Developing Signs of Safety: A Deaf-accessible counselling toolkit for trauma and addiction

The U.S. Deaf community-more than half a million Americans who communicate using American Sign Language (ASL)-experiences higher rates of trauma exposure and substance use disorder (SUD) than the general population. Yet there are no evidence-based treatments for any behavioural health condition that have been evaluated for use with Deaf people. The driving aim of our work, therefore, has been to develop and formally evaluate a Deaf-accessible trauma/SUD counselling approach. Here we describe our initial intervention development work and a single-arm pilot that evaluated the feasibility, acceptability, and preliminary clinical efficacy of Signs of Safety-a Deaf-accessible toolkit to be used with an existing, widely adopted protocol for trauma and addiction (Seeking Safety). Preliminary efficacy results indicated clinically significant reductions in PTSD symptoms and frequency of alcohol use for the Seeking Safety/Signs of Safety model. Frequency of drug use did not change significantly-likely attributable to the mid-study legalization of recreational marijuana in our state. Next steps include the redesign and refilming of Signs of Safety based on pilot participant feedback, again using a Deaf-engaged development and production process. This new toolkit will be tested via a pilot randomized controlled trial designed based on present methodological lessons learned.

Creating the Capacity to Screen Deaf Women for Perinatal Depression: A Pilot Study

OBJECTIVE

Compared to hearing women, Deaf female sign language users receive sub-optimal maternal health care and report more dissatisfaction with their prenatal care experiences. As healthcare providers begin to regularly screen for perinatal depression, validated screening tools are not accessible to Deaf women due to severe disparities in English literacy and health literacy.

DESIGN AND SETTING

We conducted a one-year, community-engaged pilot study to create an initial American Sign Language (ASL) translation of the Edinburgh Postnatal Depression Scale (EPDS); conduct videophone screening interviews with Deaf perinatal women from across the United States; and perform preliminary statistical analyses of the resulting pilot data.

PARTICIPANTS

We enrolled 36 Deaf perinatal women between 5 weeks gestation up to one year postpartum.

MEASUREMENTS AND FINDINGS

Results supported the internal consistency of the full ASL EPDS, but did not provide evidence of internal consistency for the anxiety or depression subscales when presented in our ASL format. Participants reported a mean total score of 5.6 out of 30 points on the ASL EPDS (SD = 4.2). Thirty-one percent of participants reported scores in the mild depression range, six percent in the moderate range, and none in the severe range.

KEY CONCLUSIONS AND IMPLICATIONS

Limitations included small sample size, a restricted range of depression scores, non-normality of our distribution, and lack of a fully-standardized ASL EPDS administration due to our interview approach. Informed by study strengths, limitations, and lessons learned, future efforts will include a larger, more robust psychometric study to inform the development of a Computer-Assisted Self-Interviewing version of the ASL EPDS with automated scoring functions that hearing, non-signing medical providers can use to screen Deaf women for perinatal depression.

Deaf ACCESS: Adapting Consent Through Community Engagement and State-of-the-Art Simulation

One of the most understudied health disparity populations in the United States is the Deaf community, a sociolinguistic minority group of more than 500,000 individuals who communicate via American Sign Language. Research on Deaf health disparities is lacking due to inaccessible recruitment, sampling, and data collection procedures, as well as the fundamental disconnect between medical and cultural views of Deaf people. A potential starting place for addressing inaccessible research methods and mistrust of the biomedical research community is the careful reconsideration of the traditional informed consent process, often a Deaf individual's first point of contact with the research world. Yet, most Deaf individuals experience obstacles to engaging in informed consent due to differences in language and development compared to hearing individuals. In response to these issues, our team led a three-phase, formative, community-engaged approach to adapt the informed consent process and train research staff in the updated method so that all required components are properly communicated and understood. The goals of our work were to promote Deaf engagement in research about the Deaf community, increase the number of Deaf individuals who participate in general population biomedical research, and generalize our findings to improve research accessibility for the general population.

