of literal interpretation, confidentiality and objectivity becomes necessary. A close examination and review of this triangular relationship would also foster stronger therapeutic alliances. It is important, also, to be aware of the fact that sign languages are diverse and may differ in different parts of India.
Amendments are needed to the Rights of Persons with Disabilities Act and the Mental Healthcare Act, so as to incorporate guidelines for accessibility of mental healthcare for people with all kinds of disabilities, including Deaf persons.
Mobilizing funds is, of course, essential, including advocacy for a percentage of GDP to be allocated towards the education and healthcare requirements of the Deaf community. Such funds could be used for facilitating inclusive education in sign languages in schools and hospitals;(14) generating employment opportunities for Deaf persons; encouraging research and innovations in technology using artificial intelligence to design assistive techniques (like the sign-to-text converting glove).(15)
Media and culture are of critical significance for this enterprise. Having stage shows of various kinds, and series and films and news programs on TV, in sign language, with live captioning or with interpreters rooted in Deaf culture, would not only add colors of entertainment and information to the lives of Deaf people, but also make for a society that is more inclusive of the Deaf community.
This article outlines some initial steps towards mental healthcare for the Deaf community and does not purport to discuss the intersectionality of identities of the Deaf community with other minority groups.
“Interpreters for Deaf people are often family members, which can make it difficult for the Deaf to communicate freely with MH professionals.”
 GOI (2001). Census of India 2001: Provisional Population Totals. Registrar General and Census Commissioner of India, Ministry of Home Affairs, New Delhi, India. Available at: http://www.censusindia.gov. in/2011census/PCA/pca_highlights/pe_data
 Balakrishnan, A., Kulkarni, K., Moirangthem, S., Kumar, C. N., Math, S. B., & Murthy, P. (2019). The Rights of Persons with Disabilities Act 2016: Mental Health Implications. Indian journal of psychological medicine, 41(2), 119–125. https://doi.org/10.4103/IJPSYM. IJPSYM_364_18
 The Rights of Persons with Disabilities Act (2016). Gazette of India (Extra-Ordinary); 28 December. 2016. Available from: http://www.disabilityaffairs.gov.in/ uploaad/uploadfiles/files/RPWD/ACT/2016.pdf .
 Mental Healthcare Act (2017). Available from:https:// www.prsindia.org/uploads/media/Mental%20Health/ Mental%20 Healthcare%20Act,%202017.pdf
 ET prime, (2019, October 10). Mental health in India. The Economics Times. https://economictimes. indiatimes.com/magazines/panache/mental-health-inindia- 7-5-of-country-affected-less-than-4000-expertsavailable/ articleshow/71500130.cms?from=mdr
 M. Goretti, personal communication, March 15, 2020
 V. Jayaswal, personal communication, March 15, 2020
 A. Bagadia personal communication, April 26, 2020
 V. Jayaswal, personal communication, March 15, 2020
 Southwest London and St. George’s Mental Health NHS trust. (n.d.). National Deaf Services. https://www. swlstg.nhs.uk/our-services/specialist-services/nationaldeaf-services
 Boness C. L. (2016). Treatment of Deaf Clients: Ethical Considerations for Professionals in Psychology. Ethics & behavior, 26(7), 562–585. https://doi.org/10.10 80/10508422.2015.1084929
 Whyte, A., Aubrecht A., McCullough, C., Lewis, J., Thompson-Ochoa, D. (2013, October 01). Understanding Deaf people in counseling contexts. Retrieved July 1, 2020 from https://ct.counseling.org/2013/10/ understanding-deaf-people-in-counseling-contexts/
 Jaiswal, N. (2017, January 04). With a deaf community of millions, hearing India is only just beginning to sign. The World. https://www.pri.org/ stories/2017-01-04/deaf-community-millions-hearing india-only-just-beginning-sign
 Petcosky-Kulkarni, K. (2018, January 14). A Mom Fights to get Education for her Deaf Daughters. Goats and Soda. https://www.npr.org/sections/goatsands da/2018/01/14/575921716/a-mom-fights-to-get-aneducation for-her-deaf-daughters
 Wanshel, E. (2016, April 28). Students Invented Gloves That Can Translate Sign Language Into Speech And Text. Huffington Post. https://www.huffingtonpost. in/entry/navid-azodi-and-thomas-pryor-signaloudgloves- translate-american-sign-language-into-speechtext_ n_571fb38ae4b0f309baeee06d?ri18n=true