Cognitive-Behavioral Therapy for Deaf and Hearing Persons with Language and Learning Challenges

Neil Glickman

• Publisher: Routledge
• Year: 2008
• Print ISBN: 9780805863994, 9780805863987
• eBook ISBN: 9781135591588
• Edition: 1
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

This book provides a model for adapting best practices in cognitive-behavioral therapy to consumers whose language and cognitive deficits make it difficult for them to benefit from traditional talk oriented psychotherapy.

The book focuses primarily upon the mental health care of those deaf clients, sometimes referred to as "low functioning" or "traditionally underserved, " who are particularly difficult to engage in meaningful treatment.

Drawing most heavily upon the work of Donald Meichenbaum, Marsha Linehan, and Ross Greene, this book presents adaptations and simplifications of psychotherapy which make it accessible and meaningful for persons often viewed as "poor candidates."

The heart of the book is a greatly simplified approach to psychosocial skill training, especially in the domains of coping, conflict resolution and relapse prevention skills, as well as an extensive discussion of "pre-treatment" strategies for engaging clients in mental health care.

Also included is research demonstrating how deaf mental health clients are different than hearing clients, guidelines for doing mental status examinations with deaf clients whose language dysfluency gives them the false appearance of having thought disorders, and a chapter on developing staff and creating culturally and clinically appropriate treatment programs.

Included with the book is a CD-ROM containing over 1500 beautifully drawn illustrations of a wide range of mental health and substance abuse related concepts. These pictures or "skill cards" are used in psychoeducation and therapy with persons who can not read English.

1
Language and Learning Challenges in the Deaf Psychiatric Population^*

PATRICIA BLACK AND NEIL GLICKMAN

We might start with some naïve questions. How is mental health care with deaf persons different from mental health care with hearing people? Are not deaf psychiatric clients similar to hearing psychiatric clients, except they cannot hear?

There are some obvious answers. Some deaf people use sign language. Some use hearing aids or have cochlear implants. There is special technology that deaf people use. Beyond these obvious matters, why would anything else be different?

At the time of this writing, in the fall of 2007, the idea that mental health care of deaf people is in any significant way different than mental health care of hearing people is controversial. The mainstream assumption is that deaf people suffer the same psychiatric problems as hearing people, manifest them in the same way, and require no more special expertise to serve than the assistance of a sign language interpreter. Most deaf people treated in psychiatric settings are placed in hearing psychiatric units that have no particular expertise in working with deaf persons (Trybus, 1983). They may receive accommodations consisting of limited hours of interpreting services. Perhaps someone orders a hearing evaluation and adaptive equipment like hearing aids. Maybe the captioning on the television is turned on. Someone may produce the old tty (text telephone) from the storage room not realizing how far telecommunication for deaf people has advanced beyond it. One may fairly ask why anything more is required to serve deaf clients than this.

In the second half of the 20th century, a growing number of mental health clinicians came to understand that much more is required. There is far more to working with deaf people than audiological remediation and bringing in sign language interpreters. There is a large body of special knowledge to acquire, and the knowledge domains are not merely medical and audiological but also social, historical, psychological, rehabilitative, linguistic, and cultural. There are complex new skills to acquire. Skill in American Sign Language (ASL) is the most obvious, but other skills include nonverbal communication, linguistically informed work with interpreters, skills in adapting one’s clinical role, skill in collaboration with Deaf Community helpers and leaders, and skills in adapting assessment and treatment interventions (Glickman, 1996; Zitter, 1996).

There is yet a third dimension of specialization in clinical work with deaf people. This is the dimension of self-awareness. Hearing people, as hearing people, have certain attitudes toward deaf people that can interfere with the establishment of a therapeutic alliance. An unexamined paternalistic and audist (Lane, 1992, 1996) attitude can be an even more formidable barrier to effective mental health care of deaf people than lack of signing skills. This problem leads Hoffmeister and Harvey to explore, somewhat tongue in cheek, the issue of whether there is a Psychology of the Hearing (Hoffmeister & Harvey, 1996).

