Download How to use the pictures from the book

How to use the pictures from the book
Preparing Deaf and Hearing Persons with Language and Learning Challenges for CBT:
A Pre-Therapy Workbook, by Neil Glickman
© 2017 Neil S. Glickman
The picture aids, which as a group we call skill cards, presented here were developed by
Deaf artist Michael Krajnak on the Westborough (Massachusetts) State Hospital Deaf
Unit. Several hundred of his skill cards were presented on the CD-ROM accompanying
Mental Health Care of Deaf Persons (Glickman & Gulati, 2003). Five years later,
Michael had drawn well over 1000 more pictures, and a CD-ROM with these pictures
was included with the book, Cognitive behavioral therapy of deaf and hearing persons
with language and learning challenges (Glickman, 2009). By the second version,
Michael had redrawn many, improving their quality, and organized them more clearly.
As the popularity of these cards spread, we discovered more ways to use them. We find
that educators and counselors were looking for ways to make complex ideas simpler and
clearer, and not just for persons with language and learning challenges. The folders of
psychoeducational pictorial tools, for instance, are suitable for people learning about
symptoms of mental illness or side effects of medication and could easily be used to
accompany graduate school lectures on the subject.
The categories of pictures can be organized as follows:
1 cards that represent concrete skills (the more narrow definition of skill cards)
2 cards that present pictures of behaviors
3 cards depicting feelings and thoughts
4 situation cards that depict situations that elicit use of skills
5 cards depicting substance abuse concepts and treatment concepts
6 sample rating scales, self-monitoring forms and behavioral plans
7 psychoeducational materials including cards depicting medical and psychiatric
symptoms, medication benefits and side effects, and medical procedures
8 cards presenting legal matters such as patient rights, health proxies, HIPAA
regulations, and insurance issues
9 useful metaphors
10 miscellaneous cards
The cards are best used as tools by staff who can communicate in the language and
modality preferred by clients. They are not designed to be substitutes for such staff; and
do not, in and of themselves, provide “effective communication” with deaf persons, as
mandated by the Americans with Disabilities Act. The pictures are tools designed to
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support teaching and counseling efforts, but they are not substitutes for staff who can
communicate with clients directly in the way their clients prefer.
People vary in whether or not they relate to pictures. Some people are insulted by the use
of pictures. A hearing non-signer who attempts to communicate with a literate deaf
person through pictures had better be prepared for a strong negative response. Others
people, especially many deaf people with language and learning challenges, embrace
them. The best approach is simply to ask people how they feel about use of pictures and
honor their wishes.
It is not always completely clear what a picture depicts so simple captions are usually
helpful, if not for the clients than for the staff assisting them. There is also the question of
what English words to use to caption the pictures. Some of the pictures have captions.
Others do not. We tend to use English words that we are fairly sure our deaf clients
know. We also sometimes use ASL syntax (for instance, “BLAME STOP”). We haven’t
found a solution that works for everyone as some clients (and staff) prefer “normal
English” and others do not. Users are encouraged to change or develop captions as they
see fit.
We’ve found it useful to get an inexpensive lamination machine so we can laminate some
of the most commonly used cards. This facilitates use of the cards in group activities. The
invitation to “pick a card” has gotten us through many groups where participation was
otherwise lagging.
Card categories
1 Cards depicting concrete skills
Included here are pictures of concrete skills that are used for coping, conflict resolution,
social interactions, and activities of daily living. There are also a great number of cards
depicting sensory modulation skills. These are activities that involve the senses that can
be used either to alert or calm a person
These pictures are easily brought into PowerPoint, Word or Excel documents. For
instance, Westborough State Hospital nursing and occupational therapy staff borrowed
many of the pictures in designing posters of skills they are teaching and promoting. The
hospital pharmacist borrowed pictures of medication benefits and side effects (see below)
to create teaching tools for pharmacy students.
2 Cards that present pictures of behaviors
There are many cards showing examples of good and bad behaviors. These cards are
appropriate for many children or older persons with cognitive and behavioral problems.
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They are used mainly in the development of visual self-monitoring forms, behavior and
treatment plans. The goal might be for a client to demonstrate particular good behaviors
and avoid particular bad behaviors. Pictures depicting these behaviors could be placed on
a self-monitoring form followed by a box where the client checks off “yes” or “no” to
indicate whether or not he did them that day.
Also present are cards showing problem sexual behaviors (in the Sexuality folder). Some
of these cards are, of course, fairly graphic. This is sometimes a problem for staff but
rarely a problem for clients. We would not use such pictures with them if we could
adequately address the issue using language. These pictures especially have to be used
tactfully. For instance, it may be appropriate to develop a self-monitoring form that
includes pictures of sexual behaviors or uses words like “shit.” The use of graphic sexual
pictures or street language on forms with patients obviously needs to be done with
sensitivity and tact.
3 Cards depicting feelings and thoughts
Part of mental health treatment is teaching people to identify and label their feelings and
moods. Virtually every self-monitoring form we develop starts with a rating of current
moods, most commonly represented as ratings of happiness, sadness, anger, and anxiety.
We begin community meeting and many groups with a check-in in which clients rate
their emotions at that moment. We sometimes do this before and after an activity as a
way of demonstrating to clients that what they do effects what they feel. The pictures of
emotions are usually copied into self-monitoring forms. When it is relevant, depictions of
feelings can include cravings, for instance to use a drug or to cut oneself. Helping clients
develop awareness of their cravings (i.e., stopping and noticing) is the first step towards
helping them develop skills in responding to these cravings differently.
