Policy Paper – Mental Health

a. The agreed position of IDS on the topic of mental health
b. The vision of IDS with respect to mental health service provision for Deaf people

For the purpose of this paper, we use the term mental health to encompass both mental health and mental illness. Further, we use Deaf mental health professionals as an umbrella term to include roles such as counsellors, psychotherapists, psychologists, mental health nurses and psychiatrists.

1.1 Consultation with Deaf people

As a Disabled People’s Organisation (DPO), the Irish Deaf Society emphasises the principle of the UN Convention on the Rights of Persons with Disabilities (UNCRPD) that disabled people and our representative organisations must be consulted on all decisions which impact our lives, not just on legislation specifically focussing on disability. Consultation should result in meaningful engagement, meaning that DPOs input must be genuinely taken on board, adopted wherever possible, and that clear explanations are provided wherever DPO recommendations cannot be adopted. As outlined under the UNCRPD, DPOs must be involved in consultation processes from the planning or design stage onwards. Ireland is a signatory to the UNCRPD, and as such, has undertaken to ensure and promote the full realisation of all human rights and fundamental freedoms for all persons with disabilities without discrimination of any kind on the basis of disability . Article 30 of the UNCRPD provides that disabled people are entitled, on an equal basis with others, to recognition and support of their specific cultural and linguistic identity, including sign languages and Deaf culture.

1.2 The Irish Sign Language Act 2017

The ISL Act 2017 recognises ISL as a language of its own right as well as recognises the linguistic rights of Deaf people in Ireland to use, develop and preserve ISL as their native or preferred language .The community of persons using Irish Sign Language shall have the right to use, develop and preserve Irish Sign Language . The Act explicitly places a duty on all public bodies to provide ISL users with free interpretation, and obliges them to engage only with qualified and registered ISL interpreters on the Register of Irish Sign Language Interpreters (RISLI) . Further, public bodies have a requirement under the Disability Act 2005 and the Public Sector Duty to make sure their services and information are accessible to all members of the public, including people with disabilities.

1.3 Ireland’s Mental Health Policy- “Sharing the Vision- A Mental Health Policy for Everyone”

Ireland’s national mental health policy Sharing the Vision- A Mental Health Policy for Everyone recognises the need for outreach to the Deaf community. However, persistent barriers remain in areas such as provision of accessible services in ISL, trained professionals with awareness of and competency in Deaf culture and engagement with the Irish Deaf Society as a DPO. The policy references people with “severe-to-profound deafness” as among those identified as being “high-priority” and “at risk”. This highly medical categorisation is not in line with UNCRPD principles and undermines the linguistic and cultural identity of Deaf people, as highlighted by Article 30. As this paper will outline, members of the Deaf community, regardless of their levels of hearing, can face unique and nuanced mental health challenges due to historical oppression, oralism, language deprivation and social isolation caused by inaccessible environments. Language deprivation results from a lack of exposure to a language (signed or spoken) and can lead to grave adverse consequences in linguistic, social, psychological and cognitive developmental domains in Deaf people’s lives. National sign languages play a critical role in preventing language deprivation and ensuring optimal mental, physical and social health across the lifespan of Deaf people. The World Federation of the Deaf states that access to sign language is a health need.

In its recommendations, Ireland’s mental health policy states that the National Specialist Mental Health Service and its model of care for the Deaf community must be evaluated to identify gaps and areas for improvement. Based on this evaluation, a service improvement plan is to be created and implemented in phases. Mental health staff should have the necessary skills to work effectively with Deaf individuals and a training needs analysis and a comprehensive training, support and supervision plan must be carried out.

Article 25 further sets out the obligation on States to:

a) Provide persons with disabilities with the same range, quality and standard of free or affordable health care and programmes as provided to other persons, including in the area of sexual and reproductive health and population-based public health programmes;

b) Provide those health services needed by persons with disabilities specifically because of their disabilities, including early identification and intervention as appropriate, and services designed to minimize and prevent further disabilities, including among children and older persons;

c) Provide these health services as close as possible to people’s own communities, including in rural areas;

d) Require health professionals to provide care of the same quality to persons with disabilities as to others, including on the basis of free and informed consent by, inter alia, raising awareness of the human rights, dignity, autonomy and needs of persons with disabilities through training and the promulgation of ethical standards for public and private health care;

e) Prohibit discrimination against persons with disabilities in the provision of health insurance, and life insurance where such insurance is permitted by national law, which shall be provided in a fair and reasonable manner;

f) Prevent discriminatory denial of health care or health services or food and fluids on the basis of disability.

