Loss: not just death but also Deaf

Our ears are amazing organs that take frequencies and convert them into sound. Stop and think about the sounds around you now. Is there music in the background? Can you hear a barista or your partner starting dinner in the kitchen? Or perhaps even the birds tweeting in the trees? Our hearing gives us important cues and is a vital part of our reality.

As therapists, we are more keenly aware of how important hearing can be for communication and interconnection - listening and being listened to - in sustaining us and creating the capacity for individual empowerment. 

But would you know what to do if someone were experiencing hearing loss in your therapy room? Some barriers – like language - will likely be evident to you immediately. Still, it’s likely you will find yourself facing barriers you had not even been aware of because your training and supervision have not explored this practice area with you.  

I intend to begin addressing this in this article by looking at the topic of Deafness and hearing loss as it may present in your therapy room and with your clients. To start off, we will explore Deafness and why it’s important to have an awareness before exploring some of the issues that may come up among those experiencing Deafness or hearing loss in a therapeutic setting, the current state of our provision for Deaf people and reasons for its state; and then what we can do as a community.

Throughout this article, I will illustrate the issues discussed with my own experience as a person with Deafness/hearing loss. As a transactional analyst, I will use language familiar to this way of working. 

While this topic is broad, and one article will not cover everything, I want you to walk away knowing why being aware of the issues among the Deaf or hard of hearing is uniquely important, how Deafness could present in the therapy room, and the themes that may be prominent when it does, and what you can do to equip yourself to support your clients.

Deafness and its prevalence

Hearing loss and Deafness can impact us at any stage of life: it can be congenital (Deafness from birth), temporary or permanent. For some it will be degenerative loss (a continual loss from mild to profound), for others it is a 'stabilised' loss, i.e. loss of hearing to a level where it then stays. 

You may have noticed the capitalised D in Deafness; this is on purpose as it relates not only to medical hearing loss but also to the culture and history of Deafness. Members of this group have necessarily inherited sign language to communicate among themselves. This speaking of a separate language to a larger society has created its own beliefs and history – so Deafness is a cultural identity in itself. It also holds that those who are Deaf or experience hearing loss have a difference in the beliefs they hold about themselves and their connection to, or place within, the larger society. (Padden and Humphries 1988:2) 

There are currently 12 million Deaf and hard-of-hearing people in the UK, and 151,000 people use British Sign Language (BSL) as their first language. (RNID, 2022). Considering the UK population is around 69 million, roughly 17% of the UK population is Deaf, and 0.2% of the population uses BSL. This number is only growing - in theory, one in eight of your clients/patients could be Deaf or hard of hearing (but we will explore later why they’re currently unlikely to be).

Hearing loss and grief

As well as having their own cultural identity, Deaf people may have therapeutic concerns that arise from their Deafness. One of these I experienced firsthand was the place of grief and depression during the hearing loss process. 

The concept of loss brings to mind death, and this is no different when experiencing hearing loss. There is a real parallel between death and Deaf(ness).

I have known and have been experiencing the loss of my hearing since the age of five. I'm unsure how or why - neither is important for this article. I am, however, aware of the grieving process that this forced me into. Kubler-Ross’s (1969) model of grief has enabled me to reflect on grief in relation to my hearing loss. 

The denial stage of the process lasted 20 years for me. I first denied my hearing loss as a child - it gave me the impression that I was less of a human; I refused to wear my hearing aids because I could still hear everything, and I denied my hearing loss because I didn’t know what it meant. I felt alone. My family did not know what it meant to have hearing loss – I was the odd one out in this sense. I experienced depression too - when I tried to use my hearing aids, the world immediately became. Every sound became uncomfortable and amplified. 

In school, I would be bullied and called bubble-gum ears because of the hearing aids I had. And this was in a school with Deaf students. I was further singled out because I could still hear. This was worsened by the lack of support in understanding the impact hearing loss had on me from both my family and the educational system. 

More recently, my hearing has worsened, leading me to the bargaining and anger stage, as my hearing continues to deteriorate. In 2022, I had my hearing test, and my hearing had reached the border for profound hearing loss at some frequencies. I was fuelled by anger at this decline. I raged through research on stem-cell studies - could something be done to help me? I am not ready to be Deaf yet. I spoke to specialists in Turkey who said there is no hope for stem cells yet. This left me in hopelessness and despair for some time before stepping into my acceptance phase. 

