Preparing Deaf and Hearing Persons with Language and Learning Challenges for CBT

A Pre-Therapy Workbook

Neil S. Glickman

• Publisher: Routledge
• Year: 2016
• eBook ISBN: 9781317416388
• Topic: Medicine
• Subtopic: Audiology & Speech Pathology

Preparing Deaf and Hearing Persons with Language and Learning Challenges for CBT: A Pre-Therapy Workbook presents 12 lessons to guide staff in hospital and community mental health and rehabilitation programs on creating skill-oriented therapy settings when working with people who don't read well or have trouble with abstract ideas, problem solving, reasoning, attention, and learning. Drawing from the worlds of CBT, current understandings of best practices in psychotherapy, and the emerging clinical specialty of Deaf mental health care, the workbook describes methods for engaging people who are often considered poor candidates for psychotherapy.

Lesson Five
The Power of Working “One-Down”

Introduction

In Lesson 4, you learned about the important role that empathy plays in your work. You also learned why it is critical to establish an empathetic connection with the people you serve before you begin to encourage them to learn and use skills. In this lesson, you will explore another crucial pre-therapy tool: How to invite—not force—the people you serve to participate in taking control of their development or recovery. The overall name we give to the process of inviting, not compelling, people to engage in recovery is working “one-down.”

Figure 5.1 Authority

©iStock.com/Luis Francisco Cordero

Using Power and Authority in a One-Up Stance

In cognitive behavioral therapy, we help people explore connections between their emotions, thoughts and behaviors and we help them develop and use important life skills. If people are ready and willing to do this, there isn’t much need for pre-therapy. If they aren’t, and if the obstacles have to do with language and learning challenges, we are in the world of pre-therapy. Our pre-therapy work includes:

• Creating a shared understanding (schema) that skill building is what we do here.
• Creating a positive mindset that says: “I can do this. Staff doesn’t need to do this for me.”
• Using empathy to convey that we understand how difficult it can be to learn new skills.
• Becoming skillful at inviting people to participate in this difficult process.
• Helping participants to develop foundational problem solving abilities.

The stance you take towards the people you serve will play a key role in how effective you are in achieving these goals. A stance literally means the way a person stands, their posture. In this workbook, however, the word “stance” refers to the attitude you assume toward the people you serve, especially with regard to the way that you use your power and authority. Of course, at times, a person’s attitude may literally show up in the way you stand and move.

You are in a position of authority over the people served in your program. Take a minute to consider your stance toward the people you serve and how you use the power that comes with your position:

• Do you act like you are their boss?
• Are you very concerned with whether or not the people you serve listen to you and respect you?
• Do you spend a lot of time telling people how they should behave?
• Do you tell people what they should feel or think?
• Do you think your job is to manage and control people?
• Do you see it as your job to rescue people if they make bad choices?

Definition 5.1: Stance: The attitude a person assumes, especially with regard to how much power they believe they have over another person.

Example of stance: Betty assumes a stance of authority. She tells the people she serves how they should behave. Melissa assumes a more humble stance. She is endlessly curious about why people behave as they do and asks them lots of questions. She assumes they understand themselves better than she does.

Most people in human services act from a one-up stance unless they have been specifically trained to work in another way. That is, many of us use our power to try to directly influence people we serve. This is especially true of staff who work in programs that serve people who are thought to be very impaired. In various ways, we tell them what they should do.

Look at Table 5.1 and Figure 5.2 to see what is involved in a one-up stance.

