THERAPEUTIC DYNAMICS WITH DEAF-BLIND CONSUMERS IN THE MENTAL HEALTH SYSTEM
Tomina Schwenke, PhD, CI, CT, QMHI
LEARNER OBJECTIVES • Describe mental health settings • Describe mental health workers • Learn terminology/jargon – Psychiatric diagnostic manual (DSM-5) • Identify therapeutic orientations to treatment – Transference and countertransference • Analyze demands on interpreter when working with consumers with atypical vision • Identify controls in MH deaf-blind interpreting scenario
PREVIEW Linguistic Consideration -Terminology & Jargon
Mental Health Interpreting
Contextual Dimensions -Setting -Diagnostics Interpersonal Dynamics -Professionals/Clients Demand-Control Theory -In relation to deaf-blindness
Successful Outcomes -Resources
A matter of interpretation
DEMAND-CONTROL SCHEMA •A theoretical framework for the practice of interpreting. A comprehensive approach to understanding our work with the goal towards quality
Dean and Pollard (2013)
DEMAND-CONTROL SCHEMA •Demands – Environmental – Interpersonal – Paralinguistic – Interpersonal
•Controls – Pre-Assignment – Assignment – Post-Assignment – Choices Range from more liberal to more conservative Dean and Pollard (2013)
DEMAND-CONTROL SCHEMA Four Discrete Demands: 1. Environmental 2. Interpersonal 3. Paralinguistic 4. Intrapersonal
Case Study – 1 70 year old, White male, deaf-blind (fluent ASL). Chronic inpatient hospitalizations. Diagnosed with a psychotic disorder. Forensic background including charges for sexual molestation, aggravated assault, and driving under the influence.
Currently in an inpatient setting.
Environmental Demands: Specific to the setting
DEMAND-CONTROL SCHEMA Four Discrete Demands: 1. Environmental 2. Interpersonal 3. Paralinguistic 4. Intrapersonal
ENVIRONMENTAL DEMANDS 1. GOAL of the Environment 2. Physical Surroundings 3. Personnel/Clientele 4. Terminology/Jargon
ENVIRONMENTAL FACTORS 1. Medication •
2. •
Control Symptoms
Suicide Assessment Reduce harm
3. Substance Abuse •
Control Addiction
4. Counseling •
Process Feelings
Goal
ENVIRONMENTAL FACTORS PHYSICAL SURROUNDING: •Hospital ER •Inpatient •Outpatient •Forensic
ENVIRONMENTAL FACTORS PERSONNEL/CLIENTELE: • Attending • Psychiatrist • Psychologist • Social Worker • Therapist
ENVIRONMENTAL FACTORS SPECIALIZED TERMINOLOGY: Diagnostic and Statistical Manual of Mental Disorders •Psychopharmacology •Therapeutic Approaches •Transference and Countertransference
DSM-5 • Neurodevelopmental Disorders • Schizophrenia Spectrum and Other Psychotic Disorders • Bipolar and Related Disorders • Depressive Disorders • Anxiety Disorders • Obsessive-Compulsive and Related Disorders • Trauma- and Stressor-Related Disorders • Dissociative Disorders • Somatic Symptom and Related Disorders • Feeding and Eating Disorders • Elimination Disorders • Sleep-Wake Disorders
• Sexual Dysfunctions • Gender Dysphoria • Disruptive, Impulse-Control, and Conduct Disorders • Substance-Related and Addictive Disorders • Neurocognitive Disorders • Personality Disorders • Paraphilic Disorders • Other Mental Disorders • Medication-Induced Movement Disorders and Other Adverse Effects of Medication • Other Conditions that May be a Focus of Clinical Attention
MENTAL DISORDERS Type of Mental Disorder Anxiety disorder
% Adults 18.1
.
Major depressive disorder
6.7
.
Substance use disorder
3.8
.
Bipolar disorder
2.6
.
Eating disorders
2.1
.
Schizophrenia
1.1
.
26.2
.
Any mental disorder Statistics taken from the National Comorbidity Survey Replication (NCS-R).
SCHIZOPHRENIA: DSM CRITERIA 2 or more symptoms, 1 month time period
1. Delusions 2. Hallucinations 3. Disorganized speech 4. Grossly disorganized or catatonic behavior 5. Negative symptoms (i.e., affective flattening)
ENVIRONMENTAL FACTORS SPECIALIZED TERMINOLOGY: Therapeutic Approaches Transference and Countertransference
THEORETICAL ORIENTATION • Psychodynamic/Psychoanalytic: • Freud, Adler, Jung • Id, ego, superego; defense mechanisms; transference and countertransference
• • • • • •
Behaviorism Cognitive (Behavioral) Psychotherapy Humanistic Psychotherapy Existential Psychology Feminist Non Western Approaches
TECHNIQUES • Grounding • Biofeedback • Hypnosis • Mindfulness • Progressive Relaxation • Visualization
DEMAND-CONTROL SCHEMA Four Discrete Demands: 1. Environmental 2. Interpersonal 3. Paralinguistic 4. Intrapersonal
Interpersonal Demands: Specific to the interaction of the consumers and the interpreter
INTERPERSONAL POSSIBLE DEMANDS: •
• • • • • •
Understanding of the interpreter role Adherence to expected role norms Communication directed to the interpreter Power and authority dynamics Oppression, dishonesty, & unfairness Thought worlds Communication control (e.g., turn-taking) Source: Dean & Pollard (2013)
Case Study - 2 22 year old, AA female, congenitally deaf and later deaf-blind (fluent ASL, attended various schools for the deaf), history of substance abuse, she has one daughter who is hearing She was recently hospitalized for attempted suicide
Diagnosed with Bipolar Disorder Attending outpatient psychiatric appointments for medication management and counseling
INTERPERSONAL DEMANDS POSSIBLE QUESTIONS TO ASK YOURSELF:
• What are the relationships between people? • How are the individuals the same or different - e.g. sociolinguistic and cultural background • What are the expectations of the interpreter, the deaf-blind person, audience members? • What are the power dynamics at play? • Are there oppressive or unfair events present? • Who is controlling the communication? • How is turn taking happening?
