• Need for Special Services• Communication in Psychiatry• Misdiagnosis with examples• Do Deaf People hear voices• Assessments – MDT• Inpatient Assessments and Treatment• Interpreting matters

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OUTLINE

A SIMPLE CURE – D.O.H.

• 35% - experienced difficulty communicating with Doctor

• 28% - difficult to contact their surgery to get an appointment

• 35% - left unclear about their condition

• 33% - unsure about instructions for medication – taken wrong amount of a medication

• 19% - missed more than five appointments in a year

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38.1% Deaf Population (S. Ridgeway)

12-17% Non-Deaf Population

GENERAL HEALTH QUESTIONNAIRE

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Communication is an influential determinant of inequality of access to, engagement with

and benefit from psychiatric services

COMMUNICATION

BHUI et al (August 2015)BJPsych

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• Persistent inequalities• Lack of engagement• Poorer access to effective services• Psychological interventions• Conflict between patients and staff

MINORITY ETHNIC GROUPS

BHUI et al (August 2015)BJPsych

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• Communications provide information • Deal with uncertainty/reassurance• Changes to the care to remedy dissatisfaction• Questions can also be helpful for patients who may

fear what is happening and that no one can help

IMPROVED OUTCOMES (1)

BHUI et al (August 2015)BJPsych

SHELTER FROM THE STORM

• Communication is central to psychiatric assessment• Diagnosis, treatment adherence and recovery• Professionals struggle to empathise, assess the

patient’s emotions and understand symbolic and metaphorical idioms of distress

IMPROVED OUTCOMES (2)

BHUI et al (August 2015)BJPsych

SHELTER FROM THE STORM

• Compromise clinical decisions/accurate diagnosis• Lead to disengagement/poor compliance• Cultural competence in communications• Explore patients’ narratives about their illness

IMPROVED OUTCOMES (3)

BHUI et al (August 2015)BJPsych

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• Diagnosis and Assessment• Discussion of treatment expectations• Understanding and empathy • Psychological interventions• Rely on conversation and challenging cognitive bias

THERAPEUTIC COMMUNICATION

BHUI et al (August 2015)BJPsych

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• Practical changes to the venue• Modifications of the content of written materials• Interventions in terms of language or metaphors• Use of Interpreters

ADAPTATION

BHUI et al (August 2015)BJPsych

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I.N.C.L.U.D.E.

• Intervention with• No• Communication• Leads to• Undermining the Rights of• Deaf People to• Equality

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IF YOU TALK TO A MAN IN A LANGUAGE HE UNDERSTANDS, THAT GOES TO HIS HEAD.

IF YOU TALK TO HIM IN HIS LANGUAGE, THAT GOES TO HIS HEART

Nelson Mandela

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DEAFNESS AND MENTAL HEALTH

Possible Misdiagnosis

• Deafness mistaken for Intellectual impairment• Mental Illness can be missed• Mental Illness diagnosed where none exists

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EEC STUDY – CHILDHOOD DEAFNESST MARTIN ET AL

• 3000 – Children

• 29% – Disability • 9.9% - Intellectual impairment

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MINIMAL SIGN LANGUAGE

Deaf people in mental health settings often have language dysfluency

• Some Deaf lack general knowledge/information

Exacerbated by:• Learning Disability• Communication breakdown• Impoverished emotional environment• Lack of access to appropriate education/poor incidental learning• Poor interpersonal and social relationships• Psychotic Processes

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Dysfluency Compared

DeafHearing

Incoherent MLS Compre- Proficient Fluent Eloquent hensible

Professor Robert Pollard – University of Rochester

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DO DEAF PEOPLE HEAR VOICES

• Residual Hearing• Phantasmal Voices• Tinnitus• Hallucinations of Communication• Analogous to Auditory Hallucinations• Hallucinations in Sign Language• Auditory Hallucinations

