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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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Sara’s therapist had several options for validation in this situation.
Level 1: Actively listening while Sara tells the story of the events. At this level, the therapist basically stays awake and aware for Sara and communicates interest in
    what Sara has to say.

Level 2: Reflecting back to ensure the therapist understands Sara accurately. Sara can clarify if something she’s said has been misunderstood or misrepresented.
    This happens naturally in ASL discourse.

Level 3: The therapist would make interpretations or guesses about what Sara doesn’t overtly communicate to show that she “gets” Sara. “You must have been
    feeling like your family didn’t care about you when they wouldn’t explain the joke?”

Level 4: The therapist would point out why Sara’s behavior makes sense in terms of her history. “You’ve told me that you never developed good coping skills
    because of the lack of communication at home, so I can see why you felt you had so few options of dealing with your sadness.”

Level 5: At this level, the therapist points out that Sara’s responses make perfect sense given the situation: “Anyone would have felt sad being excluded like that!”
    and to be more specific the therapist could say, “Many deaf people have the same experience feeling left out like that.”

Level 6: The therapist could say, “I know just how you feel, that happened in my hearing family as well.” Here the therapist is being radically genuine, and the
    therapist-client power differential is not apparent.

The therapist validated Sara in many different ways in this one behavior chain analysis. Additionally, the therapist will also point out the invalid, being careful not to validate the cutting behavior. (Never validate the invalid.) The therapist might say, “I completely understand why you were so hurt and angry since that would make anyone angry (level 5), but Sara, we’ve got to work on the cutting behavior. Where could you insert skills that would have avoided you cutting yourself?” A question along these lines would be asked to go back through the chain analysis and create a plan for dealing with her emotions in a more effective, skillful way the next time they arise.

The therapist worked closely with her consultation team in making sure she was on target with her treatment with Sara. Several times throughout the treatment, the team noted that the therapist had veered from providing DBT and would inadvertently provide “bad” treatment because Sara would reinforce her. For example, Sara stopped bringing her diary card to session: “I just didn’t have time, but you know I’m working on the skills.” The therapist was reluctant to say anything for fear of upsetting Sara when she’d seen such good progress to date. When the team pointed out that the therapist was treating the client as fragile and slipping away from providing effective treatment, the therapist was able to recognize this pattern and return to the use of diary cards (even though Sara grumbled about doing them). This returned the treatment to focusing on target behaviors and resulted in gradual symptom improvement.

Initially it was clear that Sara lacked effective skills for dealing with her emotions. She was reluctant to join a deaf DBT skills group (as most clients are) because of fears of lack of confidentiality. She eventually joined and as she got comfortable with the format of the group and her ability to share as little or as much detail as she wanted about her skills practice, the more she relaxed in the group (and the more she shared). She remarked to her therapist that for the first time, she didn’t feel like the only one with the problems she had, feelings she had not experienced in the hearing, interpreted group. She also stated that the skills took on a whole new meaning when presented in ASL (her preferred language). Having a chance to see how other deaf clients understood the skills and feeling free to ask questions made all the difference. Once Sara had the skills down, target behaviors began to reduce. Sara became very good at doing behavioral chain analyses of her own behaviors. She began to see what her triggers were for engaging in a target behavior and choosing the right combination of skills to decrease these behaviors. Sara’s cutting stopped altogether as her skill use increased. Her suicidal ideation went from being a chronic, daily state of mind, to an infrequent thought (less than once per week). As she began to develop emotion regulation and interpersonal skills, she became better able to handle work relationships, and at the end of treatment had held a job for over 1 year (a record for her).

Near the end of treatment, Sara stated that had she not found direct access to DBT, she probably would not be alive today. Both Sara and her therapist reported that they felt DBT was the most effective treatment she had experienced with the greatest gain. Sara went from being a chronic client to a client who built a decent life and who only required occasional episodes of treatment (usually around major life stressors).

In summary, DBT can be an effective therapy for use with many populations. To be useful for most deaf clients, materials need to be modified to fit the learning level of the individual (or group) and methods need to be modified to be culturally relevant.

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