2.2 Vulnerability to poor mental health and lack of access to appropriate services

Deaf individuals experience worse psychological and physical health relative to their hearing counterparts .
Mental health can be affected by the increased likelihood that Deaf sign language users occupy poorer socioeconomic positions, have poorer literacy, and have limited access to communication in what is a hearing-centric world . Deaf individuals may experience social isolation due to communication barriers, leading to feelings of loneliness and a lack of connection with peers, which can impact mental well-being. Being unable to participate in social and community activities such as sport or cultural events can increase the sense of marginalisation. Inadequate support and accommodations in educational settings can lead to academic struggles, bullying, and a lack of opportunities, affecting self-esteem and contributing to mental health challenges. Incidents of discrimination are directly related to suboptimal well-being amongst Deaf individuals . Deaf people with mental illness also experience double stigma, namely being stigmatised for being Deaf and for having mental illness .

Higher rates of impulse control disorders, depressive symptoms, and developmental disorders have been recorded in the Deaf population . Despite this, referral to and access to mental health services internationally for Deaf people is lower than for hearing people. Deaf children with severe and complex mental health problems are much less likely than hearing children to have their mental health needs identified and met, in terms of signposting to and use of services . Lack of access to culturally and linguistically appropriate mental health services can result in untreated mental health conditions.

2.2.1 The Irish Context

In Ireland, research shows that the Irish Deaf community are at a higher risk of mental health issues than our peers because of many factors including marginalisation, the oral education system and institutional abuse . The treatment by the State of the Deaf community in Ireland has been one of “systematic exclusion” and one of “extreme marginalisation” due to a lack of sign language recognition and provision . The socio-economic position of the Irish Deaf community is influenced by historical, medical, and religious factors, and reflects international experiences of disadvantage and discrimination. Fewer than half of those who are Deaf or hard of hearing in Ireland and of working age are employed (46%, 2016 census) . There is a tendency to attribute failure to Deaf individuals for not being willing to accept change . Deaf young people experience high rates of bullying and loneliness as well as difficulties with peer relations overall . Institutional abuse against children resident at Deaf schools has significantly impacted on the mental health of older members of the Deaf community in Ireland . In Ireland, there is no service established specifically for the mental health of Deaf children, and few Deaf children make use of existing CAMHS services in proximity to Deaf schools or Deaf Village Ireland .

Supporting positive mental health among Deaf individuals involves creating an inclusive environment that addresses the unique needs and challenges. In the context of Ireland, McAra’s (2022) survey of Deaf people’s mental health during the covid-19 pandemic highlights the need for Deaf mental health professionals, improved access to interpreters including remote services, awareness-raising about the mental health needs of the Deaf community and making healthcare services easier to contact in the first instance through email and text . These findings are further supported by research carried out by Hammond et al (2024) which explored the mental health needs and experiences of Deaf people in Ireland in general . Moreover, there are significant areas for policy improvement where triggers for poor mental health begin, such as in supporting early language acquisition.
Our advocacy extends to acknowledging and addressing the intersectional nature of mental health within the Deaf community. We recognise diverse identities and advocate for mental health services that cater to various needs, including race, gender, sexual orientation, and other layered identities. Additionally, we emphasise the importance of providing specialised support for Deaf individuals with additional disabilities, ensuring that their unique mental health needs are met.

