UNIVERSITY OF JYVÄSKYLÄ Pilot Implementation of Acceptance and Commitment Therapy in sign language: Training counselors to apply ACT using sign language Raimo Lappalainen & Leena Hassinen, Department of Psychology, University of Jyväskylä, Finland

UNIVERSITY OF JYVÄSKYLÄ Introduction In Finland there are approximately people who are deaf and use sign language as their mother tongue. About 250 of these persons attend the housing and sheltered work services of the Service Foundation for the Deaf.

UNIVERSITY OF JYVÄSKYLÄ Introduction There is some data (Lindfors, 2005) suggesting that deaf persons have slightly increased number of psychological symptoms as compared to Finnish population in general: 25% vs. 19%. The most common psychological symptoms among the deaf population were loneliness, depression and anxiety symptoms. Deaf persons reported that they needed help for discussing problems with relationships, work-related and other psychological difficulties.

UNIVERSITY OF JYVÄSKYLÄ The aim The aim of the study was to develop an intervention model to increase wellbeing of deaf or deaf-blind clients. As there is a lack of psychotherapists who can use sign language we wanted to investigate if training of counsellors using sign language can have positive impact to deaf clients’ wellbeing.

UNIVERSITY OF JYVÄSKYLÄ Method: Procedure The study was conducted in the service centre Sampola, which is owned by the Service Foundation for the Deaf. It provides supported housing services and workshops, and other work activities in sign language for deaf and deadblind persons. There are 19 staff members and 43 clients of which 35 have their accommodation in Sampola.

UNIVERSITY OF JYVÄSKYLÄ Method: Subjects 14 clients attended the trial All were deaf sign language users Their mean age was 44.3 years (22-60) All except one were working in the Service centre Sampola (94%), 9 (64%) were living there. There was an equal amount of men and women Ten (71%) of the subjects were single Seven (50%) clients had psychiatric diagnoses and medication, only 4 (29%) were receiving treatment 9 staff members participated in the trial

UNIVERSITY OF JYVÄSKYLÄ Method: Intervention 1. Two day workshop for staff members: case formulation and ACT. 2. Supervision every other week. 3. Study groups: The staff members were instructed to read ACT handbooks and had group discussions five times during the intervention period. Each staff member met one client times during a week period. One session/week.

UNIVERSITY OF JYVÄSKYLÄ Method: Intervention The staff members were instructed to construct a case formulation of the clients´ situation and then formulate a value analysis based on ACT principles with the client According to the clients needs, the intervention included experiential exercises and metaphors of ACT All intervention was done in sign language Following exercises were translated into the Finnish sign language: the Observer exercise, The Putting Emotions In Front of You Exercise 7 metaphors were translated: The Quicksand, The Man in the Hole, The Tug-of-War with a Monster, the Jelly Donuts, Hungry Tiger, The House, The Bird House

UNIVERSITY OF JYVÄSKYLÄ Method: Measurements The clients´ situation was assessed by The Symptom Checklist 90 (SCL-90), Beck Depression Inventory (BDI) and AAQ 2 before, during and after the trial. These measurements were translated into sign language before the trial (video recordings). The time between Pre- and Post-measurements was 3 months. The follow –up was done six months after the intervention ended.

UNIVERSITY OF JYVÄSKYLÄ Baseline According to the BDI at the beginning of the intervention all clients except one (94%, n=15) reported at least mild depression symptoms (BDI higher than 9), and 69% (n=11) reported at least moderate level of depressive symptoms. The mean of the SCL-90 GSI score observed in this study (m = 1.37, sd = 0.57) was close to the level observed in the Finnish psychiatric outpatient population (m = 1.56, sd = 0.61, Holi, Sammallahti, & Aalberg, 1998). This suggested that the investigated clients reported a relatively high number of psychological symptoms.

UNIVERSITY OF JYVÄSKYLÄ Application of the ACT procedures The counselors practiced value work with all participants at the beginning of the intervention. On average, each client completed 6.2 experiential exercises (min = 3 and max = 10/participant) during the intervention. The two most frequently used exercises were The Observer Exercise practiced with eight clients (50%) and The Physicalization Exercise practiced with seven clients (44%). Other exercises applied were such as The Mind Train, The Passengers on the Bus, naming objects, different kind of mindfulness exercises (for example, Follow your breathing –exercise)

UNIVERSITY OF JYVÄSKYLÄ ACT procedures The following metaphors were the most frequently used: The House (n=13), The Bird House (n=9), The Tug-of War with a Monster (n=11), The Hungry Tiger (n=7), The Man in the Hole (n=6), and The Jelly Donuts (n=3).

