Fletcher, D. (2011), "Psychotherapy: the North American experience", Advances in Mental Health and Intellectual Disabilities, Vol. 5 No. 5. https://doi.org/10.1108/amhid.2011.54205eaa.001Download as .RIS
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Psychotherapy: the North American experience
Article Type: Guest editorial From: Advances in Mental Health and Intellectual Disabilities, Volume 5, Issue 5
As we proceed into a time that the provision of psychotherapy for people who have intellectual disability is increasingly accepted, the issue is no longer whether people with intellectual disabilities are entitled to psychotherapy or will benefit from it, but how psychotherapy techniques can be adapted to meet the needs of individuals who may have limitations in expressive and receptive language skills. In this issue of Advances in Mental Health and Intellectual Disabilities (AMHID), six authors offer their insights about how this challenge can be met involving specific therapeutic modalities, while a seventh author reviews the research literature concerning providing psychotherapy to people with intellectual disabilities. There are several theoretical orientations as well as individual, group, dyadic, and family modalities. These articles are all adapted from Psychotherapy for Individuals with Intellectual Disability (Fletcher, 2011), and, as with that book, it is our hope that this issue of AMHID will serve to further stimulate interest in the provision of psychotherapy treatment for individuals who have intellectual disabilities co-occurring with significant mental health problems.
It has taken a number of years to reach our current understanding of the extent of mental health problems among people who have intellectual disabilities and the efficacy and effectiveness of psychotherapy – when appropriately modified – for these individuals. Historically, there have been several reasons why psychotherapy has not been used broadly for this group of people. First, maladaptive behaviors were often perceived as part of the condition of intellectual disability. Second, psychotherapy was not viewed by the professional community as being effective. Third, there has been a bias on the part of mental health clinicians that echoes the thought that providing therapy for people with intellectual disabilities is not challenging or interesting. Fourth, there has been a near absence of academic training for professionals in learning how to provide psychotherapy treatment for this group of people. Furthermore, there has been a lack of professional literature on this subject matter. Traditionally, the concept of addressing people’s feelings and emotions in this population has neither been fully addressed nor sufficiently acknowledged.
Over the last several decades, we have been moving away from a public policy of institutionalisation toward community based living and supports. Also during this time period, we have recognized that some people with intellectual disabilities can also have significant mental health problems. People with intellectual disabilities are at greater risk for stress than individuals in the general population. However, we have been slow in meeting the emotional and psychological needs of this group of people. Now that people who have intellectual disabilities are living in a community, we are beginning to understand their emotional needs, and community-based mental health providers are at an early stage of modifying therapy techniques that are appropriate for people with intellectual disabilities.
AMHID published a special issue on psychotherapy in the December 2009 issue with Nigel Beail as the guest editor (volume 3, issue 4). In the 2009 special issue, there were several articles on psychodynamic psychotherapy. These articles were written by authors from the UK. In contrast, this current issue is written by authors from North American who employ different theoretical orientations and therapy techniques. The difference between the North American and the European approach to the provision of psychotherapy may reflect the difference in our respective training and orientation. Nevertheless, there is clear agreement that psychotherapy for persons with intellectual disabilities can be appropriate and should be available.
The following will provide a summary of the articles that appear in this special issue.
Margaret Charlton, PhD and Eric J. Dykstra, PsyD offer adaptations to dialectical behavioral therapy (DBT) that they have made in developing what they call dialectical behavior therapy for special populations (DBT-SP). They note that DBT-SP was adapted specifically to address the needs of psychotherapy clients who have to develop better skills for managing their impulsivity, dealing with frustrations, and interacting with others. The adaptations involved in DSP-SP involved adjusting the presentation and language to a level that persons with intellectual and developmental disabilities can more easily comprehend and that the adolescent target population would find more appealing. The language was adjusted to make concepts more accessible. Some of the concepts were paired down and/or simplified to allow better comprehension. Handouts were re-written and re-formatted to increase attention and aid in understanding. Client feedback, repetition, and rehearsals have been incorporated into the therapy structure to aid in learning, retention, and generalization. In addition to describing the development of DBT-SP, Dr Margaret Charlton and Dr Eric J. Dykstra describe a pilot study conducted with adolescent clients in a day treatment program providing education and treatment for children and adolescents with significant developmental and behavioral health needs.
In her paper, Valerie L. Gaus, PhD notes that with some modifications and extra attention to skill-building, cognitive behavioral therapy (CBT) approaches can be successfully used to address the co-morbid anxiety and mood disorders of higher functioning adults who have autism spectrum disorders (ASD) as well as help them learn needed social and coping skills. Dr Valerie L. Gaus explores ASD among adults and offers the benefits of CBT for these individuals. Although her paper focuses on patients who may have little or no intellectual disability as defined by standard intelligence quotient tests, they do demonstrate significant impairments in the social and communication domains of functioning. Strategies for increasing social and coping skills and for reducing symptoms of anxiety and depression are discussed.
Judith Hill-Weld, MS, MFT discusses the value of using family systems theory as a meta-theory in practicing psychotherapy with persons with intellectual disabilities. Family systems theory prioritizes the reciprocal impact of the familial (or family-like) group and the individual. This perspective can enrich understanding of the problem and expand opportunities for change.
With changing attitudes and more tolerance for people with intellectual disabilities to become companions or couples, to live together, or to marry, the paper by J. Dale Munro, MSW, RSW, FAAIDD offers insight into providing positive support couple therapy. This model which incorporates elements of the strength-based social work perspective, positive psychology, and unconditionally constructive mediation and helps build effective working relationships with the couple, their extended families, and service system representatives.
Nancy J. Razza, PhD, Daniel J. Tomasulo, PhD, and Dick Sobsey, EdD discuss providing group psychotherapy, using the interactive-behavioral therapy (IBT) model with trauma survivors who have intellectual disabilities. As they note, people with intellectual disabilities are at increased risk of experiencing interpersonal trauma in their lifetimes, and also their capacity for coping with such traumas is compromised. IBT draws on the theoretical underpinnings of Moreno’s psychodrama and has much to offer in the treatment of people with intellectual disabilities.
Bronwyn Robertson, LPC reviews the ways mindfulness has been utilized in psychotherapy and examines the use of these techniques by individuals with intellectual disabilities. She notes that the experiential, skills-based practices of mindfulness-based psychotherapy make it easily adaptable and applicable for use with many populations and mental health challenges. Among the approaches to mindfulness-based psychotherapy that are considered are acceptance and commitment therapy, mindfulness-based stress reduction, DBT, and mindfulness-based cognitive therapy.
H. Thompson Prout, PhD and Brooke K. Browning, MS provide an overview of the current status of psychotherapy outcome research with persons with intellectual disabilities in their article chapter on “The Effectiveness of Psychotherapy with Persons with Intellectual Disabilities.” After a brief look at early research on the effectiveness of psychotherapy, including a definition of psychotherapy, they examine the research literature, looking at six reviews of the research literature. Using the broad definition of psychotherapy, the reviews, published reports, and dissertations support that psychotherapeutic treatments offer some degree of benefit to persons with intellectual disabilities. Dr Prout and Ms Browning offer a number of conclusions and implications for future research.
Dr Robert J. Fletcher
Fletcher, R.J. (Ed.) (2001), Psychotherapy for Individuals with Intellectual Disability, NADD Press, Kingston, NY