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American Annals of the Deaf

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Psychotherapy with Deaf Clients from Diverse Groups

Irene W. Leigh, Editor

Part Four: Special Issues

Chapter 17
Dialectical Behavior Therapy for Deaf Clients:
Cultural and Linguistic Modifications for Outpatient Mental Health Settings

amanda o’hearn, robert pollard, and sharon haynes

Dialectical behavior therapy (DBT) is a form of cognitive behavioral therapy originally developed for treating chronically suicidal women with borderline personality disorder (BPD) (Linehan, Armstrong, Suarez, Allmon, & Heard, 1991; Linehan, Heard, & Armstrong, 1993). DBT developed through Linehan’s efforts to get her suicidal clients to stay in treatment. She found that when she focused too much on pushing her clients for change, they often felt invalidated and dropped out of treatment. When Linehan began to balance the treatment between pushing for change and accepting the client exactly where she was (i.e., validation), her clients were more likely to stay in treatment. She began to see clients improve where other therapies had failed them. Hermotivation to work with a traditionally difficult-to-treat client population resulted in the development of a comprehensive treatment for BPD. She created treatment manuals (Linehan, 1993a, 1993b) based on what she had learned. The manuals detail protocols and strategies for working with individuals with BPD. DBT features elements of psychodynamic, client-centered, and gestalt therapy approaches, but its use of behavioral science, mindfulness, and dialectical principles sets DBT apart from other treatments (Koerner & Dimeff, 2007).

This chapter first describes the basic components of DBT and its efficacy with a variety of (hearing) patient populations and settings. We then describe modifications of DBT materials and methods that we have found effective in employing DBT in an outpatient setting with deaf individuals.

Dialectical Behavior Therapy Overview

More detailed descriptions of DBT can be found elsewhere, most notably in Linehan’s original text (1993a). The following brief overview will help facilitate some understanding of this therapy approach and clarify the nature of the modifications needed to enhance DBT’s applicability for a deaf clientele.

The DBT treatment approach balances acceptance with change, in relation to clients and their circumstances as well as therapists and their application of the treatment. Linehan’s study of Eastern philosophy and Buddhism influenced her development of DBT, and Zen-like teachings are woven throughout the therapy (Kabat-Zinn, 2005). The approach focuses on acceptance of clients exactly where they are, while simultaneously working toward changing behaviors that are harming their lives; this is the key “dialectic” in the treatment. For Linehan, understanding this dialectic (i.e., apparently opposing truths) and coming to a synthesis between them helps move the client away from “absolute thinking,” which tends to create an impasse and, instead, toward change and progress.

DBT was initially designed for clients diagnosed with BPD. Linehan views these individuals as emotionally vulnerable, a product of both biology and trauma experiences. Individuals with BPD often exhibit higher sensitivity to emotional stimuli, higher emotional reactivity, and a slower return to emotional baseline than the average person (Fruzzetti, Shenk, & Hoffman, 2005; Linehan, 1993a).

The developmental environment from which many people with BPD come is often invalidating. An invalidating environment is one in which an individual’s personal experiences, feelings, and viewpoints are discounted, disbelieved, or ignored. These individuals are not respected and their thoughts, feelings, and experiences are disregarded. An extreme example of invalidation would be chronic child abuse. In such environments, individuals do not learn to trust their own thoughts or feelings and do not learn how to regulate emotional arousal or tolerate distress. Linehan posits that BPD develops based on the interaction of invalidating environments and the individuals’ inherent emotional vulnerability. She refers to this as a transactional process in which each party (the at-risk individual and the environment) influences and reinforces the other. Because of this transactional cycle, even a slightly invalidating family and a slightly emotionally vulnerable child can, over time, evolve into a situation that is highly invalidating to both the family and the child (Fruzzetti et al., 2005). An invalidating environment over-simplifies problem solving (e.g., “you just need to try harder”) and often reinforces escalation of emotional responses (e.g., the child must display a temper tantrum to get a reasonable degree of attention).

The technique of validation in DBT treatment helps strengthen the client’s progress, serves as a balance to the stresses of making change, and serves to strengthen the therapeutic alliance. All clients benefit from validation, but Linehan believes it is particularly important for those prone to emotional dysregulation and sensitivity (Linehan, 1993a). Linehan describes six levels of validation. Validation can simply involve active listening (level 1) and reflection of what the client is saying (level 2); it can also be validation of the client’s unexpressed emotions or thoughts (level 3). Validation can involve understanding client behaviors in terms of past experiences or learning (level 4) or in


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