UNIVERSITY OF JYVÄSKYLÄ Experiences of the counselors According to the counselors’ evaluation, all except one of the clients (n= 15) had benefitted positively of the intervention. Many counselors experienced a desire for similar ways of working also in the future. All counselors reported that the project had impacted positively their work and most of them reported that it had influenced positively their work satisfaction. The counselors reported that they had received new tools, changed their working habits and the relationship with the clients had become more equal. About half of them reported that the project had been very or too demanding (5/9), e.g. the concepts of ACT were difficult to communicate to the participants.

UNIVERSITY OF JYVÄSKYLÄ Experiences of the clients At the end of the intervention all 16 participants wanted to recommend this kind of intervention to others. The majority of the clients (94%, n=15) reported that it was easier for them to focus on what was important in their life and that the intervention had increased their ability to recognize emotional reactions (100%, n=16).

UNIVERSITY OF JYVÄSKYLÄ The clients’ experiences of the translated ACT exercises and metaphors (signed on DVD) were generally positive. On the other hand, new terms and new concepts caused problems. Some of the clients reported that they sometimes had to watch the signed ACT-DVD several times before they understood the meaning of the exercise. Also, many of them experienced the assessment methods as challenging and needed individual support when completing the questionnaires.

UNIVERSITY OF JYVÄSKYLÄ Results: Pre- Post and Follow-up groups results (n =14)

UNIVERSITY OF JYVÄSKYLÄ Results: Depression symptoms (BDI) d=0.67 d=0.43 F=2.95, p=0.068

UNIVERSITY OF JYVÄSKYLÄ Results: SCL d=0.16 d=0.50 F=3.15, p=0.057

UNIVERSITY OF JYVÄSKYLÄ Results: SCL-90, anxiety subscale d=0.11 d=0.45 F=3.56.p=0.041

UNIVERSITY OF JYVÄSKYLÄ 6 weeks web-based ACT intervention: No face-to-face contact

UNIVERSITY OF JYVÄSKYLÄ Results There were low correlations between BDI and SCL-90 (r=-0.21), and BDI and AAQ-II (r=0.07) measurements at the beginning of the study. The correlation between SCL-90 and AAQ-II was higher (r=-0.69). These low correlations between BDI and SCL- 90/AAQ-II are exceptional as compared to other Finnish studies including clients with equal level of depression symptoms. For example, in a Study by Kohtala et al. (in press) the pre-measurement correlation between BDI and SCL-90 was 0.70 and between BDI and AAQ

UNIVERSITY OF JYVÄSKYLÄ Results: Figure on changes in SCL GSI (n =14) Decrease of symptoms 10 of 14 subjects reported decrease of psychological symptoms

UNIVERSITY OF JYVÄSKYLÄ Results: Figure on changes in BDI (n = 14) Decrease of depression symptoms 8 of 14 subjects reported decrease of depression symptoms

UNIVERSITY OF JYVÄSKYLÄ Results: Figure on changes in ACT-2 (n = 14) Increase of flexibility 10 of 14 subjects reported change/increase of psychological flexibility

UNIVERSITY OF JYVÄSKYLÄ Conclusions It is important to notice that the investigated population does not represent the Finnish Sign Language uses as a whole. It is obvious that the majority of the selected persons experienced a significant number of personal problems. In practice, because of the limited services available the only way to provide psychological interventions to the selected participants was to train the counselors to apply intervention methods. Thus, we believe that this study provides an example how psychological interventions could be provided to minority groups.

UNIVERSITY OF JYVÄSKYLÄ Conclusions It is possible to train counselors working with deaf persons to apply ACT. It is possible to use ACT with sign language. But the treatment process takes more time, and assessment procedures can be problematic. Short ACT intervention delivered by the counselors seems to have some positive effects to psychological and depression symptoms of deaf persons, and the intervention has some positive effects on the psychological flexibility among the majority of the deaf persons.

UNIVERSITY OF JYVÄSKYLÄ Conclusions The measures were translated into Finnish Sign Language and they were used for the first time in this study. How to measure the effects of the intervention could be a problem. Thus, there is a possibility of misunderstanding of the measurements, and assessment can take a long time to complete.

UNIVERSITY OF JYVÄSKYLÄ Discussion The ACT sign –intervention was well accepted both by the clients and by the counselors. There were reports indicating that there were positive changes at the Sampola community during and after the intervention. This is an example that in some cases the only way to influence the quality of life of the minorities is to train staff members to use psychological methods The model of training staff members to use ACT seems to be workable.