In the latter half of the 20th century, mental health care of deaf persons emerged as a clinical discipline (Pollard, 1996). Besides a growing body of research and clinical literature, there are graduate programs that train students to work with deaf people, practica and internships in specialty programs, professional journals, and national and international conferences on various aspects of mental health care of deaf people. Indeed, as American Sign Language gained recognition as a real language and the Deaf Community gained recognition as a cultural community, an array of new ethical standards emerged for working with deaf people (Gutman, 2002). For instance, it is increasingly recognized that clinicians without specialized training who work with deaf persons are violating ethical standards of their discipline. Standard 2.01, Boundaries of Competence, of the 2002 American Psychological Association Ethical Principles of Psychologists and Code of Conduct states:

(a) Psychologists provide services, teach, and conduct research with populations and in areas only within the boundaries of their competence, based on their education, training, supervised experience, consultation, study, or professional experience.

(b) Where scientific or professional knowledge in the discipline of psychology establishes that an understanding of factors associated with age, gender, gender identity, race, ethnicity, culture, national origin, religion, sexual orientation, disability, language, or socioeconomic status is essential for effective implementation of their services or research, psychologists have or obtain the training, experience, consultation, or supervision necessary to ensure the competence of their services, or they make appropriate referrals, except as provided in Standard 2.02, Providing Services in Emergencies. (American Psychological Association, 2002).

Are there significant differences between the characteristics of deaf and hearing psychiatric patients, beyond the issue of hearing loss, that warrant this special training?

The purpose of the first two chapters of this book is to address this question. Some of the controversy has focused on the question of whether there is such a thing as a psychology of deafness. At least four books have been published with this idea in the title (Levine, 1960; Myklebust, 1964; Paul & Jackson, 1993; Vernon & Andrews, 1990). We address it here by looking at characteristics of deaf psychiatric inpatients. As we review the literature, we will certainly find that deaf people have been diagnosed with all the same kinds of psychopathology as hearing people. However, the qualifications of the clinicians who performed these assessments and the validity of their assessments are open to challenge. Another issue, as we will see, is whether the population of deaf persons served in mental health facilities is in some significant ways different from their hearing peers. We will demonstrate that some differences are so pronounced that clinicians without specialized training are wholly unprepared for the task.

Both issues come together when we consider the subpopulation of deaf persons sometimes referred to as low functioning deaf (LFD). In this chapter we review some of the literature on LFD, followed by a review of the literature on deaf psychiatric inpatients. We then turn to an analysis of the characteristics of deaf patients on a specialty psychiatric Deaf Unit over a seven-year period. Our goal is to answer the naïve questions posed at the beginning of this chapter. How is mental health care with deaf persons different from mental health care with hearing people?

Traditionally Underserved Deaf People

The subgroup of low functioning deaf persons is well known in the Deaf Community and by service providers who work with deaf people. The name low functioning deaf is problematic because the group is heterogeneous, people may be skilled in some domains while unskilled in others, and because it is pejorative. Other labels that have been used include “severely disabled,” “underachieving,” “minimal language skilled,” “multiply handicapped,” and “traditionally underserved” (Dew, 1999). The last term is often favored because it is the least pejorative. I (Neil Glickman) offered the term psychologically unsophisticated (Glickman, 2003) but it has not caught on, even with me.

The use of the term low functioning deaf does not seem appropriate in this book because one of the key pretreatment strategies, discussed in Chapter 4, is to notice and reinforce the skills and strengths these persons do have. We are presenting a strength-based model, and that should be reflected in our language. In Chapter 2, we refer often to deaf persons who are language dysfluent due to language deprivation. For the purposes of this current chapter, we stay with traditionally underserved when not quoting directly because this is the term most accepted in the literature we review. In Chapters 3 through 9, we use the phrase language and learning challenged (LLC) for both the deaf and hearing clients who are the focus of our attention.

According to the comprehensive report of the Institute on Rehabilitation Issues Prime Study Group on Serving Individuals Who Are Low Functioning Deaf (Dew, 1999), Rehabilitation Services Administration (RSA) research between 1963 and 1998 produced consensus on six characteristics that seem to describe persons who are LFD.

1. Inadequate communication skills due to inadequate education and limited family support. Presenting poor skills in interpersonal and social communication interactions, many of these individuals experience difficulty expressing themselves and understanding others, whether through sign language, speech and speech reading, or reading and writing.

