Efficacy of Dialectical Behavioral Therapy with Deaf Psychiatric Patients: Longitudinal Changes

Amanda O’Hearn, Ph.D.University of Rochester School of Medicine

Abstract

Dialectical Behavior Therapy was originally developed to treat chronically suicidal individuals and has become the treatment of choice for those diagnosed with Borderline Personality Disorder. DBT is behaviorally based and incorporates validation and change strategies. It has been adapted and used to treat a number of patient populations in different settings. Studies have shown it to be effective in reducing self-harm behaviors. DBT typically includes individual therapy as well as group therapy to address deficits in interpersonal skills, distress tolerance, and emotion regulation skills.

Although deaf patients are commonly mainstreamed into hearing groups, or occasionally into all-deaf groups where available, no studies of the ability of deaf consumers to comprehend the workbook or benefit from the therapy have been conducted. As the workbook is currently written, the average deaf consumer is unable to use and comprehend the materials adequately. The workbook is only accessible to consumers who are fluent in English and familiar with culture-bound concepts presented. This excludes the bulk of the deaf mental health patient population, whose literacy level and fund of information is poorer than the average deaf population at large. Clinicians and interpreters attempting to employ or translate DBT concepts with deaf patients informally report considerable effort being expended in the process with questionable confidence in the efficacy of such translation/explanation attempts.

The Deaf Wellness center desired to make DBT accessible to deaf clients. This required considerable modifications in both materials and methods. A workbook closely following the original DBT workbook has been developed and used in all-deaf groups and has received positive feedback from current patients and therapists.

Data is currently being collected from patients enrolled in all-deaf DBT groups in Rochester at the Deaf Wellness Center and will be compared to mainstream and wait-list conditions. Future studies include national collaboration sites where data will be collected on DBT groups modified for clients with poor language (ASL and English) skills and lower cognitive skills, as well as groups modified to treat dually diagnosed (substance abuse and mental illness) clients.

Methodology

Subjects: Deaf outpatients at the DWC who qualify for DBT treatment based on either:

•diagnosis (Borderline Personality Disorder), or

•symptom manifestation (any other mental health diagnosis which interferes with quality of life as a result of skills deficits in one or more of the following areas: interpersonal skills, emotion regulation, or distress tolerance)

Subjects must also be new to DBT treatment and not be actively psychotic or with cognitive impairment.

Procedure: Subjects are enrolled in DBT skills groups and Individual DBT treatment. If subject’s schedule does not permit joining the Deaf group, subject will be offered a mainstream group (hearing group with interpreter), or the waitlist. Skills groups run for 90 minutes per week and cycle through 3 modules. Individual therapy occurs weekly for 50 minutes per session.

Data is collected before treatment begins, at 9-10 week intervals during treatment (coinciding with skills module completion), at completion of treatment, and at 6- and 12- month follow-ups.

Measures:

•DBT Comprehension Test

•Working Alliance Inventory: Client and Clinician Forms

•Beck Depression Inventory II

•Beck Scale for Suicidal Ideation

•Beck Anxiety Inventory

•Parasuicidal History Inventory

•Peabody Individual Achievement Test R: Reading Comprehension (given only at pre-treatment interval)

Workbook Modifications

Characteristics of Deaf Wellness Center DBT Research Program

Individual DBT Treatment: 50 minutes per week. Sign-fluent clinician (deaf or hearing). Therapist helps patient generalize skills learned in Group and seeks to maintain a balance between acceptance of the patient (validation) with push for change.

Group Skills Training: 90 minutes per week. Sign-fluent clinicians (deaf or hearing). Patient learns skills in classroom-like setting in three modules: Interpersonal Skills, Distress Tolerance (Crisis skills), and Emotion Regulation Skills. Goal is to learn skills to improve life and reduce self-harm and other maladaptive behaviors.

Psychopharmacology (if needed): Via Nurse Practitioner with sign language interpreter

Consultation Team: For clinician support and to reduce burn-out with this client population.

Discussion

Data is still being collected. Qualitatively, patients are responding well to treatment and there have been no inpatient or emergency psychiatric services utilized during treatment. Out modifications are constantly evolving as a result of feedback from both patients and clinicians.

Confidentiality remains the biggest barrier for patients to be willing to join Skills Groups. The Deaf community is small and almost never is it the case that a deaf patient can join a group and not know anyone else around the table. Because of the small nature of the community, confidentiality is addressed frequently during the course of group.

Cohesion of groups is another issue that needs to be addressed. Matching people on level of cognitive functioning, ability to use ASL and ability to use English seems to be the most important consideration.

Therapists report feeling more competent when treating patients with Borderline Personality Disorder or skills deficits. The consultation team adds a level of support that helps improve therapist motivation.

Mindfullness Walk: Take a walk. Be aware of the things you see, hear, smell, taste,touch. Be aware of nature and write down what you experience of each sense. M i n d f u l n e s s D i a r y C a r d

D a y o f t h e w e e k S k i l l

S u n M o n T u e s W e d T h u r s F r i S a t

W i s e M i n d - ( B a l a n c e d M i n d )

T h i n k , f e e l i n g , k n o w d o r i g h t

O b s e r v e S t o p , P a y A t t e n t i o n t o Y o u r F e e l i n g s

D e s c r i b e T e l l o t h e r s / y o u r s e l f a b o u t y o u r f e e l i n g s

P a r t i c i p a t i o n J o i n G r o u p / A c t i v i t y

N o n j u d g m e n t a l

S e e r e a l t h i n g s a n d a c c e p t

I n t h e M o m e n t

P a y A t t e n t i o n t o o n e t h i n g

D o Y o u r B e s t I c a n d o b e t t e r

C R I S I S – F e e l b e tte r w h e n y o u h a v e b a d d a y T h in g s w i ll h e lp y o u to fe e l b e tte r

1 . E x e rc ise w ill h e lp y o u fe e l b e t te r

2 . C le a n : a c le a n h o u se w i ll h e lp y o u fe e l b e tte r

3 . E v e n ts : g o to a sp e c ia l e v e n t, l ik e a m o v ie

4 . F r ie n d s : v is i t in g fr ie n d s w ill h e lp y o u fe e l b e tte r

Characteristics of Subjects Enrolled

All Deaf, ASL users

Age Range: 34-56 37.5% 1 or more past suicide attempt

87% Caucasian 50% Self-rated ASL skill “very good”

75% Some college or AA level degree 37.5% Self-rated reading skill “very good”

50% Borderline Personality Disorder 87% Mood disorder

37.5% Previous Psych ED Admission 12.5% Previous Inpatient stay

Future Plans

*Several adaptations of the DBT skills manual to address: Varied English reading abilitiesVaried proficiency in activities of daily livingVariations in abstract reasoning abilities

*DBT Skills Training Tapes in ASL with “Deaf-friendly” scripts:“Opposite Action: Changing Emotions You Want to Change” “From Suffering to Freedom: Radical Acceptance”

*Training for those working with Deaf clients

Funded by the National Institute on Disability and Rehabilitation Research