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with Deaf Clients from Diverse Groups|
One of the DBT distress tolerance skills is referred to as “half smile.” This is a “Mona Lisa” type smile that clients can use to help boost their mood (researchers believe that the change in facial expression causes physiological changes in the brain). Even good deaf readers initially had difficulty comprehending this skill because the words “half smile” don’t make sense at a literal level. Deaf clients often thought it meant that half of your mouth should smile while the other half should frown. We therefore changed the wording to “little smile,” which increased comprehension of this term in the written materials without changing the fundamental meaning or impact of the skill itself.
Two DBT skills training films have been modified to be more relevant to deaf clients (Pollard & Dimeff, 2006, 2007). The films utilize an all-deaf cast and include many deaf-specific references, such as content regarding Deaf values and Deaf culture. The films also feature a dialogic style of information exchange, repetition of key learning points, and the use of deaf people as experts and authority figures. To make these adapted films accessible to the widest audience (including hearing and hard of hearing viewers), an English language vocal track and open-captions were added. In-depth descriptions of recommended practices for adapting educational material for deaf audiences have been described by Pollard, Dean, O’Hearn, & Haynes (2009) and, regarding DBT in particular, by O’Hearn & Pollard (2008).
s k i l l s g r o u p m o d i f i c a t i o n s
As noted earlier, all-deaf DBT skills groups need additional time for the variety of reasons detailed. DBT skills modules with hearing groups span 8 weeks, which is usually not enough time for deaf groups. Depending primarily on the language characteristics of the group and how much extra time is needed to address fund of info gaps and literacy limitations, 1 to 4 additional weeks are typically needed. Depending on the size of the group, even more time may be needed to allow for the dialogic and storytelling aspects of ASL.
Mindfulness practices that involve “going inward” and counting breaths, or observing internal sensations, may be too challenging for some deaf clients who have never been exposed to this concept or who need more overt or guided mindfulness practices. In such cases, other “active” mindfulness activities can be used, such as studying a penny in great detail (without the mind wandering to other topics), playing a game within the group while fully attending to the game, eating a raisin mindfully, or taking a mindfulness walk. Then, as clients become more familiar and comfortable with mindfulness, internal and “quiet” mindfulness practices can be introduced with more success.
p h o n e c o a c h i n g
As noted, being available to coach DBT clients outside of sessions is necessary to help them avoid engaging in undesirable behaviors that have been targeted for change. Coaching deaf clients can be done via videophone, TTY, and/or pagers and cell phones, depending on what technologies the client and therapist have access to. For phone coaching to be effective, clients must be oriented as to the purpose and the format of coaching, as described above.
f o r m a t i o n o f g r o u p s
Similar to forming therapy groups in small towns or rural areas, issues regarding confidentiality need to be considered when planning the formation of all-deaf therapy groups (O’Hearn & Pollard, 2008). Forming all-deaf groups, regardless of the rural or urban setting, usually means that some, if not all, of the prospective deaf members will know at least one other person in the group. If at all possible, care should be taken to avoid placing romantic partners, relatives, coworkers, or other persons who are in current, close contact with each another in the same group. Despite such efforts, it can be nearly impossible to completely avoid clients knowing each other. Therefore, the DBT therapist must make judgment calls regarding what types of preexisting relationships will be acceptable for placing associated members in the same group. This is best done on a case-by-case basis, based on information gathered through a private, individual conversation with each of the prospective members. In general, clients who know each other from church or clients who used to be in a class together often are fine to place in the same DBT group. All prospective group members should be coached on handling the discomfort that might result in seeing familiar faces, especially on the first meeting of the group. Because the Deaf community is small, clients frequently need to utilize this skill in the real world as well. DBT clients are also encouraged to avoid socializing with one another until after the group sessions have ended, in order to minimize the potential for outside conflicts or the emergence of cliques that might cause problems with broader group cohesion. Clients are encouraged to focus on skills acquisition in the group: DBT skills groups are not psychotherapy process groups; they function more like a classroom than a therapy session.
Once the issue of preexisting relationships has been addressed, the next important step involves creating a group where clients have similar learning and language styles. This allows members to acquire the skills at a similar pace. As mentioned above, DBT learning and practice materials may need to be modified to fit different language and learning levels.
c o n f i d e n t i a l i t y
Deaf clients’ biggest fear in joining an all-deaf group is that their confidentiality will not be maintained. Before clients attend their first group meeting, we orient them individually on the necessity of maintaining confidentiality. During this conversation, their fears about breaches of confidentiality are validated. Knowing that other group members are just as worried as they are about confidentiality usually makes clients feel somewhat relieved. As well, clients are reminded that they are free to share as little or as much as they like about their personal lives when in group sessions. While they will be encouraged to share examples of DBT skills they have used during group sessions, there is no need to go into detail about the target behavior(s) they are working on or why they are in treatment.