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Non Psychotic

Psychotic

AUDITORY PHENOMENA

• Tinnitus

• Phantasmal Voices

• Residual Hearing

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People born profoundly deaf

• Can understand the voices

• Voices are non-auditory – no sound, no pitch, no volume

• May see image of hands signing, lips moving or even vague figure

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J Atkinson

J Atkinson

J Atkinson

J Atkinson

J Atkinson

J Atkinson

EPIDEMIOLOGY

• Same incidence of Schizophrenia as hearing people

• PD and Behaviour/Adjustment problems increased

• More likely to have Organic Syndromes

• Not less likely to suffer from depressive or neurotic disorders

• No more likely to suffer from paranoid psychoses

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Mental Illness

Pervasive Developmental Disorders

Problems Related to Deafness and Communication

Personality Disorder

Learning Disability

DIAGNOSIS

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0

10

20

30

40

50

60

5 10 15 20 25 30 35 40 45 50 55 60 65 70 75+

AGES OF 250 REFERRALS

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ASSESSMENT VARIOUS SETTINGS

• Outpatient Clinics• Domiciliary Visits• Other Hospitals• Court Reports• Prisons/Remand Centres• Probation Offices/Solicitors

• Residential Centres for Deaf People• Schools and Colleges for Deaf Children• Deaf Clubs

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ASSESSMENT OF DEAF PEOPLE

• Deafness and Development• Modes of Communication• Family Dynamics• Social / Relationship• Intellectual Ability• Educational Issues• Mental Disorder / Behaviour• Forensic Issues• Psychosexual Issues• Deprivation

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MDT ASSESSMENTS

• Mental State Assessment Psychiatrists/Psychologists• Risk Assessment Nursing Staff/Assistants• Social Care Assessment O.T./Art Therapist• Psychological/Neuropsychological SALT• Speech & Language Assessment Social Workers• O.T. Assessment Administrators• Community Assessment Interpreters• Family Assessments

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• Make questions specific not vague• Ask time questions carefully• Clarify name signs, placement and directional verbs • Ask what signs you don’t know mean• Check understanding• Use experienced interpreters and deaf relay interpreters

How to communicate with Deaf people who are mentally ill

• Limited emotional vocabulary• Limited world view and knowledge gaps• Don’t assume knowledge• Poor literacy• Misunderstandings• Nodding

Be aware of possible

• Awareness of:• Cultural, Linguistic, Psycho-Social Aspects of Deafness

• Understanding of:• Causes, Associated conditions, Deprivation, Development

• Facility in:• Sign Language• Communication Modes

KNOWLEDGE AND SKILLS (1)

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KNOWLEDGE AND SKILLS (2)

• Mental Health Issues• Mental Health Legislation• Forensic Issues• Risk Assessment and Management• Safeguarding

• Actuarial Risk Assessments• HCR-20• RSVP

• File review, psychometric tests • Structured clinical judgement• Factors likely to increase/decrease risk • Risk formulation / management plan

RISK ASSESSMENTS(HEARING)

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Hearing Population

• Actuarial risk assessments valid / reliable • Can be used Deaf population, with caution• Meaningfulness of certain items need to be considered

- Deaf developmental processes • Access to resources• Interpersonal Issues

DEAF RISK ASSESSMENTS

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• Items considered with caution in Deaf assessments • Employment• Early Maladjustment• Deprivation • Personality issues are less predictive of Risk in Deaf

population • Relevance of future Risk in relation to needs and resources

HISTORICAL RISK FACTORS: DEAF

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• Deaf Cognitions• Belief that offence occurred because of deafness• Don’t know/Don’t understand

• Attitudes Towards Hearing People• Negative and hostile attitudes towards hearing people • Paranoia misdiagnosed assessed by Mental Health professionals

• Hearing Environment/Services• Stressful / Poor communication / Isolation• Staff do not have the skills to assess changes of Risk

• Specialist Services requested to avoid mistakes

FACTORS UNIQUE TO DEAFNESS

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DEAF CENTRED THERAPIES

• Therapeutic Milieu• SALT• O.T.• Psychoeducational • Psychological Interventions

Sex Offender Treatment Substance Misuse Work Offence Related Work Anger Management

Group IndividualCBTA

DAPTED

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The environment is a therapy

• We think of tablets and counselling as therapies

• The environment is a powerful therapeutic tool

• Deaf people are particularly attuned to visual inputs

• This means the environment can be an especially powerful

therapeutic tool to help Deaf people achieve mental wellbeing

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H. Miller

The Therapeutic Milieu

• Therapeutic environment in which treatment is conducted• The therapeutic environment could be a source of improvement• The milieu or ‘life space’ provides a safe environment that is rich with social opportunities and feedback from caring staff• The milieu is mindful of the physical institutional, psychological and social environment• The environment is Deaf Aware

