Piloting "Signs of Safety": A Deaf-Accessible Therapy Toolkit for Alcohol Use Disorder and Trauma

The U.S. Deaf community - more than 500,000 Americans who communicate using American Sign Language (ASL) - experiences nearly triple the rate of lifetime problem drinking and twice the rate of trauma exposure as compared to the general population. Although there are validated treatments for alcohol use disorder (AUD) and post-traumatic stress disorder (PTSD) in hearing populations, there are no evidence-based treatments for any behavioral health condition that have been validated for use with Deaf clients. To address these barriers, the study team has developed "Signs of Safety", a Deaf-accessible therapy toolkit for treating AUD and PTSD. The study team's ongoing aims are to conduct a two-arm pilot RCT of "Signs of Safety" and to collect data on feasibility, preliminary clinical outcomes, and potential mediators and moderators of outcome.

Study Overview

• Status: Completed
• Conditions: Post Traumatic Stress Disorder; Alcohol Use Disorder
• Intervention / Treatment: Behavioral: Seeking Safety + Signs of Safety toolkit

Detailed Description

The U.S. Deaf community - 500,000+ Americans who communicate using American Sign Language (ASL) - experiences nearly triple the rate of lifetime problem drinking compared to the general population and twice the rate of trauma exposure. Although there are validated treatments for comorbid alcohol use disorder (AUD) and posttraumatic stress disorder (PTSD) in hearing populations, there are no evidence-based treatments to treat any behavioral health condition with Deaf clients. Current treatments fail to meet Deaf clients' unique linguistic and cultural needs. Deaf people's median English reading level falls at the fourth grade, and many have low health literacy due to reduced incidental learning (e.g., inability to communicate with hearing parents, overhear family conversations, or understand spoken health information on TV/radio/public service announcements). Written treatment materials, therefore, require plain text revisions, ASL translations, or ASL narrative storytelling. Equally important are materials that incorporate Deaf values and social norms, increasing clinicians' cultural competence and enhancing client engagement.

To address these barriers, the Principal Investigator conducted a pilot study to develop a prototype of "Signs of Safety": a Deaf-accessible toolkit to be used alongside a widely-disseminated protocol for addiction/PTSD - Seeking Safety. Seeking Safety has demonstrated efficacy for reduction of AUD and PTSD symptoms in hearing populations. Among available evidence-based protocols, "Seeking Safety" is the optimal choice to adapt for Deaf clients - its focus on simple coping skills that simultaneously target AUD and PTSD (or either alone) is an ideal match for Deaf people's language and learning deficits, which prohibit use of verbal problem-solving and cognitive processing strategies that other psychotherapies require. Yet, Seeking Safety's client materials rely on written English and are not well understood by Deaf clients. As such, the "Signs of Safety" toolkit includes a therapist guide and population-specific client materials (e.g., visual handouts; ASL teaching stories on digital video). It is designed for Deaf/signing clinicians, as well as non-signing clinicians working with ASL interpreters.

Data from the Principal Investigator's "Signs of Safety" single-arm pilot study (n = 13) show significant reductions in alcohol use frequency and PTSD severity from baseline to immediate post-treatment follow-up. Participants also reported high levels of satisfaction with the model, and provided detailed feedback about how to further improve "Signs of Safety" for a professional-quality, second iteration. The proposed study builds upon the Principal Investigator's pilot work by generating a final, professional iteration of Signs of Safety to be used in future efficacy work. Based on pilot results, the study team created a second iteration of the "Signs of Safety" toolkit, including re-filming ASL teaching stories, re-designing visual handouts, and revising the therapist companion guide. The study team will then develop a training program for "Signs of Safety" and certify four study clinicians.

The study team proposes to conduct a two-arm pilot RCT of "Signs of Safety". The study team aims to enroll 60 Deaf adults with past-month PTSD and past-month alcohol consumption to participate in 12 weekly individual treatment sessions. The pilot RCT will compare the 12-session protocol of Seeking Safety + "Signs of Safety" toolkit with an assessment-only waitlist control. Across conditions, assessment will occur at baseline, week 4, week 8, immediate post-treatment/week 12, and one-month follow-up/week 16. The study team will analyze key aspects of feasibility for both study arms (e.g., recruitment, retention, assessment process). Primary clinical outcomes at immediate post-treatment and one-month follow-up are past 30-day alcohol use frequency/quantity and past 30-day PTSD severity. Exploratory analyses will be conducted to examine potential moderators and mediators of change (e.g., motivation for treatment, provider cultural competency, coping skills, self-compassion, understanding of health information) leading to positive outcome. Results from this study will produce feasibility and preliminary efficacy data to support for a full-scale RCT to evaluate "Signs of Safety", and a community-engaged model for conducting RCTs with Deaf participants.