Table 5.1 Examples of One-Up Stances

Stance	Description	Example
Directing	Telling people what to do or	• “You should just ignore him”
	giving them advice about what	• “You need to take a time
	you think they should do	out right now”
		• “You need to use your
		coping skills now”
Informing	Telling people what is right	• “That behavior is
	or wrong, appropriate or	inappropriate”
	inappropriate, healthy or	• “You are not respecting my
	unhealthy	boundaries”
	Informing includes giving both	• “You are being manipulative”
	praise and criticism	• “This is what you need to
		do now”
Controlling	The person’s overall intent	• Staff work on “fixing”
	is to control the way	a behavior without the
	others behave. Within this	person’s knowledge,
	framework, clients are	participation or consent.
	typically described as either	This can include creating a
	“cooperative” or “resistant”	behavior plan designed to
	based on whether or not	reinforce certain behaviors
	they accept staff control.	• A program is based on
	If the person responds by	rules. Staff’s job is to get
	attempting to control staff in	program participants clients
	return, the individual is often	to cooperate and follow the
	labeled “manipulative”.	rules

Figure 5.2 “I’m the boss!”

©iStock.com/Ostill

Definition 5.2: One-up stance: The attitude and behavior that one person has power and authority and their job is to use it to directly influence or control other people.

Example of a one-up stance: A staff person tells Sam, a program resident, that his shouting and cursing are unacceptable and that he won’t take Sam out to the store until Sam stops the behavior and apologizes for his outburst.

Figure 5.3 ASL sign for ONE-UP

Used with permission

Figure 5.4 Are program staff members substitutes for the police?

©iStock.com/alashi

One-up treatment environments focus on rules. Staff members view their work as primarily to make sure everyone in a program follows the rules. They are authority figures; they are in charge. As a result, staff members sometimes behave like police. Even if staff members have good intentions, they spend the majority of their time telling people what to do. This work style is extremely common.

Questions to ponder 5.1: How many of your interventions with clients take the form of directing, informing or controlling? If you haven’t thought about your stance toward the people you serve until now, chances are that most of your interactions are done with a one-up stance, meaning you are directive and controlling.

The Role of Control in Mental Health Programs

Many mental health programs are preoccupied with staff having control over the people they serve. If a program is based on the assumption that the people being served are “impaired,” then staff members are more likely to believe that their primary job is to fix or correct problems. For staff members working in these programs, fixing, correcting and controlling are all viewed as forms of helping. This often leads to the unstated assumption that staff members, themselves, are not impaired because they are being paid to do the helping. In other words, staff members assume they are healthy and competent while assuming the people they serve are unhealthy and incompetent.

Many staff members work in these programs because they want to help people. However, many never examine how easy it is to cross the line that separates helping from controlling. They may believe that helping means to correct, fix, guide, shape, protect or control for the person’s own good.

Recently, however, many people who receive services have begun to challenge this model. They are speaking out, saying things like: Stop treating us like children! Respect our ability to make decisions and, yes, to make mistakes. They are talking about the “dignity of risk,” meaning that, like everyone else, they have the right to make mistakes and deserve to have this right respected by the professionals who support them.

Many programs are based on a medical model which assumes that the people served in the program are patients who are sick. In this model, medical professionals, with their expert knowledge and skills, are trained to try to fix patients’ problems, to help them “get better.” This is the traditional way the medical field has worked. This stance or attitude often promotes a passive model of recovery—the patient follows the doctor’s orders, takes medication as prescribed. The doctor knows best.

Fortunately, this stance is changing as more of today’s medical professionals recognize that medication is not enough and begin to understand that patients get better through learning t...

Table of contents

• Cover
• Title
• Copyright
• Contents
• Acknowledgments
• Introduction
• LESSON ONE Coping Skills
• LESSON TWO Conflict Resolution Skills.
• LESSON THREE Strength-based Work
• LESSON FOUR Empathy
• LESSON FIVE The Power of Working "One-Down"
• LESSON SIX Questions Are Better than Answers
• LESSON SEVEN Promoting Self-Assessment
• LESSON EIGHT Thoughts and Self-Talk
• LESSON NINE The Connection between Thoughts, Feelings, and Behaviors
• LESSON TEN Changing Self-Talk
• LESSON ELEVEN Deaf Mental Health Care and Relapse Prevention I
• LESSON TWELVE Deaf Mental Health Care and Relapse Prevention II