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with Deaf Clients from Diverse Groups|
responses of “It’s not important” or “I’ll explain later” are common and would be invalidating to most people. Many deaf people also experience invalidation outside the family context—in school, at work, and in the community. Sign language, Deaf culture, and Deaf social norms and values typically are not valued by the dominant (hearing) culture, which can be experienced as invalidating or even oppressive. “Audism” is a term that is increasingly used to encompass this concept of oppression and invalidation at both the individual and societal levels, when based on one’s ability or inability to hear (Bauman, 2004). Because of its emphasis on validation, even in the absence of a diagnosis of BPD, DBT may be particularly salient for deaf clients (O’Hearn & Pollard, 2008).
DBT also may be particularly useful for deaf people because of the skills training group therapy component. In light of common fund of information gaps, as well as the aforementioned lack of communication within the family, DBT skills group can be a useful adjunct to other (non-DBT) types of treatment. It is common for deaf clients to present for mental health treatment manifesting deficits in coping and emotional regulation skills (even emotional vocabulary), regardless of their psychiatric diagnosis. Glickman (2009) addresses this topic in great detail in his book on cognitive-behavioral therapies with deaf people with language and learning challenges.
Modifications in Using DBT with Deaf Clients
Normally, DBT skills groups are taught using a workbook (Linehan, 1993b) which includes diary cards. Given the wide range of reading abilities in the deaf population, particularly in the clinical population (Black & Glickman, 2006; Glickman & Gulati, 2003), modifications are needed to make written materials accessible. Furthermore, the videotapes used in the context of skills training groups with hearing people (e.g., Linehan, Dimeff, Waltz, & Koerner, 2000; Linehan, 2003b, 2003c) are not captioned. Even if they were, this would not be a suitable alternative for deaf clients with limited literacy. Even for clients with good English literacy, these videos are intended for hearing audiences and do not “speak to” the Deaf experience; clients may feel disengaged while watching these tapes. The deaf mental health client population often presents with more language and learning challenges than the general deaf population (Black & Glickman, 2006; Glickman, 2009, Glickman & Gulati, 2003). Accordingly, modifications to learning materials must take these factors into account in order for such modifications to allow optimal accessibility and learning for clients (Pollard, Dean, O’Hearn, & Haynes, 2009).
The DBT skills training workbook frequently uses mnemonics (Linehan, 1993b). Mnemonics are problematic because of the lack of 1:1 equivalence between words in English versus ASL as well as because mnemonics are not a technique used in ASL to aid memorization. For example “improve the moment” is a particular DBT distress tolerance skill. Each of the letters of the word “improve” stands for a specific distress tolerance skill that can be used by clients (e.g., using imagery, finding meaning for suffering, prayer, etc.). While mnemonics often help hearing, English-speaking clients, their relevance and helpfulness as a memory tool is questionable for ASL users.
Since fund of information gaps must be addressed in deaf skills training groups, more time is generally needed—especially for groups with greater than average language or learning challenges. ASL is a dialogic language (Metzger & Bahan, 2005; Pollard, Dean, O’Hearn, & Haynes, 2009) so more time may be needed for information exchange via group discussion. Allowing for more back-and-forth time in groups, both among members and with coleaders, is necessary to ensure that information gaps are being addressed and comprehension is maximized. Hearing DBT clients tend to summarize the skills they used without including a lot of detail. However, storytelling is a key cultural feature of ASL (Padden & Humphries, 1988) and details, not summarizing, are valued. For all these reasons, deaf skills training groups typically need more time, depending on the size and language/learning abilities of the group.
One of the core DBT skills is mindfulness. Several of the mindfulness practices taught to hearing clients through skills group include instructing clients to close their eyes and reorient to the sound of a bell. With deaf clients, mindfulness must be taught in ways that do not rely on auditory ability or require that members close their eyes while instruction is taking place.
The issue of confidentiality needs special attention in deaf DBT groups, in ways that are not as relevant for hearing groups. O’Hearn and Pollard (2008) provide particular details in this regard. Finally, therapist consultation teams, an important DBT provider resource, may be diffi cult or impossible to form if an insuffi cient number of local clinicians work with deaf clients and use DBT.
u s e o f i n t e r p r e t e r s
Engaging qualified sign language interpreters is, of course, a reasonable accommodation when no sign-fluent providers are available. However, the presence of an interpreter does not necessarily indicate that a deaf client has the same access to effective treatment as a hearing client. Glickman (2003) refers to this common presumption as the “illusion of inclusion.” O’Hearn and Pollard (2008) explain why the presence of interpreters does not result in equal access to DBT treatment. As mentioned previously, the clinical deaf population likely has fund of information deficits and lower literacy levels than the average deaf person. An interpreter does not typically have time, especially in a group setting, to fill these gaps or accommodate for literacy limitations. Particularly in the context of DBT treatment, which has its own jargon and metaphors, the interpreter would be faced with the “interpersonal demand” (Dean & Pollard, 2005) of attempting to bridge the “thought world” of the hearing group members/therapists with the thought world of the deaf client. Unless time is unlimited, this will not happen. Also, DBT metaphors, which make sense to hearing people, do not translate well into ASL or fit the average deaf client’s experience (Isenberg, 1996).
Using interpreters in a group setting also makes it difficult for the deaf client to feel like part of the group. The lag time necessary for translation means that the deaf person is always receiving information a bit later than the rest of the group, which makes equal participation difficult. Additionally, it is impossible to read the workbook materials or diary card while simultaneously watching the interpreter, a barrier that hearing clients do not face. Simply having a third party in the room for therapy, especially when the deaf client knows the interpreter from other contexts, can be uncomfortable.