4 Situation cards that depict situations that elicit use of skills
Situation cards present pictures of situations that call for coping and conflict resolution
skills. The cards are often used in group treatment, frequently as part of a game format as
discussed in Chapters 5 and 6 of the 2009 text. For instance, clients are asked to “pick a
card” depicting a particular provocative situation and the group then role plays the use of
various skills in response. The folder on provocations/triggers present more situation
cards that can be used in teaching relapse prevention skills and concepts such as trigger.”
Behaviors depicted in the Good and Bad Behaviors folders may provide additional
provocations and triggers. Other resources are in the Substance Abuse folder.
5 Cards depicting substance abuse concepts and treatment concepts
The Substance Abuse folder has three subfolders. The first one, indicators of drug use,
contains a large number of pictures depicting signs and symptoms of drug use. These are
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organized under personality (e.g., mood swings, secretive, stealing), physical appearance
(e.g., poor grooming, not sleeping), school and social activities (e.g., low grades, loss of
interest in friends), and by specific drugs. In this third folder, common signs and
symptoms are organized by the class of drugs. These pictures are easily incorporated into
substance abuse education. They can be placed on posters and other educational tools
such as PowerPoint slides. They can also be used as part of self-monitoring forms (i.e.,
download the picture and place it alongside some kind of rating such as “yes” or “no.”)
The Relapse Prevention folder contains pictures that can be used in psychoeducation
about relapse as well as in treatment sessions. It includes folders with pictures for
cravings, cycles, lapses and relapses, recovery skills, risk factors, and triggers and
warning signs.
The Recovery Skills folders contain a wealth of pictures of specific skills essential to
treatment. There are cards depicting concepts such as “admit problem,” “blame stop,”
“honest,” and “notice cravings drink.” We would conceptualize and teach these as skills.
6 Sample rating scales, self-monitoring forms and behavioral plans
Cards can be used as pictorial self-monitoring forms or to create them. The pictures are
placed on a page alongside some rating scale, most commonly 0 to 10 or yes/no. Other
rating scales are faces with different emotions and thumbs up, thumbs middle, and
thumbs down. Forms can be developed with or without words. Our experience has been
that it usually helps to add simple words beneath pictures because clients may be able to
read the words and it also helps orient staff. A few sample self-monitoring plans are
included but these need to be individualized for each client. Besides considering whether
or not to use pictures, and what kind of rating scale, clinicians also consider what they are
asking clients to monitor. Options include: good and bad behaviors; feelings and moods;
thoughts, symptoms, attitudes, activities engaged in; and skills used. People who can
write may prefer a more open ended self-monitoring in which they describe what they
were thinking, feeling, or doing.
7 Psychoeducational materials
Psychoeducation is one of the main uses for skill cards. Some of the most useful cards
here include:
 Pictures of common allergies
 Procedures during a medical check-up
 Pain scales
 Pictures of behaviors that worsen health (“poor health behaviors’)
 Rating scales for particular classifications of medications (see Rating Scales Side
Effects) Physicians should look at these cards before they are used because they
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may disagree with our selection and organization of side effects. In these cases,
new cards with pictures of many side effects can be created.
Often when our LLC patients leave the hospital, they need to follow a medication plan.
To make this easier, we give them medication cards with pictures of the time of day, form
of medication (pill, injection), symptom the medication is treating, name of medication,
etc. Several examples of such cards are in the folder Medication Cards. To create new
cards, draw on pictures in the folders for Time (in the Miscellaneous folder) and Taking
Medicine.
There is also a wealth of cards depicting symptoms of mental illness, organized roughly
by syndrome. Cards depict symptoms associated with mood, anxiety, psychotic, and
behavioral disorders. Personality disorders are trickier to convey in pictorial form, and
pictures do tend to simplify and exaggerate. This is one reason why the pictures are
designed to supplement therapeutic dialogue, not substitute for it. Nonetheless, the
pictures here help illustrate anti-social, borderline, histrionic, narcissistic, schizoid, and
schizotypal personality disorders.
8 Cards presenting legal matters such as patient rights, health proxies, HIPAA
regulations, and insurance issues
We are constantly faced with the challenge of explaining abstract and complex legal
matters to persons with language and learning challenges. Where they have very limited
capacity to understand these matters, we consider the need for a guardian. However, staff
are often too quick to assume that clients cannot understand these matters when they
(staff) lack the language skills, and appropriate tools to explain them. The deficit is also
with staff, yet it is the client who may suffer when a guardian is appointed to represent
them.
Cards found here help explain the concept of healthy proxy, the elements of the HIPAA
law as it pertains to patient records, and common patient rights. The picture of the “3 day
letter” depicts the steps that patients in Massachusetts must go through to petition to be
discharged from a psychiatric hospital.
9 Useful metaphors
Included here are some of the metaphors we have found useful in treatment:
 Bait fish: suggests temptation, deception, or possibility of making an important
mistake
 Detective: metaphor for stopping and noticing, searching, exploring
 Dialectic: illustrated with a slinky
 Dominoes: used to illustrate triggers and the relapse process
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Fire hazards, lifeboat, mountain volcano, runaway train, swim clouds: depict
warnings signs and risk factors
Climbing out of pit, climbing over walls, choosing a path, climbing a ladder:
depict the process of treatment, striving for goals, making decisions
Traffic light, shield (see Chapter 5)
Psychic: making predictions, anticipation, as in relapse prevention work
10 Miscellaneous cards
Included here are cards depicting aspects of religious practice, people and animals, time,
community, and the treatment team.
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