Clinical Considerations for Working with Deaf Clients

Clinical Considerations for Working with Deaf Clients

Cassandra L. Boness, M.A.

Doctoral Candidate, University of Missouri

Worldwide, nearly 360 million people, or 5% of the world’s population, have disabling hearing loss (World Health Organization, 2015). According to the 2010 U.S. Census Bureau, about 7.6 million people (3.1%) in the United States have experienced a hearing difficulty, 1.1 million of who have severe difficulty hearing. Research demonstrates high rates of substance abuse and mental illness among individuals with hearing loss. Further, access to treatment is low and mental health professionals are generally mistrusted (Fellinger, Holzinger, & Pollard, 2012; Leigh & Pollard, 2003). This points to the need for mental health professionals that are competent to treat individuals with hearing loss, specifically the Deaf.

There are different types of hearing loss. These include: Deaf, deaf, Hard of Hearing, and Late Deafened. Therefore, individuals with hearing loss are heterogeneous group of individuals. The current article will focus on the Deaf. The “D” is capitalized as an affirmation of culture. The Deaf do not see themselves having a disability in need of a cure, but instead see themselves as a cultural and linguistic minority. Therefore, psychologists should treat the Deaf as they would treat any other cultural or linguistic minority. To provide the best mental health services, this requires multicultural competence on the behalf of the provider. Multicultural competency for working with diverse groups includes: awareness, knowledge, and skills (see Sue & Sue, 2016).

Although the current article is not intended to give comprehensive background on Deaf Culture, a brief summary is necessary. Deaf Culture is defined as a set of values, behaviors, social beliefs, history, art and literary traditions, and institutions of people who have a hearing loss and communicate through American Sign Language (ASL). Norms in the Deaf culture include the use of ASL, Deaf cultural pride, Deaf identity, and eye contact. Value and traditions include, for example, storytelling and showing versus telling. Over 90% of children born with a hearing loss are born to hearing parents. Further, few hearing families with a Deaf child will learn to sign (Mitchell & Karchmer, 2004). For a more comprehensive background see Boness (2016).

Titus and Guthmann (2013) outline five competencies for professionals who want to use evidence based practices with diverse populations, including the Deaf. These include: (1) recognizing the power of a historical perspective (e.g., the Deaf have a long history of being oppressed by hearing people and professionals), (2) appreciating the impact of cultural explanations and stigmas (e.g., fears about losing confidentiality and lack of information about available services deter Deaf people from accessing treatment; Steinberg, Sullivan & Loew, 1998), (3) respecting cultural variations, expectations, and communication (e.g. the psychologist will need to assure confidentiality due to how tight-knit the community is), (4) creating an atmosphere of cultural safety (e.g., minimizing everyday frustrations for people in the clinic by, for example, asking the client about their communication preference and accommodating them), and (5) showing adaptability and flexibility (e.g., there are no evidence-based treatments for the Deaf, so providers need to adapt to client preferences and needs).

Further, there are a number of ethical concerns that should be considered before taking on a Deaf client. We will consider a few here, including: (1) competence, (2) multiple relationships and boundary issues, (3) confidentiality, (4) assessment, diagnosis and evaluation, and (5) communication and using interpreters (Boness, 2016). When considering competence, the psychologist should consider: their own biases and assumptions about the Deaf, factors associated with Deaf culture and ASL (including clarifying misconceptions about therapy), have an awareness of linguistic and communication preferences and obtain training, experience consultation or experience to ensure competence. Given the closeness of the Deaf community, multiple relationships and boundary issues are necessary considerations. Psychologists must consider the fact that clients may know each other from other contexts, and the client and clinician may encounter each other outside of treatment settings. When making decisions about multiple relationships and boundary issues, the psychologist must consider the potential for risk of exploitation, loss of therapist objectivity, and harm to the professional relationship. Similarly, multiple relationships can complicate confidentiality and it is therefore important to ensure that clients are informed about their right of confidentiality, as well as the limits. Given many Deaf clients will not be familiar with the therapy context, the clinician may need to spend more time on confidentiality than they might with a hearing client. As with any other cultural/linguistic minority, it is absolutely necessary to consider culture and language in assessment, diagnosis, and evaluation and clinicians should be conservative in drawing conclusions without taking these factors into consideration. Further, the reliability and validity of the instruments used to draw conclusions should be evaluated in light of the norms they are based on. Last, it is absolutely imperative for a hearing therapist that is not fluent in ASL to use an interpreter when working with a Deaf client. When working with an interpreter, the therapist must consider rule for working with an interpreter, including potential challenges such as ensuring accurate interpretation.

Overall, there is a dire need for mental health professionals that are competent and willing to work with individuals from the Deaf culture. Before professionals consider treating a Deaf client, an understanding of Deaf cultural is imperative. Further, they must the relevant consider treatment adaptations and ethical issues. When in doubt, referrals should be made to treating professionals that are competent to work with Deaf clients (which is rare), or adequate consultation and supervision should be sought. For a more in depth discussion see Boness (2016).


Boness, C. L. (2015). Treatment of Deaf Clients: Ethical Considerations for Professionals in Psychology. Ethics & Behavior, 8422(September), 1–24.

Fellinger, J., Holzinger, D.,&Pollard, R. (2012). Mental health of deaf people. The Lancet, 379, 1037–1044.

Leigh, I. W., & Pollard, R. Q. (2003). Mental health and deaf adults. In M. Marschark & P. E. Spencer (Eds.), Oxford handbook of deaf studies, language, and education (pp. 203–215). New York, NY: Oxford University Press.

Mitchell, R.E., & Karchmer, M.A. (2004). Chasing the mythical ten percent: Parental hearing status of Deaf and Hard of Hearing students in the United States. Sign Language Studies, 4(2), 1380163.

Steinberg, A., Sullivan, V.J., Loew, R.C. (1998). Cultural and linguistic barriers to mental health service access: The Deaf consumer’s perspective. American Journal of Psychiatry, 155(7), 982-984.

Sue, D. W. & Sue, D. (2016). Counseling the Culturally Diverse: Theory and Practice (7th Edition). New York: John Wiley & Sons.

Titus, J.C., & Guthmann, D. (2013). Using evidence-based practices with people who are Deaf or Hard of Hearing. Counselor. Retrieved from

World Health Organization. (2015). Deafness and hearing loss. Retrieved from factsheets/fs300/en


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