2.3 The role of language in Deaf people’s mental health

The mental health and wellbeing of Deaf people is related to the capacity to express ourselves and be understood in everyday life. The 6th World Congress on Mental Health and Deafness calls on governments, non-government organisations and mental health care providers to “prioritise and promote the right of Deaf, Hard of Hearing, Late Deafened and Deafblind people to recognition of their linguistic and cultural identity as early as possible to preserve and protect their mental health”. Further, we echo Article 2 of the World Federation of the Deaf’s (WFD) Declaration on the Rights of Deaf Children which states “all Deaf children have a right to a sign language. National sign language(s) are the only fully accessible language for Deaf children from birth onwards”.

This is related to a wide range of issues faced by the Deaf community in childhood language acquisition and family communications, access to education and experience in schooling, access to and participation in community life, including sports and cultural activities, access to and experience in the workplace, and access to and experience in healthcare and public services. Difficulties in communication with hearing individuals who do not know sign language or are unaware of Deaf culture can lead to isolation, misunderstandings, and feelings of exclusion . This can hinder access to information, services, and social interactions, leading to frustration and mental health challenges. Particularly in family life, the WFD highlight the issue of communication neglect which is often faced by Deaf children and adults in their paper on Access to National Sign Languages as a Health Need which is “the ongoing exclusion from indirect family communication and incidental learning”.
National sign languages play a critical role in preventing language deprivation and ensuring optimal mental, physical and social health across the lifespan of Deaf people. Language deprivation (a persistent lack of access to a natural language) can lead to grave adverse consequences in linguistic, social, psychological and cognitive developmental domains in Deaf people’s lives. Language deprivation is caused by social and environmental factors which stem from systems focusing on medical devices and speech & language therapy, rather than acknowledging that humans have an innate ability to acquire language and ensuring early access to the national sign language.

The WFD Declaration on the Rights of Deaf Children explicitly states in Article 7 that “all Deaf children have the right to protection from language deprivation” and that the failure to provide a Deaf child access to a sign language constitutes discrimination. Full access to a signed language can have a positive effect on a Deaf child’s mental health and development . Children who experience delays in acquiring language skills at an early age may face a higher risk of maltreatment, which can contribute to mental health issues and behaviours that pose risks . We echo the WFD recommendations in their position paper on Access to National Sign Languages as a Health Need in terms of ensuring “early intervention and sign language services guided by Deaf professionals and community members, Deaf sign language teachers, and Deaf advocacy organizations” and that “health, medical, and social service professionals provide accurate and proper information on national sign languages and promote Deaf children and their families’ free access to and learning of national sign language(s) from the earliest possible age”.

3. Mental health services for Deaf people

IDS aims to spearhead awareness campaigns and community-based initiatives to foster a deeper understanding of mental health issues prevalent within the Deaf population, ultimately promoting a more empathetic and supportive society. IDS has developed a Wellbeing and Mental Health Working Group in order to represent our community and work with the State and healthcare providers to ensure access for the Deaf community in organisations strategies, action plans and services. This group consists of members and advocates of the Deaf community, mental health professionals and experts and professionals working within the Deaf community. This paper will support the group’s work in campaigning for better overall mental health services for Deaf people, including but not limited to developing a proposal for a Deaf Child and Adolescent Mental Health Service (CAMHS), Deaf Inpatient Service, Deaf Adult Services Team and a Deaf Community Service.

3.1 Accessing current public Mental Health Services and the need for Deaf Awareness Training among hearing mental health professionals

While the position of IDS is that there should be a specialist Deaf mental health service delivered by Deaf mental health professionals fluent in ISL, this section will outline the minimum expected standards for providing mainstream public mental health services to Deaf people in Ireland. Internationally, there is a significant shortage of mental health professionals who are proficient in sign language or understand the specific needs of Deaf individuals.

There is currently in place a Liaison Mental Health Service for the Deaf Community. The service is intended for ISL-using Deaf patients aged 18-65. This is known as the General Adult cohort. There are clinical staff consisting of a consultant psychiatrist, a clinical nurse specialist and an Occupational Therapist. The service has access to a limited number of sessions from an ISL using, trained psychotherapist. Generally, the ISL interpreters that are employed are experienced in mental health work. Deaf interpreters have been used where this has been deemed appropriate. Referrals are taken from family doctors or community-based adult mental health teams. 70% of referrals have come from family doctors. Deaf people from all of the 26 counties can be seen and assessed. However, it is easier for those in the Dublin area to access the service as it is located in Cabra. Most clients have been ISL users with approximately 10% being non-ISL using Deaf people. In the medium term, the service hopes to appoint a psychologist, non-consultant hospital doctor, further nursing posts and social worker.

