The Importance of Improving Deaf and Hard-of-Hearing Competency in Psychiatric Practice

Psychiatrists and mental health clinicians should treat care for Deaf and hard-of-hearing (DHoH) patients as a domain of clinical competency rather than solely an accessibility concern, according to a Viewpoint published in JAMA Psychiatry.¹ The authors argue that failing to account for how hearing loss and signed languages influence the Mental Status Examination (MSE) can lead to misattributed symptoms, diagnostic errors, and patient mistrust and disengagement.

The Viewpoint was written by Jessica Williams, MD, of the Department of Psychiatry at Washington University School of Medicine in St Louis and the Deaf Services Clinic at BJC Behavioral Health; Laura Shapiro, MSW, LCSW, of the Deaf Services Clinic at BJC Behavioral Health; and Kristina H. Petersen, PhD, of Washington University School of Medicine.

Hearing loss affects 22.2% of the US population, or more than 70 million individuals,² and is associated with increased risk for depression, anxiety, and psychosis.³ Yet DHoH patients remain underserved, in part because of limited professional training in DHoH mental health, shared the authors.¹

They distinguish 2 groups: Deaf sign language users, many of whom identify not as disabled but as a linguistic minority, and hard-of-hearing (HoH) individuals who primarily use speech and device-mediated or residual hearing. Both groups face the so-called "deaf tax," the emotional, cognitive, and financial burdens stemming from systemic barriers. Lifelong communication barriers can also limit mental health literacy, so these patients may need additional psychoeducation about the goals of an encounter, their diagnosis, and treatment adherence.¹

Adapting the MSE

For Deaf patients who use American Sign Language (ASL), facial expressions can convey both emotional affect and linguistic content. Physical sign characteristics provide data analogous to the "Speech" section of the MSE; instead of volume or tone, the psychiatrist notes the amplitude and forcefulness of signs.¹

Certain signing patterns may signal psychopathology. Signing in a different direction from the psychiatrist may represent a response to internal stimuli, while rigid, ritualistic repetition of a specific sign may reflect obsessive-compulsive pathology. Because questions about auditory hallucinations may not apply, the authors suggest asking, "Is someone trying to signal to or communicate with you?"¹

Language deprivation, common among Deaf signers, can produce dysfluency that mimics disorganized thought or psychosis, with hallmarks including incorrect sign usage, difficulty with abstract reasoning, and syntactical errors.⁴ Idiosyncratic "home signs" may be mistaken for neologisms, and an interpreter unaware of the clinical goals may "clean up" disorganized language into coherent English, masking a thought disorder.

Because mental health–specific training for ASL interpreters is rarely offered, the authors place responsibility on the psychiatrist to prebrief and debrief with the interpreter, use the same interpreter across encounters when possible, and, in cases of significant dysfluency, bring in a certified Deaf interpreter to work alongside the hearing ASL interpreter.

Hard-of-Hearing Pitfalls

HoH patients often rely on context clues and speech-reading, which background noise, masks, accents, and rapid speech can disrupt. The resulting listening fatigue may present as irritability or diminished concentration and, over time, may predispose patients to social withdrawal or depression. Reduced auditory feedback can alter tone and prosody, mimicking monotony, and incorrectly filling in missed information can cause confusion resembling disorientation, delirium, or paranoia.

Across the DHoH spectrum, patients may engage in social bluffing, or the "deaf nod," feigning comprehension to avoid embarrassment. The authors describe regular check-ins and teach-back methods as "not only ethically but also diagnostically essential," and they urge psychiatrists to ask explicitly about accommodations, which can change over time.¹

Training and Systems

Medical students and psychiatry residents receive minimal exposure to DHoH mental health, and existing education tends to focus on basic communication access rather than clinical relevance, according to the authors. They recommend curricula covering the deaf tax and the social model of disability, hearing loss–relevant MSE adaptations, and interpreter collaboration, developed in consultation with DHoH community members.

At the organizational level, clinics should provide sign language interpretation and assistive technologies such as frequency modulated (FM) systems and live captioning. In-person ASL interpreters are typically preferred to video-remote interpreters because they better support rapport and are more likely to recognize regional sign variants.

"In sum, without competency in DHoH mental health care, psychiatrists risk misunderstanding both what patients say and how they think," wrote Williams, Shapiro, and Petersen.¹

The authors added that developing DHoH competency can strengthen not only disability-informed practice but also psychiatrists' ability to care for all linguistically and culturally diverse patients.

References

1. Williams J, Shapiro L, Petersen KH. Deaf and hard-of-hearing competency in psychiatric practice. JAMA Psychiatry. Published online September 23, 2026.

2. Haile LM, Orji AU, Reavis KM, et al; GBD 2019 USA Hearing Loss Collaborators. Hearing loss prevalence, years lived with disability, and hearing aid use in the United States from 1990 to 2019: findings from the Global Burden of Disease Study. Ear Hear. 2024;45(1):257-267.

3. Fellinger J, Holzinger D, Pollard R. Mental health of deaf people. Lancet. 2012;379(9820):1037-1044.

4. Glickman NS, ed. Deaf Mental Health Care. Routledge; 2012.