Tonkin’s (1996) model of adapting to loss and growing around it, really fits with my experience of how I have reached acceptance in my grieving process. Whilst my grief hasn’t changed in shape or size, my innate human capacity to adapt has meant that my life has grown around it in response to the loss. I feel my own oscillation between both the Loss and the Restoration (see Stoebe and Schut’s Grief Compass, 1995, fig. 1).

Provision for the Deaf and those with hearing loss

As I went through my own journey, I had the experience of therapy that could not address this type of bereavement. And I suspect I am not alone in finding current mental health provision lacking – something that can have big problems.

Deaf people and those with hearing loss, who also struggle with their mental health, are a ‘minority within a minority’ and access to appropriately inclusive counselling and psychotherapy is limited. This lack of appropriate access is seemingly leading to Deaf people turning to alcohol more to cope (National Institution for Mental Health England 2005).

With a lack of practical inclusion (i.e. sign language proficiency) and the lack of contextual understanding discussed above, we are potentially missing (or mistreating) up to 12 million clients. 

And, little is being done to address this exclusion in the literature. The little research out there which addresses mental health issues relating to Deafness shows that people with hearing loss suffer from greater levels of anxiety and depression and suffer greater cognitive decline, leading to dementia. This population also has a higher rate of suffering from psychosis. (Help.Org)

Even in the TAJ (Transactional Analysis Journal) I could only find one article which explicitly discusses issues around Deafness: A Transactional Analysis Model for Psychological Work with Pediatric Patients with Hearing and/or Speech Problems Anna Rita Carone Craig & Francesco Craig 2005. In this, they open by stating “It is thus important to provide counseling that supports psychological and social adjustment so that problems do not become chronic” (Craig & Craig, 2005). This was a statement made in 2005. We are now 20 years on and not much has changed in our field of psychological support.

Why are we where we are?

Why do we, as a community, ignore this group? I consider the historical culture and attitudes in which Deaf people have been living a huge factor. At the 1880 Millan Conference, Alexander Graham Bell (father of the telephone) advocated for a complete ban on Sign language in education (Deaf History). He also did not want the Deaf to intermarry. This created an us vs. them mentality back in the 1880s, and only recently has Deaf education moved from oralism to bilingualism/signed. 

This attitude had set the stage for medical communities to attempt to ‘fix’ the Deaf, while social workers were meant to be their advocates. We see this reflected in the history of counselling and psychotherapy. Freud - the father of modern psychotherapy through which everything is filtered - was a medical doctor. He was concerned about fixing and curing. This thread is carried through into Transactional Analysis. Therefore, historically, if we take on the medical model, we could make the assumption that a Deaf person had something “lacking” from being considered a person in full until this “condition” was ‘fixed’. This is the cultural memory that I assume has been passed through the generations of Deaf people in history. 

In recent years, we have seen a massive increase in awareness and access to psychological therapies and training to support other specialist areas, such as neurodivergent clients, and rightly so. The ADHD population currently accounts for 2.6% of the population, however (ADHD UK). Where is our accountability for meeting the needs of the Deaf community within counselling and psychotherapy? 

My concern is whether we are at what Goulding described as an impasse (1978). 12 million people cannot be reached or communicated with at the same level as their hearing peers. Are we, as therapists, discounting (Schiff et al. 1975) the Deaf community without realising it? 

More research and explorations are taking place abroad — as a UK community of therapists, we are behind. For instance, the International Institute of Psychoanalysis (IIP), based in Brazil, has a number of trainers and researchers studying and working with Deaf people in Therapy. Whilst the focus of their research is on the use of language from the Psychoanalysis perspective, it is more than the UK is currently doing, both from a research point of view and that of accessible provision.  

My view is that we need to supply therapists with Deaf awareness training specifically for the therapy industry. While general Deaf awareness training is good, it will not give you enough tools. We need therapists to become aware and, where possible, train in communicating with Deaf people in their preferred language. Even simple conversational signs will encourage the Deaf community to build trust with the hearing therapist.