Additionally, the HSE provide the GP Access Scheme which is operated by Sign Language Interpreting Service (SLIS). This provides ISL interpreters for Deaf people for GP appointments. In the vast majority of cases (> 90%), mental health is dealt with in primary care. However, the pool of interpreters available for this service is small due to the specialised domain of medical interpreting. SLIS also operate an emergency out-of-hours service for medical (and other/emergencies).

The HSE National Guidelines on Accessible Health and Social Care Services set out a number of steps to be taken by healthcare practitioners in ensuring access to services by Deaf people, including access to premises, booking systems, and other aspects of healthcare provision as well as direct contact with practitioners . The guidelines provide advice on communicating with Deaf people and the provision of interpretation services, including the development of appropriate enabling communication channels, consultation on preferred methods of communication, remote interpretation services in an emergency or where an unplanned visit arises, avoidance of use of family members, including children, to interpret for the individual in care, which compromises both autonomy and privacy, and provision of written language materials in plain, simple terms, with the help of visual aids and ISL translations. Accessibility is a precondition for persons with disabilities to live independently and participate fully and equally in society and is one of the principles on which the UNCRPD is based (Article 3 (f)) . Healthcare providers and professionals should collaborate with Deaf organisations to develop and implement effective and inclusive mental health programs and initiatives. Further, we encourage mental health service providers to be pro-active and have a plan in place for when a Deaf person wishes to access a service.

3.1.1 Provision of ISL Interpreters and Deaf Interpreters

In terms of accessing existing mental health services, the provision of ISL interpreters is considered the minimum with a considerable amount of Deaf awareness and education of mental health professionals required. The Belfast Statement on Mental Health and Deafness (endorsed by WFD) sets out the right to effective communication access in mental health settings for Deaf, hard of hearing, late Deafened and Deafblind people of all ages as enshrined in key international declarations such as the UNCRPD. We further advocate for the implementation of visual aids, technology, and accessible formats for effective communication.

While the provision of ISL interpreters is mandated by the ISL Act 2017, sign language interpreting can conceal the need for language-concordant public services, leading to the belief that there is no need for specialist Deaf mental health services.

Mental health therapists have reported that providing therapy through interpreters can prevent accurate communication, particularly in the difficult emotional expressions that therapy requires and its navigation by professionals . Misunderstanding and misinformation, if allowed to happen, can have serious and devastating consequences for Deaf clients . Interpreters themselves must be trained specifically in mental health interpreting. ISL interpreters include both hearing and Deaf interpreters. Deaf interpreters are highly skilled interpreters who are native ISL users and often work with hearing interpreters to translate information in a nuanced way. Sometimes Deaf interpreters are required in mental health situations or when a vulnerable person in involved. The legal obligation to provide ISL interpreters does not apply to private services. As a result, Deaf people do not always have access to the relevant mental health services. This further supports our rationale for the provision of a specialist Deaf mental health service.

3.1.2 Deaf Awareness Training for Mental Health Professionals

Deaf awareness is foundational in providing mental health services to Deaf people. Deaf awareness means having an understanding of Deaf culture and an ability to communicate in a Deaf-friendly way. Deaf Awareness Training highlights the experience of Deaf people and the issues and barriers that they face historically and in the present. Mental health professionals and service providers should be educated in cultural competence, learning about Deaf culture, language, and communication preferences to offer culturally sensitive care to foster an environment where Deaf people feel understood and supported. Awareness of issues such as oppression and discrimination should be understood by the professional to be able to understand mental health difficulties of the Deaf person. Deaf individuals should be empowered to participate actively and self-advocate in decision-making processes that affect their mental health. We also advocate for a workforce that reflects diversity within mental health services to better understand and cater to the needs of the Deaf community.