• Study Type: Interventional
• Enrollment (Actual): 16
• Phase: Not Applicable

Contacts and Locations

Study Locations

• United States
  • Massachusetts
    • Worcester, Massachusetts, United States, 01655
      • University of Massachusetts Medical School

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

• Self-identification as a Deaf ASL user
• Age 18 or older
• Past-month alcohol consumption, as measured by the Alcohol Use Disorder Identification Test
• Subthreshold or full PTSD on the PTSD Checklist for DSM-5 (past-month referent time period; "subthreshold" = endorsement of at least two B-E criteria at a severity of "moderate" or higher)
• Ability to attend weekly study sessions at one of three study locations (Eastern, Central, or Western MA)
• Ability to access a videophone (the standard telecommunication device for the Deaf community)

Exclusion Criteria:

• Participation in concurrent therapies (Note: Participants in both study conditions will be asked to refrain from concurrent formal psychotherapy; however, aligning with the Seeking Safety model, AA/NA/DRA attendance will be encouraged and attendance will be tracked as a potential outcome mediator).
• Members of the following special populations: Adults unable to consent; Individuals younger than 18; Prisoners; Pregnant women (Note: We will not knowingly include pregnant women as participants; however, we will not assess participants' pregnancy status.)

Exclusion criteria are intentionally minimal to recruit a diverse sample. Other behavioral health comorbidities (e.g., mood/anxiety disorders, substance use disorders other than AUD) will not be excluded, given high rates of comorbidity.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Double

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Seeking Safety + Signs of Safety toolkit; Participants randomized to receive the intervention will be provided 12 one-hour weekly individual treatment sessions with one of four ASL-fluent study clinicians in Massachusetts. Assessments will occur at baseline, week 4, week 8, immediate post-treatment/week 12, and one-month follow-up/week 16.	Behavioral: Seeking Safety + Signs of Safety toolkit; Seeking Safety is an existing, present-focused, first-stage manualized treatment for trauma and addiction. Session content engages clients in themes relevant to addiction and trauma, and to help them learn a specific skill to target symptoms of both AUD and PTSD (e.g., "Coping with Triggers," "Asking for Help"). "Signs of Safety" is a culturally and linguistically Deaf-accessible toolkit to be used alongside Seeking Safety. The toolkit includes a therapist guide and population-specific client materials (e.g., visual handouts; ASL teaching stories on digital video). It is designed for Deaf/signing clinicians, as well as non-signing clinicians working with ASL interpreters.
No Intervention: Assessment-only Waitlist Control; Participants randomized to the waitlist control condition will be offered the opportunity to receive the 12-session Seeking Safety + Signs of Safety toolkit intervention after an approximate 16 week waiting period. This 16 week waiting period is equivalent to the current waitlist to receive psychotherapy services through the PI's outpatient clinic. Assessments will occur at baseline, week 4, week 8, immediate post-treatment/week 12, and one-month follow-up/week 16.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Change From Baseline Percent Drinking Days Per Month at Immediate Post-Treatment	Change from baseline percent drinking days per month (i.e., days with 1+ drink) at immediate post-intervention or 12 weeks as assessed by Alcohol Timeline Followback	Change from baseline to immediate post-intervention at 12 weeks
Change From Baseline Percent Drinking Days Per Month at One-month Follow-up	Change from baseline percent drinking days per month (i.e., days with 1+ drink) at one-month follow-up or 16 weeks as assessed by Alcohol Timeline Followback	Change from baseline to one-month follow-up at 16 weeks
Change From Baseline Percent Binge Drinking Days Per Month at Immediate Post-Treatment	Change from baseline percent binge drinking days per month (i.e., days with 5+ drinks for men, 4+ for women) at immediate post-intervention or 12 weeks as assessed by Alcohol Timeline Followback	Change from baseline to immediate post-intervention at 12 weeks
Change From Baseline Percent Binge Drinking Days Per Month at One-month Follow-up	Change from baseline percent binge drinking days per month (i.e., days with 5+ drinks for men, 4+ for women) at one-month follow-up or 16 weeks as assessed by Alcohol Timeline Followback	Change from baseline to one-month follow-up at 16 weeks
Change From Baseline Number of Drinks Per Month at Immediate Post-Treatment	Change from baseline number of drinks per month at immediate post-treatment or 12 weeks as assessed by Alcohol Timeline Followback	Change from baseline to immediate post-intervention at 12 weeks
Change From Baseline Number of Drinks Per Month at One-month Follow-up	Change from baseline number of drinks per month at one-month follow-up or 16 weeks as assessed by Alcohol Timeline Followback	Change from baseline to one-month follow-up at 16 weeks
Change From Baseline Past 30-day PTSD Severity to Immediate Post-Treatment as Assessed by PCL-5	Total Score on the PCL-5 divided by 20 items. Minimum score = 0; Maximum score = 4. Higher values represent more severe symptoms of PTSD.	Change from baseline to immediate post-intervention at 12 weeks
Change From Baseline Past 30-day PTSD Severity at One-month Follow-up as Assessed by PCL-5	Total Score on the PCL-5 divided by 20 items. Minimum score = 0; Maximum score = 4. Higher values represent more severe symptoms of PTSD.	Change from baseline to one-month follow-up at 16 weeks