SHELTER FROM THE STORM

H. Miller

Hearing hospitals do not promote normalisation for Deaf people

• Visually very ‘noisy’• Confusing communication (writing) • No Deaf Awareness• Tired and stressed trying to concentrate• Feel isolated and frightened• Never know what is happening• No Sign Language Users

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Communication

• Subtitles on TVs• Use of pictures in signage• Visual materials displayed• All written materials are simple and avoid use of jargon• Pictures of staff are displayed• Visual timetables of activities

SHELTER FROM THE STORM

H. Miller

Communication

• Deaf staff work on the ward

• All staff learn Deaf awareness and Sign Language

• The ward has a Signing Policy

• Staff and patients work closely with interpreters who

have expertise in mental health work

SHELTER FROM THE STORM

H. Miller

ROLE OF INTERPRETERS

• Professional Sign Language Interpreters (NACDP)

• Training in Mental Health and Deafness

• Interpreter must be familiar with language dysfluency

• Regional Variations

• Do not use well meaning friends/relatives/staff

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KNOWLEDGE AND SKILLS INTERPRETING IN MENTAL HEALTH SETTINGS

• Recognised qualifications, Registration with National Body• National Register of Communication Professionals working with Deaf and Deaf Blind• Ability to modify language – Language Deprivation• People with Learning Disabilities, ASC• Dysfluency / Minimal Sign Language• Information as signed – not try to make sense (Psychoses – Thought Disorder)

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DO’S AND DON’TS

• Speak to and look at the Deaf person (not the Interpreter)

• Discuss with Interpreter prior to interview

• Clarify terminology and jargon

• Be aware that everything you say will be interpreted

• Assessment takes longer than with a hearing person

• Book 2 Interpreters/Breaks

DO

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• Use the third person e.g. “is he saying this?”, “Ask him”

• Ask Interpreter to comment on patient’s mental state

• Feel de-skilled if lack of coherent responses/simplify/clarify

• Feel embarrassed if asked to rephrase questions

• Accept ‘nodding’ as evidence of understanding

DO’S AND DON’TS

DO NOT

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CHALLENGES FOR INTERPRETERS

• BSL - articulate, emotive, descriptive, full of nuance

• Deaf people with mental health issues can have limited communication

• Proportion of Deaf population have ‘minimal language’/Dysfluency

• Idiosyncratic sign language/family home signs

• Finger spelling but words misspelt

• Not been given enough context to interpret

• Do they step out of role – to intervene

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OPEN INPATIENTBEDS IN UK

(16)LONDON

(12)BIRMINGHAM

(14)OLDHAM

(18)MANCHESTER

SHELTER FROM THE STORM

RAMPTON HOSPITAL

HIGH SECURE

NOTTINGHAMSHIRE

DEAF SERVICES SINCE 2011

MANCHESTERLONDON

BIRMINGHAM

ALL SAINTS

ST ANDREWSNORTHAMPTON

MEDIUM

ALPHABURYLOW

ST MARYSWARRINGTON

MEDIUM

ALL SAINTSOLDHAM

LOW

FENCE

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12

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46

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SHELTER FROM THE STORM

COMMUNITY

• Outpatient programmes

• CPN and Domiciliary Treatment

• Advocacy and Counselling

• Occupational Therapy and Home support

• Day Centres

• Residential Centres/Hostels

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Family

Social Worker

Local Doctor

Hospital Doctor

Hospital Ward

HEARING

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Family

Local Doctor

Hospital Doctor

Hospital Ward

Social Worker

DEAF

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Resp

onse

to T

reat

men

t

Team Effectiveness

Initial Provision

Pseudo Team

Potential Team

Real Team

Highly Effective

Team

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EDUCATIONAL ROLE

• Post Graduate Trainees• Psychiatrist/GPs• Audiologists• Speech & Language Therapist

• Social Workers• Counselling Certificate/Diploma• Mental Health and Deafness – Deaf Studies• Training Days – Open Days• Conferences

• BSMHD/ESMHD/WFD• Placements

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REFERRAL FROM A GP(1987)

“This deaf man has been very aggressive and challenging. He may be Schizophrenic,

mentally retarded or anything. Please do the necessary.”

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“As Ms Smith is profoundly Deaf, I would be grateful if you could possibly arrange for her to see a trained counsellor, who is able to do

sign language with knowledge of the deaf culture”

REFERRAL FROM A GP(2006)

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LUNCH

SHELTER FROM THE STORM