Evaluating Signs of Safety: A Deaf-Accessible Therapy Toolkit for AUD and Trauma

In partnership with Deaf-owned agency National Deaf Therapy, the study team will conduct the first-ever full-scale psychotherapy trial conducted in the Deaf community - "Evaluating Signs of Safety: A Deaf-Accessible Therapy Toolkit for AUD and Trauma." The U.S. Deaf community - more than one million Americans who communicate using American Sign Language (ASL) - experiences nearly triple the rate of lifetime problem drinking compared to the general population (33.0% vs. 12.3%) and twice the rate of trauma exposure. Among Deaf people in treatment for alcohol use disorder (AUD), 74% report lifetime physical, emotional, or sexual abuse and 44% report past-year abuse. Comorbid AUD/PTSD impairs multiple domains of functioning, especially for Deaf individuals, who show poorer functional outcomes than hearing individuals in socialization, employment, and physical health.

Hearing individuals have access to several validated treatments for comorbid AUD/PTSD; yet there are no evidence-based treatments to treat any behavioral health condition with Deaf clients. Available treatments fail to meet Deaf clients' unique language access needs. Deaf people's median English literacy level falls at the fourth grade and health-related vocabulary among Deaf sign language users parallels non-English-speaking U.S. immigrants. Available treatment resources, therefore, require plain text revisions, filmed ASL translations, or education through storytelling to better match Deaf clients' language needs.

Leveraging extensive community engagement to address these barriers, the Principal Investigator's team of Deaf and hearing researchers, clinicians, filmmakers, actors, artists, and Deaf people with AUD/PTSD developed and pilot tested Signs of Safety, a Deaf-accessible toolkit to be used with the Seeking Safety treatment protocol. Seeking Safety is a manualized, non-exposure-based, cognitive behavioral therapy for trauma and addiction. Among evidence-based treatments for AUD/PTSD, Seeking Safety is the optimal choice for Deaf clients - its focus on psychoeducation and simple coping skills is an ideal match for Deaf people's language and literacy disparities, which prohibit the use of narrative, verbal problem-solving, and cognitive processing strategies that other AUD/PTSD therapies require. Yet, Seeking Safety's client materials rely on written English and are, therefore, not well understood by Deaf clients. As such, the Signs of Safety toolkit provides a supplemental therapist guide and population-specific client materials (e.g., visual handouts, filmed ASL teaching stories).

Preliminary data from the Signs of Safety single-arm pilot and randomized feasibility pilot showed reductions in alcohol use frequency and PTSD severity from baseline to follow-up on the Reliable Change Index. The delivery of the experimental intervention was deemed feasible by study therapists and was well-received by participants, especially when moved to a virtual platform. In response to the COVID-19 pandemic, the study team overhauled in-person study methods to implement a virtual clinical trial - an acceleration of the inevitable development needed to scale Signs of Safety to a national level. This adaptation also established a crucial collaboration with National Deaf Therapy (NDT), by far the nation's largest provider of Deaf mental health services, currently serving clients across 21 states. This collaboration, paired with comprehensive feasibility data the study team collected by testing a variety of virtual methods, serves as the foundation of the study team's proposed aims.

The study team will conduct a nationwide, full-scale, virtual clinical trial of Signs of Safety. Leveraging the existing infrastructure and robust referral network of NDT, the study team will enroll 144 Deaf adults with past-month PTSD and problem drinking. Primary clinical outcomes at immediate post-treatment are change from baseline percent binge drinking days per month (Alcohol Timeline Followback) and change from baseline past 30-day PTSD severity (PTSD Checklist for DSM-5). Assessment will occur at baseline, mid-treatment, immediate post-treatment, three-month post-treatment follow-up, and six-month post-treatment follow-up. Participants residing in states served by NDT (n = 96) will be randomized to receive either (1) a 12-session protocol of Seeking Safety + Signs of Safety, or (2) 12 sessions of therapy as usual (TAU; general, open-ended, non-manualized supportive counseling provided by an NDT therapist). The study team will enroll an additional 48 Deaf adults into a contemporaneous no-treatment control arm. These individuals will be recruited from the existing NDT waitlist, comprised of Deaf individuals residing in the states not yet served by NDT but voluntarily awaiting NDT services. Additionally, the study team will analyze potential moderators and mediators that lead to positive outcome. Identified from the literatures on Seeking Safety, alcohol treatment research, and Deaf mental health research, mechanisms of change are coping self-efficacy, self-compassion, motivation for treatment, and access to health information.

They study team's proposed aims build upon eight years of empirical work, moving the program of research from Stage IB (two-arm feasibility and pilot testing) to Stage II/III (real world efficacy). This clinical trial will potentially validate the first-ever evidence-based therapy for Deaf people, as well as provide future behavioral health researchers with a vital roadmap for conducting community-engaged clinical trials with Deaf people.

• Change from Baseline Percent Drinking Days Per Month at Immediate Post-Treatment as Measured by the Alcohol Timeline Followback [Time frame: Change from baseline to immediate post-treatment at 12 weeks]
• Change from Baseline Percent Drinking Days Per Month at Three-month Follow-up as Measured by the Alcohol Timeline Followback [Time frame: Change from baseline to three-month follow-up at 25 weeks]
• Change from Baseline Percent Drinking Days Per Month at Six-month Follow-up as Measured by the Alcohol Timeline Followback [Time frame: Change from baseline to six-month follow-up at 38 weeks]
• Change from Baseline Percent Binge Drinking Days Per Month at Three-month Follow-up as Measured by the Alcohol Timeline Followback [Time frame: Change from baseline to three-month follow-up at 25 weeks]
• Change from Baseline Percent Binge Drinking Days Per Month at Six-month Follow-up as Measured by the Alcohol Timeline Followback [Time frame: Change from baseline to six-month follow-up at 38 weeks]
• Change from Baseline Number of Drinks Per Month at Immediate Post-Treatment as Measured by the Alcohol Timeline Followback [Time frame: Change from baseline to immediate post-treatment at 12 weeks]
• Change from Baseline Number of Drinks Per Month at Three-month Follow-up as Measured by the Alcohol Timeline Followback [Time frame: Change from baseline to three-month follow-up at 25 weeks]
• Change from Baseline Number of Drinks Per Month at Six-month Follow-up as Measured by the Alcohol Timeline Followback [Time frame: Change from baseline to six-month follow-up at 38 weeks]
• Change from Baseline Past 30-day PTSD Severity to Three-month Follow-up as Measured by the PCL-5 [Time frame: Change from baseline to three-month follow-up at 25 weeks]
• Change from Baseline Past 30-day PTSD Severity to Six-month Follow-up as Measured by the PCL-5 [Time frame: Change from baseline to six-month follow-up at 38 weeks]
• Change from Baseline Diagnostic and Statistical Manual (DSM)-5 diagnostic criteria for Alcohol Use Disorder to Immediate Post-Treatment as measured by the DSM-5 AUD Assessment Tool [Time frame: Change from baseline to immediate post-treatment at 12 weeks]
• Change from Baseline Percent Days of Drug Use Per Month at Immediate Post-Treatment as Measured by the Timeline Followback - Drugs, Cigarettes, and Marijuana [Time frame: Change from baseline to immediate post-treatment at 12 weeks]