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
The Brief Comprehensive Effects of Alcohol Questionnaire (B-CEOA)	All four subscales: Min. = 1, Max. = 4. Risk and Aggression/Liquid Courage/Sociability Subscale: Higher values indicate greater outcome expectancies of drinking alcohol on risk-taking, aggression, courage, and sociability. Self-Perception/Cognitive and Behavioral Impairment Subscale: Higher values indicate greater outcome expectancies on distorted self-perception and impaired behavior. Sexuality Subscale: Higher values indicate greater outcome expectancies on sexual behavior. Tension Reduction Subscale: Higher values indicate greater outcome expectancies on tension reduction.	Baseline/Pre-intervention, Week 4, Week 8, Week 12/Post-intervention, and Week 16/One-month Follow-up
Penn Alcohol Craving Scale (PACS)	Total score = sum of all 5 items. Minimum = 0; Maximum = 30. Higher values indicate higher severity of alcohol craving.	Baseline/Pre-intervention, Week 4, Week 8, Week 12/Post-intervention, and Week 16/One-month Follow-up
Trauma Symptom Checklist - 40 (TSC-40)	Sum of all items divided by 40 items. Minimum = 0; Maximum = 3. Higher values indicate more severe trauma symptoms.	Baseline/Pre-Intervention, Week 12/Post-Intervention, Week 16/One-month Follow-up
Behavior and Symptom Identification Scale - 24 (BASIS-24)	Sum of all items divided by 24 items. Minimum = 0; Maximum = 4. Higher values indicate worsening behavior or more severe behavioral health symptoms.	Baseline/Pre-Intervention, Week 12/Post-Intervention, Week 16/One-month Follow-up