Deaf Qualitative Health Research: Leveraging Technology to Conduct Linguistically and Sociopolitically Appropriate Methods of Inquiry

One of the most understudied health disparity populations in the United States is the Deaf community-a sociolinguistic minority group of at least 500,000 individuals who communicate using American Sign Language. Research within this population is lacking, in part, due to researchers' use of methodologies that are inaccessible to Deaf sign language users. Traditional qualitative methods were developed to collect and analyze participants' spoken language. There is, therefore, a paradigm shift that must occur to move from an auditory data schema to one that prioritizes the collection and analysis of visual data. To effectively navigate this shift when working with Deaf sign language users, there are unique linguistic and sociopolitical considerations that should be taken into account. The current article explores these considerations and outlines an emerging method of conducting qualitative analysis that, we argue, has the potential to enhance qualitative researchers' work regardless of the population of focus.

Barriers and Facilitators to Deaf Trauma Survivors' Help-Seeking Behavior: Lessons for Behavioral Clinical Trials Research

Deaf individuals experience significant obstacles to participating in behavioral health research when careful consideration is not given to accessibility during the design of study methodology. To inform such considerations, we conducted an exploratory secondary analysis of a mixed-methods study that originally explored 16 Deaf trauma survivors' help-seeking experiences. Our objective was to identify key findings and qualitative themes from consumers' own words that could be applied to the design of behavioral clinical trials methodology. In many ways, the themes that emerged were not wholly dissimilar from the general preferences of members of other sociolinguistic minority groups-a need for communication access, empathy, respect, strict confidentiality procedures, trust, and transparency of the research process. Yet, how these themes are applied to the inclusion of Deaf research participants is distinct from any other sociolinguistic minority population, given Deaf people's unique sensory and linguistic characteristics. We summarize our findings in a preliminary "Checklist for Designing Deaf Behavioral Clinical Trials" to operationalize the steps researchers can take to apply Deaf-friendly approaches in their empirical work.

A Pilot Study of Deaf Trauma Survivors' Experiences: Early Traumas Unique to Being Deaf in a Hearing World

Conducting semi-structured American Sign Language interviews with 17 Deaf trauma survivors, this pilot study explored Deaf individuals' trauma experiences and whether these experiences generally align with trauma in the hearing population. Most commonly reported traumas were physical assault, sudden unexpected deaths, and "other" very stressful events. Although some "other" events overlap with traumas in the general population, many are unique to Deaf people (e.g., corporal punishment at oral/aural school if caught using sign language, utter lack of communication with hearing parents). These findings suggest that Deaf individuals may experience developmental traumas distinct to being raised in a hearing world. Such traumas are not captured by available trauma assessments, nor are they considered in evidence-based trauma treatments.

Deaf people's help-seeking following trauma: Experiences with and recommendations for the Massachusetts behavioral health care system

OBJECTIVE

Deaf trauma survivors are one of the more underserved populations in behavioral health care and experience significant obstacles to seeking help. Repeated encounters with these barriers fuel negative perceptions and avoidance of behavioral health treatment. The current study sought to explore Deaf trauma survivors' help-seeking experiences and elicit their recommendations for improving Deaf behavioral health services in Massachusetts.

METHOD

We conducted semistructured American Sign Language interviews with 16 trauma-exposed Deaf individuals that included questions from the Life Events Checklist and the PTSD Symptom Scale Interview and questions about Deaf individuals' help-seeking behaviors. Qualitative responses regarding help-seeking experiences were analyzed using a grounded theory approach.

RESULTS

In the aftermath of trauma, our participants emphasized a desire to work with a signing provider who is highly knowledgeable about Deaf culture, history, and experience and to interact with clinic staff who possess basic sign language skills and training in Deaf awareness. Most stressed the need for providers to better outreach into the Deaf community-to provide education about trauma, to describe available treatment resources, and to prove one's qualifications. Participants also provided suggestions for how behavioral health clinics can better protect Deaf survivors' confidentiality in a small-community context.

CONCLUSIONS

Deaf-friendly trauma treatment should incorporate the components of trauma-informed care but also carefully consider key criteria expressed by our participants: direct signed communication, understanding of Deaf history and experience, stringent practices to protect confidentiality, provider visibility in the community, and reliance on peer support and Deaf role models in treatment interventions. (PsycINFO Database Record