2. Vocational deficiencies due to inadequate educational training experiences during the developmental years and changes in personal and work situations during adulthood. Presenting an underdeveloped image of self as a worker, many exhibit a lack of basic work attitudes and work habits as well as a lack of job skills and/or work skills.

3. Deficiencies in behavioral, emotional, and social adjustment. Presenting a poorly developed sense of autonomy, many exhibit low self-esteem, have a low frustration tolerance, and have problems of impulse control that may lead to mistrust of others and pose a danger to self and others.

4. Independent living skills deficiencies. Many of these individuals experience difficulty living independently, lack basic money management skills, lack personal hygiene skills, cannot manage use of free time, do not know how to access health care or maintain proper nutrition, and have poor parenting skills.

5. Educational and transitional deficiencies. Most read at or below a fourth-grade level and have been poorly served by the educational system, are frequently misdiagnosed and misplaced, lack a supportive home environment, are often discouraged in school and drop out, and are not prepared for postschool life and work. Approximately 60% of the high school leavers who are deaf cannot read at the fourth-grade level.

6. Health, mental, and physical limitations. Many have no secondary physical disabilities, but a large number have two, three, and sometimes more disabilities in addition to that of deafness. In fact, 30% of high school leavers who are deaf had an educationally significant additional disability. These secondary disabilities range from organic brain dysfunction to visual deficits. These problems are further compounded in many instances by a lack of knowledge on how to access health and/or self care. (Dew, 1999)

Long, Long, and Ouellette (1993) provide a useful definition based on responses to a survey conducted by the Northern Illinois University Research and Training Center on Traditionally Underserved Persons Who Are Deaf (NIU-TRC):

A traditionally underserved person who is deaf is a person who possesses limited communication abilities (i.e., cannot communicate effectively via speech, speech reading, sign language and whose English language skills are at or below the third grade level) and who possesses any or all of the following characteristics:

• Cannot maintain employment without transitional assistance or support;

• Demonstrates poor social/emotional skills (i.e., poor problem solving skills, difficulty establishing social support, poor emotional control, impulsivity, low frustration tolerance, inappropriately aggressive);

• Cannot live independently without transitional assistance or support [emphasis maintained from original]. (p. 109)

The most important distinguishing characteristic of this group is the poorly developed language skills. These language deficits are most easily measured in English or other spoken languages, but perhaps more important are the language deficits in what is usually their best language: ASL. These persons generally are not fluent in ASL and may have difficulty expressing themselves even among deaf people. The language deficits are significant because they create or contribute to most other problems these individuals face. To live in a predominantly English-speaking country without fluency in English is certainly a major disadvantage, but to have no native language in which one is truly fluent is a handicap with far more serious ramifications.

Among hearing people, outside of those with extreme brain pathology or environmental deprivation, the kinds of language dysfluency we find in traditionally underserved deaf people is extremely rare. This means that most teachers, physicians, rehabilitation workers, and mental health providers will not have come across this problem unless they have had very specialized clinical training or exposure to large numbers of deaf people. They will be unprepared for these clients, and they will make unintentional errors when assessing and treating them that can result in serious and sometimes life-long damage (Glickman & Gulati, 2003).

Population estimates for this group of persons are 125,000 to 165,000 (Bowe, 2004; Dew, 1999). Hard numbers are not available in part because the federal government has not funded specialized programming for them long enough to establish consistent, clear criteria for identifying them or to complete program evaluations and establish best practices (Harmon, Carr, & Johnson, 1998).

The primary so...

Table of contents

• COUNSELING AND PSYCHOTHERAPY: INVESTIGATING PRACTICE FROM SCIENTIFIC, HISTORICAL, AND CULTURAL PERSPECTIVES
• Contents
• Series Preface
• Acknowledgments and Dedication
• Introduction
• 1 Language and Learning Challenges in the Deaf Psychiatric Population*
• 2 Do You Hear Voices?
• 3 Language and Learning Challenges in Adolescent Hearing Psychiatric Inpatients
• 4 Pretreatment Strategies to Engage and Motivate Clients
• 5 Coping Skills
• 6 Conflict Resolution Skills
• 7 Relapse Prevention and Crisis Management Skills
• 8 Staff and Program Development
• 9 Summary and Conclusions
• Appendix I How to Use the CD-ROM
• Appendix II Skill Card Menu
• References
• Index