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
Client Satisfaction with Treatment Sessions as Assessed by Seeking Safety End of Session Questionnaire	Participants in the intervention group will complete a questionnaire at the end of each weekly therapy session to assess level of helpfulness and satisfaction with the session. The questionnaire includes four questions (e.g., How helpful was today's session for you?) that are rated on a 4-point scale from 0 (Not at all) to 3 (A great deal), and two open-ended questions for comments and feedback on the session. Scores range from 0-12, with higher scores indicating greater satisfaction with the session.	Weeks 1 - 12
Client Feedback on Intervention as Assessed by Seeking Safety End of Treatment Questionnaire at week 12	Participants in the intervention group will complete a questionnaire after completing the intervention to assess level of helpfulness and satisfaction with the treatment overall. The questionnaire uses a 7-point rating scale from -3 (Greatly harmful) to 0 (Neutral) to 3 (Greatly helpful) for questions regarding the helpfulness of the treatment and includes open-ended questions for feedback and comments.	Week 12
Client Satisfaction with Intervention as Assessed by the Client Satisfaction Questionnaire (CSQ-8) at 12 weeks	The Client Satisfaction Questionnaire (CSQ-8) is an 8-item instrument used to assess general client satisfaction levels regarding a service. Items are rated on a 4-point scale. Scores are summed across items. Items B, D, E, and H are reverse scored. Total scores range from 8 to 32, with the higher number indicating greater satisfaction.	Week 12
Therapist Fidelity as Assessed by "Signs of Safety" Fidelity Scale	All intervention sessions will be videotaped, with 25% (3 sessions per participant) rated for fidelity on an ongoing basis by the Fidelity Consultant. One tape will be randomly selected from sessions 1 - 4; one from 5 - 8; and one from 9 - 12. The session tapes will be rated using the "Signs of Safety" Fidelity Scale to assess therapist integrity with regards to the following domains: (1) Focus on Deaf experience, (2) Comparison of Deaf and hearing people's recovery, (3) Communication access, (4) Validation of Deaf experience, (5) Respect for Deaf culture, (6) Attention to body language, and (7) Attention to language. Questions are rated on a 4-point scale with higher scores indicating greater integrity and fidelity.	Weeks 4, 8, 12
Therapist Adherence to Intervention as Assessed by Seeking Safety Adherence Scale	All intervention sessions will be videotaped, with 25% (3 sessions per participant) rated for adherence on an ongoing basis by the Fidelity Consultant. One tape will be randomly selected from sessions 1 - 4; one from 5 - 8; and one from 9 - 12. The session tapes will be rated using the Seeking Safety Adherence Scale to assess adherence in three domains: (1) Format (e.g., did they clinician follow the session structure of Seeking Safety?), (2) Content (e.g., Did the clinician use the Seeking Safety content?), (3) Process (e.g., Did the clinician use strong general clinical skills?). Questions are rated on a 4-point scale with higher scores indicating greater adherence to the intervention.	Weeks 4, 8, 12
Participant Adherence to Intervention	Participant Adherence will be measured using the number of sessions completed, comprehension of session content, and rates of participants' treatment enactment (i.e., completing "homework" between sessions).	Post-Intervention at Week 12
Exit Interview	Qualitative interview in which participants are asked their opinions and feedback on study design including suggested improvements for future research studies with Deaf participants.	Post-Intervention and after study completion

Collaborators and Investigators

• Sponsor: University of Massachusetts, Worcester
• Collaborators: National Institute on Alcohol Abuse and Alcoholism (NIAAA)
• Investigators: Principal Investigator: Melissa L Anderson, PhD, University of Massachusetts, Worcester

Publications and helpful links

General Publications

• Heffernan K. Seeking Safety: A Treatment Manual for PTSD and Substance Abuse. Psychother Res. 2003 Mar;13(1):125-6. doi: 10.1080/713869629. No abstract available.

Study record dates

Study Major Dates

• Study Start (Actual): June 3, 2019
• Primary Completion (Actual): July 31, 2022
• Study Completion (Actual): July 31, 2022

Study Registration Dates

• First Submitted: February 1, 2019
• First Submitted That Met QC Criteria: February 15, 2019
• First Posted (Actual): February 19, 2019

Study Record Updates

• Last Update Posted (Actual): March 12, 2024
• Last Update Submitted That Met QC Criteria: February 16, 2024
• Last Verified: February 1, 2024

More Information

Terms related to this study

• Keywords: addiction; trauma; psychotherapy; Deaf
• Additional Relevant MeSH Terms: Mental Disorders; Chemically-Induced Disorders; Drinking Behavior; Alcohol-Related Disorders; Substance-Related Disorders; Trauma and Stressor Related Disorders; Alcohol Drinking; Alcoholism; Stress Disorders, Traumatic; Stress Disorders, Post-Traumatic
• Other Study ID Numbers: H00016364; R34AA026929 (U.S. NIH Grant/Contract)

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: YES
• IPD Plan Description: Individual participant data after deidentification that underlie the reported results (text, tables, figures, and appendices) will be available beginning 9 months and ending 36 months following article publication. Investigators whose proposed use of the data has been approved by an independent review committee may use the data for individual participant data meta-analysis. Proposals may be submitted up to 36 months follow article publication. Please contact the Principal Investigator for information regarding submitting proposals and accessing data.
• IPD Sharing Time Frame: Data will be available beginning 9 months and ending 36 months following article publication.
• IPD Sharing Access Criteria: Investigators whose proposed use of the data has been approved by an independent review committee may use the data for individual participant data meta-analysis.
• IPD Sharing Supporting Information Type: STUDY_PROTOCOL; SAP; ICF; ANALYTIC_CODE

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No