How should we support a Deaf or hard of hearing client?

The medical world has made some great advancements. Medical technology, as assistive technology, has advanced so much in just the last five years. Behind-ear hearing aids are practically invisible now (which appeals to me for discreteness) — and they are even Bluetooth compatible with our phones. Those who meet the criteria may choose the newer technology offered through surgical options such as cochlear implants or BAHAs (Bone-Anchored Hearing Aids).

Social support through a community will necessarily evolve, too, as people explore new ways of communicating and adjust again to everyday challenges. What is missing, however, is therapeutic support in the Deaf community.  

Becoming Deaf aware – the industry

Before we consider how we can be more aware of the needs of our Deaf or hearing-loss clients, we need to ensure they can find provision. 

Some change is happening — services such as Sign Health have therapists who can provide therapy in different modalities, Samaritans have a text line, and Shout, a phone-based helpline, now has a text-based system to support Deaf people in crisis (note: specialist text services are necessary due to the different languages in which Deaf people text). 

A quick search on the NCPS, BACP, and UKCP registers is revealing. We can filter language and select sign language. However, profiles do not currently state whether a therapist can competently work with a BSL user (that is, a qualified Level 6 or native BSL user). This is to minimise risk to clients as we are working with a minority group that requires specialist support. 

And then we need to start practising what we preach. I have been to events where accessibility has been a key discussion, but there was not access for a wheelchair user or a blind person, and I have not seen interpreters provided at events to give access to Deaf people or Deaf therapists.

We will eventually need to act anyway. The BSL Act (2022) is now enshrined in law. This is predominantly a parliamentary requirement for BSL in political communications currently (you may have seen an interpreter at the COVID-19 briefings, for example). The aim is for this to be extended into the everyday lives of the Deaf community, so eventually, we will need to be inclusive through force, if nothing else.

Becoming Deaf aware – ourselves

We should not wait to be forced, and as therapists, we care about all our clients. So, we should look at becoming deaf-aware ourselves. A very large step could be to learn sign language completely — which would be great — but it is a bit of a leap. 

From my own experience, the following would make you a more Deaf aware therapist and be prepared to support that increasing proportion of Deaf patients and those with hearing loss:

• Learn some basic sign language – this will allow you to have simple conversations with a Deaf person.
• Understand the impact that Deafness or someone’s progressive hearing loss might have on their therapeutic needs. You are more likely to work with someone with hearing loss than Deaf.
• Understand the impact of community and culture may have had on the client’s agency or autonomy in their interactions with you. Personally, I found I could not speak up about conditions in my past therapy to ask for them to be changed. Even a simple request like – can we swap seats?
• Consider basic adaptations in your therapy room. In my own therapy, a plain background and lack of clutter in the room allows me to focus (especially true of those who lip read)

Learning to adapt to the ever-silencing world is scary, and the journey to acceptance is difficult. As therapists, we need to actively support clients in building the support system around them. Our role as therapists is to educate ourselves in those ways. How many of you have been on any form of Deaf awareness training? How many of you have said, ‘I would love to learn Sign Language’ but have not taken the step to learn the basics?

If you take nothing else from this article, I hope that you consider the following:

• Would you know what to do if a Deaf or hard-of-hearing person walked into your therapy space?
• Do you have the skills needed to work with the Deaf and hard-of-hearing community? 
• Do you want to learn these skills to become a Deaf aware therapist? 
• Will you invest in an underrepresented community that needs even a basic level of support?

References:

• Padden, C. and Humphries, T. (1988) Deaf in America, Cambridge, Mass, Harvard University Press.
• RNID. (n.d.). Prevalence of deafness and hearing loss.
• Craig, A.R.C. and Craig, F. (2005). A Transactional Analysis Model for Psychological Work with Pediatric Patients with Hearing and/or Speech Problems. Transactional Analysis Journal, 35(3), pp.262–273. 
• Anon, (n.d.). About ADHD | ADHD UK.
• Deaf History. 1880: the Milan Conference. [Accessed 26 July 2023]
• Help.Org. (2023). Hearing Loss and Mental Health.  Last updated: 17 October 2023. [Accessed 26 November 2023].