INTERPRETER ROLE • • • • • •
Confidentiality Transference/Counter transference Function as a team in a clinical process Maintain personal & professional boundaries Pre & Post Sessions Self-awareness
TREATMENT • What are the challenges of individual and group therapy ? • What is transference/countertransfer ence • What are possible ethical issues/dilemmas?
Interpersonal
DEMAND-CONTROL SCHEMA Four Discrete Demands: 1. Environmental 2. Interpersonal 3. Paralinguistic 4. Intrapersonal
Paralinguistic Demands: Specific to the quality of the consumers’ expressive language
PARALINGUISTIC POSSIBLE DEMANDS: • • • • •
Communication modalities Linguistic fluency Communication speed Communication clarity Technical vocabulary
Source: Dean & Pollard (2013)
DEMAND-CONTROL SCHEMA Four Discrete Demands: 1. Environmental 2. Interpersonal 3. Paralinguistic 4. Intrapersonal
Intrapersonal Demands: Specific to the Interpreter
INTRAPERSONAL POSSIBLE DEMANDS: • • • • • • • •
Nature and intensity of event Vicarious reactions Safety concerns Physiological responses (e.g., sweating, upset stomach, heart racing, fatigue, etc.) Distractions Doubts regarding performance Availability of supervision and/or peer support Liability concerns Source: Dean & Pollard (2001)
INTRAPERSONAL INTERNAL PROCESSING: Self-dialogue Self-talk Inner monologue Internal dialogue Internal speech Process of thoughts, sparking feelings/emotions and then actions • Positive or negative • • • • • •
SelfTalk
Keeping the Balance Controls
Demands
CONTROLS
Pre-Assignment Assignment Post-Assignment
THREE POINTS OF ASSESSMENT 1. Pre-assignment B. Individual-specific factors A. Interpreter-related factors: • Logistical information • Prior knowledge of the assignment & working – Partner, team, lead environment (i.e. location, • Educational background content to be discussed) – School for the deaf, school for • Assignment professional deaf-blind, mainstreamed requirements (i.e. attire, • Language of the individual previously established – Tactile, close vision, tracking relationships) • Consumer visual needs • Preview of materials • Potential visual environmental • Consumer language needs challenges • Consumer SSP, additional support • General experience in deaf- needs blindness Adapted from http://www.terptopics.com/DemandControl.htm
THREE POINTS OF ASSESSMENT 2. Assignment Pre-conferencing with consumer & on-site contacts Establishing language/communication preference Assessing logistics Orientation to the environment Incorporating visual information/changes in the environment • On-going modification process for optimal language access • • • • •
Adapted from http://www.terptopics.com/DemandControl.htm
THREE POINTS OF ASSESSMENT 3. Post-assignment • Post-conferencing with consumer • Talk about how the session went for the individuals involved • Reflect on how the session went for you – Pros and cons – Problems and solutions • Feedback to hiring agent • specific to visual and additional support needs of the consumer • Checklist for future assignments Adapted from http://www.terptopics.com/DemandControl.htm
INTRAPERSONAL POSSIBLE CONTROLS: Supervision/Mentorship • Talking about your thoughts with those more experienced, finding solutions Peer support • Sharing thoughts and feelings with peers
Challenges to sharing: • Issues of Confidentiality • DB community small • Dual relationships common • Job structure-not a lot of time to chit-chat, rushing, may or may not be with partner, sometimes unpredictable work situations • Not well understood • Confusing professional issues for loved ones, therapists, & others to comprehend
SUCCESSFUL OUTCOMES • Continued training – Workshops – Coursework – Experience • Mentorship – Develop relationship with mentor who has more experience in that area • Work on your own selfawareness • Take care of yourself • Collect and share resources
RESOURCES • The Alabama Department of Mental Health, Mental Health Interpreter Training (MHIT) http://www.mhit.org • The Deaf Wellness Center at the University of Rochester: http://www.urmc.rochester.edu/dwc/ • The Registry of Interpreters for the Deaf: http://www.rid.org • TerpTopics http://www.terptopics.com/DemandControl.htm • The APA PsychInfo database: http://psycinfo.apa.org/ • ADARA, Professionals Networking for Excellence in Service Delivery with Individuals who are Deaf or Hard of Hearing, http://www.adara.org/
CONTACT Tomina J. Schwenke, Ph.D., CI/CT, QMHI tomina.schwenke@mac.com
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EVALUATION
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