General Expectations During Communication

Although we nowadays are in contact with numerous cultural minorities, the ability to understand and cope with different languages and cultures is not required of medical professionals even in centres serving patients from all over the world. It is no wonder, then, that the understanding of deaf culture and sign language has been quite limited until recently. As an introduction to deaf cultures and sign languages, it may be worthwhile to first analyze our patterns of communication from a more general perspective.

We are sensitive to facial expressions, and often react negatively to deviant expressions. For example, individuals with cerebral palsy are often misinterpreted because of their grimaces. Patients with bilateral facial palsy are often experienced as nonchalant or cold because of their lack of expressions. This is particularly likely to happen if the patient is totally deaf and we lose information conveyed by the tone of voice which cannot be controlled accurately.

Facial expressions of deaf people may differ from those of hearing persons and are sometimes experienced as disturbing - not to the point of preventing the information from being transmitted but disturbing enough so that the doctor's reaction is altered at times causing some rejection.

In everyday communication among hearing people, we expect certain listening actions. Among the white, western population it usually means rather frequent eye contact and attentive behavior from the listener (those colleagues who see patients with other cultural backgrounds should be aware that listening actions are different in many cultures). We expect to see some active listening responses at certain moments of communication to be sure that the person understands the information given. This is interactional listening.

Because of the time lag in communication when interpretation is used, the listening action becomes "out of synch". When signed information is used, not only is there a time lag but the attention of the patient is directed to the interpreter.

Fixed attention from the patient, before attempting explanation, is something we are all accustomed to. This crucial interaction is often disturbed in cases of visual impairment since the patient does not seem to fixate on the face of the speaker due to extrafoveal viewing or nystagmus. Deaf patients often show usual fixed attention briefly when the doctor begins to say something. They first try to get a visual clue about the attitudes of the doctor and then turn their attention away from the doctor to the interpreter who has to delay the signing until the patient has established contact.

Doctors usually learn to suppress the negative feelings and uncertainty (insecurity) related to abnormal eye contact. The lack of normal eye contact may disturb the interpreter's work. We have to remember to explain to the interpreter how the patient is using his vision if he seems not to be looking at the interpreter. This is always a delicate situation because we often forget that our communication is to the patient and not to the interpreter. It is important to remember to start by saying "You know that you use the side part of your vision when you look at something. I must explain it to the interpreter" . . . then explain. The interpreter will then translate the discussion to the patient as a discussion between the doctor and the interpreter.

Since the deaf person is primarily looking at the interpreter and not the doctor, the doctor may experience the interpreter as a rival in his own office. If one accepts the role of the interpreter as "a talking machine", one is less likely to see him as a rival or as a person responsible for things other than interpretion.

Total communication is a term that describes the communication used by deaf persons. It is not just sign language, but a rich mixture of signs, expressions, mime and body movements used to convey the message, often much more expressive than our academic English. Since we tend to assume that deviations, even rather minor deviations in bodily expression, are indicative of deviations in personality structure, we may be confused by the body language related to deafness. Very few physicians or nurses have experience in deaf culture and therefore the "deviant" body language is often erroneously attributed to aggressive behavior when the contrary is true. This misunderstanding can be dangerous. It has happened more than once that psychologically healthy, deaf patients have been taken into closed psychiatric wards when they have become upset, cried and signed passionately in a doctor's office, frightening the inexperienced staff working without an interpreter.

When a deaf person develops visual impairment, or a visually impaired person loses hearing, communication is bound to become problematic. This is true in medical examinations as well. The loss of reliable communication in both major channels, combined with seemingly negative feedback from the patient, may create a tense atmosphere which many deaf patients and their families describe as "very unpleasant, to say the least".

An additional negative factor is related to the fear of the dual sensory disability, and to the misbelief that deafblind individuals are unable to function on almost any level, a misbelief still quite common among both ENT and eye specialists everywhere. A specialist who is afraid of deafblindness conveys that fear through his body language which the patient often understands better than the spoken information sprinkled with Greek and Latin terms. In this case the visit, instead of being a part of the patient's rehabilitation, becomes an additional emotional blow and burden.

We should learn from the recent publicity on deafness and deaf education that numerous deaf and deafblind individuals work at many skilled and demanding occupations. They may be college or university professors, writers, poets, mathematicians, engineers, psychologists, public relations specialists, graphic designers, actors, librarians, counsellors and accountants, as well as engaging in the numerous traditional jobs of blind craftsmanship. The dual sensory impairment does not need to be the limiting factor for schooling and occupation today.

If we learn to analyze our own expectations and those of the patient, and remember that when communicating with deafblind persons some of our usual expectations are unrealistic, the entire situation becomes a lot easier.