3.1.3 Access to information

Access to mental health information and signposting through general healthcare is important for both Deaf adults and children. Difficulties in accessing a GP or other general healthcare services, including sexual health and maternity services can prevent mental health difficulties being identified at an early stage . Where a referring professional is inexperienced in relating to and assessing Deaf people with mental health problems, this can result in incomplete or inaccurate information being provided. Peer support can be invaluable in promoting mental well-being, and support groups or communities where Deaf individuals can connect, share experiences, and offer mutual support can provide this.

3.2 The need for a specialist Deaf Mental Health Service including a Deaf Child and Adolescent Mental Health Service (CAMHS)

It is the strong position of IDS that there should be a national, specialist mental health service adequately resourced for the Deaf community. Tailored mental health services for Deaf individuals should be made available and delivered by Deaf mental health professionals who are fluent in ISL. This includes counselling and therapy services which should be specifically designed for Deaf individuals, incorporating visual and culturally relevant approaches. Barriers to referrals into tailored services, such as cumbersome administrative procedures, should be reduced as far as possible. Such a service should consist of both adult services and child and adolescent services and should also comprise a team of experts who work with local mental health services who will be able to advise about assessment and treatment for Deaf people and provide specialist support and education about Deaf culture and language. An example of a national Deaf mental health service can be observed in the UK and considered a best practice model.

Deaf children in particular require tailored mental health services which recognise and address their needs, and which provide adequate support and information to their families . The clinical staff would have a high level of expertise and experience in working with Deaf children with exceptional needs, and would have time allocated from their substantive roles to provide this specialist support and to ensure their knowledge base is current. Specialist support should be provided within a multi-disciplinary model and at a national level, with dedicated staff to signpost to available specialist supports and to track services received. Tailored training is needed for professionals working with Deaf children in Primary Care services and Children’s Disability Network Teams. Individual and family counselling and support services should be available at key transition points in the child’s life, with longitudinal data for monitoring of outcomes. Key groups amongst Deaf children should have automatic referrals.

IDS call for State investment into the establishment of a national Deaf mental health service in Ireland. There first must be consultation via meaningful engagement with IDS as a recognised DPO under the UNCRPD and other relevant stakeholders including Deaf mental health experts. This service must be resourced by highly skilled Deaf mental health professionals who are fluent ISL users. These professionals should come from the Deaf community and a campaign should be launched to recruit and train Deaf people to work in this sector. A Deaf-led service is critical to its effectiveness. Intensive Deaf awareness training must be provided to hearing mental health professionals who work with Deaf people currently and in the future. Further, ISL interpreters and Deaf interpreters (all of whom must be registered with RISLI) must receive specialist training for working within mental health settings.

Access to sign language plays a crucial role in the mental health of Deaf people (especially Deaf children) and is identified as a health need by the WFD. We outlined standards for mental health professionals who work with Deaf people in mainstream mental health services, however we advocate for a specialist Deaf mental health service including a Deaf child and adolescent mental health service. IDS are willing to engage with the State and mental health service providers to develop policies with respect to Deaf people and access to these services.

Supporting documentation:

ISL Act 2017- https://www.irishstatutebook.ie/eli/2017/act/40/enacted/en/html
IDS Strategy Plan 2023-2026- https://irishdeafsoc.wpenginepowered.com/wp-content/uploads/2023/06/IDS-Strategy-2023-2026-Web-Download-1.pdf

Karen Sinnott (Co-Chairperson & Deaf mental health service user)

Breda O’Grady (Co-Chairperson & Deaf mental health service user)

Senan Dunne (Deaf counsellor IACP & Deaf Interpreter)

Emma Barrow (Deaf Social Care Worker)

Brendan Lennon (Chime representative)

Carri O’Donnell (Hearing counsellor IACP & ISL Interpreter)

Ray Greene (ISL Interpreter with experience in mental health settings)

Vanessa O’Connell (ISL Interpreter with experience in mental health settings)

Robert McAra (Deaf Social Care Practitioner)

Elaine Grehan (IDS representative)

John Sherwin (IDS representative)

Edel Walsh (IDS representative)

Robyn Cunneen (IDS representative)