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Sign Language Studies

American Annals of the Deaf

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Psychotherapy with Deaf Clients from Diverse Groups
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During the first group meeting, confidentiality is again discussed, this time with the group as a whole. The diary card, which clients complete each day, includes a place to note if they had any urges to break confidentially or if confidentiality was broken. A confidentiality challenge could be as simple as encountering a fellow group member at the grocery store and, when a third party asks how the two of them know each other, a client replies, “I can’t tell you; it’s confidential.” While truthful, the response only superficially keeps the confidentiality rule; it invites further inquiry or speculation that is counter to the confidentiality goal. Another problematic answer might be, “We go to DBT together.” We discuss examples like this in group and engage in confidentiality role-plays so clients will feel prepared if they find themselves in situations where they need to maintain confidentiality skillfully.

If confidentiality is breached, the DBT cotherapists should meet with the clients involved and make a decision about what should be done. In less serious cases, it might be decided that the offending client can make amends to the group as well as the individual whose confidentiality was broken in some manner agreed upon by the therapists and clients involved. In more serious cases (such as ones with malicious intent, or where significant personal details have been shared), the offending group member may need to be terminated from the group.

Once deaf clients overcome any fears regarding confidentiality, they typically benefit from the group in ways that are uniquely linked to the group experience and include benefits that they likely would not experience if they had joined an interpreted group with hearing clients. Deaf clients often remark that they are relieved to know they aren’t the only ones with problems, and often benefit more from the feedback of fellow group members than input from the coleaders.

t h e r a p i s t  c o n s u l t a t i o n  t e a m s

As noted, DBT consultation teams function to provide DBT therapists with support (to decrease burnout) as well as to enhance the therapist’s skill set in working with hard-to-treat clients. Consultation teams also function to help the therapist remain adherent to the tenets of DBT treatment. Ideally, a therapist treating deaf clients would have access to a consultation team composed of other therapists treating deaf clients. In the absence of this, a DBT therapist could join a hearing consultation team. If interpreters are needed because the therapist is deaf, similar interpreting issues as mentioned above will need to be addressed, including educating the team on how best to work with interpreters and the challenges and limitations of interpreted meetings. Joining a consultation team that doesn’t understand Deaf culture or the relevant language issues involved in providing DBT treatment to deaf individuals may be less helpful to the deaf-specialist therapist. An alternative might be to join a “virtual” team of providers working with deaf clients by using technology to link providers who live in geographically diverse areas.

Case Example

Sara[1] is a deaf, 40-year-old single, White female who has struggled for years with symptoms related to BPD including intense fears of abandonment, lack of sense of self, and instability in interpersonal relationships (both family and partners). She had chronic suicidal ideation as well as frequent self-mutilating behavior (cutting), impulsivity with spending and sexual exploits (often with men she’d just met), and frequent anger outbursts, which resulted in negative consequences for her (such as being arrested).

Sara’s parents and siblings are hearing. She was raised orally but later learned ASL when she attended a deaf college. She describes a conflictual relationship with her family members and is closest to her older brother. However, even that relationship vacillates in her eyes between being great and being awful. Sara had been jumping from job to job, usually quitting because of an interpersonal conflict or being fired for inappropriate behavior (anger outbursts). She was on public assistance at the time of treatment.

Sara had been in and out of therapy for depression, anxiety, and BPD for the past 20 years. She came to our clinic from a hearing clinic where all services were provided through the use of a sign language interpreter. She had attended DBT skills group and was working with a DBT trained individual therapist. However, both she and the therapist felt she would make better progress in a clinic where she could receive direct services.

Initial treatment involved targeting Sara’s cutting behaviors (several times per week) and suicidal ideation. Treatment had to be structured around these behaviors as a priority to minimize Sara’s wanting to talk about the crisis de jour (e.g., the fight she’d had with her boyfriend, her lack of happiness with her life in general, her feeling like she’d never find the career she wanted). DBT treatment is structured to attend to life-threatening behaviors (as mentioned earlier) before anything else for the reason alluded to here: Putting out fires week after week for a person whose life is chaotic and painful is tempting to do (the therapist wants to feel helpful to the client, and the client wants to talk about what feels most relevant), this makes it difficult to make any real progress. Both Sara and her therapist had to stay on track with the stages of treatment. Diary cards that Sara completed during the week (recording skills used, target behaviors engaged in) allowed both Sara and her therapist to see exactly where the treatment needed to be for each session.

Early in treatment, Sara came to her session with her diary card indicating she cut herself. Sara and her therapist conducted a behavior analysis of the target behavior (cutting) and determined that Sara had been sitting around the table at dinner and misunderstood a joke that her mom was telling her sister. Sara’s family did not try to clarify the joke. Sara began feeling hurt and sulked off to her room. She began thinking about all the other rejections she has experienced in her life and became very upset. She tried to calm herself down by paging a friend, but the friend wasn’t available. To stop the unbearable feelings she was experiencing, Sara got a razor she kept in the back of her drawer (even though she’d agreed to throw this out) and cut her forearm. Her sadness immediately decreased. Soon afterwards, she felt guilty since she had promised to work on not cutting to cope with her emotions. Her friend finally replied on her pager and gave Sara the support she needed.

1. This is a composite of a real case, with identifying information changed.
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