Deaf or Hard-of-Hearing Clients Require Special Ethical Consideration

By Cassandra L. Boness, M.A.
November 5, 2017

deaf hard-of-hearing pyschologist ethicsYou receive a request for services via voicemail from an individual using a video-phone relay service, suggesting the potential client is deaf or hard-of-hearing (HOH). Upon returning this individual’s call, they identify themselves as deaf and request the presence of a licensed and certified American Sign Language (ASL) interpreter at their intake the following week. You have never worked with a deaf or HOH individual before.

Psychologists are required to be familiar with the relevant ethical and legal issues related to working with deaf and HOH clients. The Americans with Disabilities Act (ADA) requires that the individual providing such service (i.e., the psychologist in the above example) provide a qualified interpreter. Similarly, Section 504 of the Rehabilitation Act forbids organizations from excluding or denying individuals with disabilities an equal opportunity to participate in, and have access to, program benefits and services.

What qualifies as a licensed interpreter? According to the ADA, a qualified interpreter is someone who is able to interpret effectively, accurately and impartially both receptively and expressively. For a deaf or HOH client, this means the interpreter should be proficient in ASL (or the client’s preferred language) and also familiar with relevant mental health terminology. In fact, many states have specific, advanced training to work in mental health settings. While a hearing therapist may consider using a family member as an interpreter, or using pen and paper to communicate with the client, this is highly inappropriate and strongly cautioned against due to issues of confidentiality, accuracy and efficiency, among others. A qualified interpreter is required in such an instance.

For many psychologists, especially those in independent practice, the cost of an interpreter may be prohibitive. The ADA requires that an interpreter must be covered by the service provider unless doing so would result in “undue hardship.” Undue hardship is determined by a business’s overall resources, including financial and human resources.

From a risk management perspective, it would be wise to consult legal counsel on a case-by-case basis to determine whether the cost of an interpreter would quality as undue hardship.  However, the APA Practice Organization recommends that in most circumstances, even when undue hardship may be arguable, the psychologist should provide an interpreter. That is, the cost is generally outweighed by the risk of a potential ADA complaint, especially considering the frequency with which this situation is likely to occur.

Even if one can afford an interpreter and is willing to pay, the question then becomes, is the psychologist competent to treat a deaf or HOH individual? For example, do they possess the cultural competence or necessary supervision required to treat this client?

While one may not be able to argue that undue hardship is reasonable, the psychologist may determine they are unable to treat this client based on lack of access to the resources required to become competent and/or the lack of access to supervision.

While this might seem to be an answer to the psychologist who is trying to find a way out of this obligation, a good faith effort still should be made to receive training in the necessary competencies. Further, the psychologist should determine, consistent with APA Ethics Code 1.02, how to handle such a situation, given that it presents a conflict between ethics and law (i.e., ADA and Section 504 or the Rehabilitation Act). Documentation of the decision-making process is important in such cases.

These issues only brush the surface of the relevant ethical and legal issues to consider when treating deaf and HOH clients. It is imperative to consider additional matters, such as multiple relationships and boundary issues, psychological assessment, diagnosis and evaluation, among others, in order to ensure the ethics of the profession are being upheld and the client is receiving the best treatment possible.

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Cassandra L. Boness, M.A., is a graduate student in clinical psychology at the University of Missouri-Columbia. Her chief research interest relates to alcohol use disorder diagnosis. Her clinical interests include ethics, treatment of deaf clients and Dialectical Behavior Therapy. She may be reached by email at:

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