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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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Each DBT skills training module typically lasts 8 weeks. The first half of each week’s session is dedicated to homework review, during which clients discuss the skill they have practiced from the previous week and the homework they have completed. Diary cards are used to monitor target behaviors and make note of skill use during the week. The second half of the session focuses on learning a new skill. Clients are assigned homework related to the new skill to work on during the next week. Ideally, two DBT skills trainers lead the groups.

Coaching calls between skills training sessions function to help the client generalize the skills they have learned. Clients are instructed on when they should or should not contact their therapist for a coaching call. The metaphor that works here is of a basketball coach who isn’t present for the game. In most public mental health settings clients generally visit their therapist 1 hour per week or less; the remaining 167 hours per week, they are out “on the field” applying what they are trying to learn through therapy. It is quite reasonable to anticipate that clients could use help “during the game,” which is the purpose of encouraging coaching calls to the therapist outside of formal DBT sessions. Coaching calls are structured to focus on problem solving specific to the situation raised by the client and are explicitly not a minitherapy session. Clients are asked to describe what current skills they are using in the moment and are coached on other skillful behaviors they might try if they have exhausted their ideas. The purpose of the call is to help the client avoid engaging in self-harming behaviors or other problematic behaviors that make the situation or their lives worse. Encouraging the client to contact the therapist before engaging in problematic behaviors reinforces the client (through the therapist’s positive attention) for trying to be skillful and extinguish previously dysfunctional but reinforcing behaviors (e.g., cutting).

Comprehensive DBT treatment also includes the utilization of a consultation team for therapists providing DBT treatment. The consultation team functions to decrease therapist burnout (which is not uncommon in working with BPD or other difficult-to-treat patient populations) and also helps therapists stay on track in providing effective treatment. Team members provide feedback to each other and are meant to be a form of treatment for the therapist.

Research Findings

When presented as part of a comprehensive therapeutic program, DBT reduces suicidal ideation (Koons et al., 2001; Linehan et al., 2006), and self-injurious behaviors (Koons et al.; Linehan et al., 1991; Linehan et al., 1993; Linehan et al., 2006). Frequency of emergency room visits decreases (Linehan et al., 2006); length of inpatient stays decreases (Linehan et al., 1991), and overall costs associated with mental health treatment decrease (Aos, Lieb, Mayfi eld, Miller, & Pennucci, 2004). Of all treatment for suicidal clients with BPD, DBT presently has the greatest degree empirical support.

Modifications have been made to DBT to accommodate different settings as well as different client populations, including:

  • Elderly depressed individuals (Lynch, Morse, Mendelson, & Robins, 2003)
  • Families (Hoffman, et al., 2005; Woodberry, Miller, Glinski, Indik, & Mitchell, 2002)
  • Couples (Fruzzetti, 2006)
  • Adolescents (Miller, Rathus, & Linehan, 2006; Rathus & Miller, 2002)
  • Bulimia (Safer, Telch, & Agras, 2001)
  • Binge eating (Telch, Agras, & Linehan, 2001)
  • BPD with comorbid substance abuse disorders (Linehan et al., 1999; Linehan et al., 2002; van den Bosch, Verheul, Schippers, & van den Brink, 2002)
  • Clients with intellectual disabilities (Lew, Matta, Tripp-Tebo, & Watts, 2006)
  • Inpatient units (Bohus et al., 2000; Katz, Cox, Gunasekara, & Miller, 2004)

Adaptations also have been made for non-English speaking populations. The DBT skills manual has been translated into Spanish, French, German, and Dutch (Linehan,1996a, 1996b, 2000, 2003a).

Unfortunately, none of these modifications or adaptations address the barriers that deaf clients face in accessing this useful form of treatment. The deaf client population often presents with limited English literacy skills, fund of information deficits (Pollard, 1998), and limited language skills, even in American Sign Language (ASL). These factors and unique cultural characteristics require considerable modification of DBT materials and methods in order to make the treatment accessible (O’Hearn & Pollard, 2008).

d b t  a p p l i c a t i o n s  f o r  d e a f  p e o p l e

DBT should be available to deaf people who have suicidal behaviors or have BPD, just as it is for hearing people. Several studies suggest that deaf people have a higher risk for suicide behaviors than hearing people (Boyechko, 1992; Critchfield, Morrison, & Quinn, 1987; Dudzinski,1998; Samar et al., 2007; Turner, Windfuhr, & Kapur, 2007) suggesting the potential value of DBT for this population. While empirical evidence regarding mental illness epidemiology in the deaf population is limited (Pollard, 1994), deaf people may be at higher risk for developing BPD (O’Hearn & Pollard, 2008). Researchers believe that deaf people experience higher rates of abuse in childhood (Embury, 2001; Sullivan & Knutson, 2000) and that abuse is associated with the development of BPD.

Also, as noted earlier, BPD is believed to result from the transaction of an invalidating environment and the biological vulnerabilities of the individual. Deaf people are usually born into hearing families, where their experiences and sense of self are often at odds with the language and culture of their parents, siblings, and extended family, which certainly may constitute an invalidating experience. The commonly described “dinner table syndrome,” in which the deaf individual is routinely left out of family conversation, laughter, and information sharing provides one example of invalidation that many deaf people experience. When asked what an animated dinnertime conversation is about,


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