Journal of Developmental and Physical Disabilities, Vol. 10, No. 4, 1998

Individual and Group PsychotherapyApproaches for Persons with MentalRetardation and Developmental Disabilities

Anne DesNoyers Hurley,1 Daniel J. Tomasulo,2 and Albert G. Pfadt3

Although the prevalence of mental illness among persons with mentalretardation and developmental disabilities (MR/DD) is well documented, mostpsychotherapists have not expanded their practices to include patients fromthis population. The majority of reports in the early literature documented thatpeople with MR/DD could benefit from treatment, and reports from recentyears continue to inspire optimism about the effectiveness of psychotherapy.To some extent, many professionals have favored the use of training groups(e.g., social skills training) over group therapy, and this is unfortunate as thetherapeutic value of groups has a powerful, generalized effect promotingself-confidence and improvements in mental health. Those that have workedwith patients who have MR/DD have, however, found that a standard list ofadaptations can be applied by psychotherapists interested in working with thispopulation, independent of theoretical orientation and training background. Itis imperative that psychotherapists be encouraged to treat patients with MR/DDand be given the information to successfully adapt their skills for work withthis population.

INTRODUCTION

Within the past 2 decades, a major change occurred in the field ofdevelopmental disabilities, acknowledging that people with mental retarda-

1Bay Cove Human Services and Tufts University School of Medicine, Boston, Massachusetts 02111.2Holmdel, New Jersey.3New York State Institute for Basic Research in Developmental Disabilities, Staten Island,New York 10314.

KEY WORDS: psychotherapy; mental retardation; developmental disabilities; psychiatricdisorders; counseling.

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tion and developmental disabilities (MR/DD) suffer from the full range ofpsychiatric disorders seen among the general population (Borthwick-Duffy,1994; Reiss, 1994; Sovner and Hurley, 1981). Prior to that, mainstream psy-chiatry and psychology had little interest in the mental health needs ofpersons with MR/DD, and, unfortunately, the present state of training inmajor disciplines continues to suggest that there is little interest in treatingpatients with MR/DD. A report in 1991 funded by the American PsychiatricAssociation found few residency programs offered training in MR/DD (Szy-manski et al., 1991). Similarly, Nezu reported the results of a survey ofgraduate clinical psychology and counseling psychology programs (con-ducted by Phelps and Hammer), finding 75% of clinical and 67% of coun-seling programs did not include mental retardation in the curriculum (Nezuand Nezu, 1994). It is not surprising, then, that few mental health cliniciansfeel adequately prepared to treat individuals with MR/DD and to treatthem using psychotherapy.

Conceptual and theoretical positions stressing verbal abilities in thepast provided a rationale for believing that psychotherapy services to thispopulation were not fruitful. Even with advancement in the understandingof mental illness and its prevalence in the MR/DD population, and thedevelopment of news types of psychotherapy, the provision of psychother-apy services has remained at inadequate levels. Psychotherapists frequentlyassume that limitations in intelligence prevents persons with MR/DD fromparticipating in the psychotherapeutic process. Early studies and case re-ports, however, demonstrated that psychotherapy could be an effectivetreatment for persons with MR/DD, although a few studies showed littleimprovement (Abel, 1953; Albini and Dinitz, 1965; Baran, 1970; Butler andElnig, 1963; Fine and Dawson, 1964; Feldman, 1946; Fisher and Wolfson,1953; Gorlow eT al., 1963; Kaldeck, 1950; Meizio, 1967; Michel-Smith, 1955;Rosen and Rosen, 1969; Rudolph, 1955; Sarason, 1953; Silvestri, 1977;Sternlicht, 1965; Stone and Coughlin, 1973; Snyder and Sechrest, 1959; Vail,1955; Wilcox and Guthrie, 1957; Young and O'Connor, 1954). Since thattime, there have many detailed accounts of psychotherapeutic approachesnoting the rich mental lives of those with MR/DD and the effective use ofpsychotherapy, but these works have not resulted in great interest in serv-icing this population among the general mental health community (Blotzerand Ruth, 1995; Dosen, 1984, 1990; Fletcher, 1993; Hellerendoon, 1990;Hurley, 1989a,b; Hurley and Hurley, 1986, 1987; Hurley et al., 1996; Levitasand Gilson, 1989; Pfadt, 1991; Nezu et al., 1992; Tomasulo, 1992;Symington, 1981; Szymanski, 1980; Szymanski and Rosefsky, 1980).

A central misunderstanding of cognitive abilities underlies the reti-cence of psychotherapists in treating persons with MR/DD. Psychothera-pists frequently assume that limitations in ability to generate verbal

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mediators to regulate overt, nonverbal behavior negates use of verbal psy-chotherapeutic techniques. Similarly, cognitive limitations in ability to de-velop "insight" or recognize causes and consequences of behavior isthought to prevent the use of interpretations. In addition, because psychi-atric conditions directly related to brain dysfunction may be present, it isthought that the presenting problem is, therefore, not amenable to reme-diation by psychotherapy. Collectively, these assumptions cause practitio-ners to defer to either behavior modification therapies or sedatingmedications for "behavior disorders."

Another possibility for the prohibitive stance taken towards psycho-therapy is the fact that people with MR/DD are generally neither self-re-ferrals nor financially capable (through public or private funds) of payingfor psychotherapy. As such, this may create a passive barrier towards thedelivery of services. Prior to the 1980s this was not the case. In addition,there is a paucity of adequately trained psychotherapists to deliver highquality services and current funding constraints present a fiscal disincentivefor investing scare resources to obtain help from mental health profession-als outside the MR/DD service system.

Some advocates for person-centered supports have de-emphasized theneed to diagnose and treat psychopathology and have even gone as far asto label such efforts as a misguided service that "blames the victim." Inorder to counteract these forces against providing psychotherapy for thosewho need it, it is necessary for psychotherapists to develop a theoreticalrationale for why psychotherapy should be effective for the people and theconditions for which it is being proposed. Kaplan (1988) notes that "withouta theoretical framework, the clinician lacks a coherent way to organizeknowledge, ascribe meaning to observations, or predict outcomes" (p. 18).

At the present time, a number of different theoretical frameworks havebeen proposed by psychotherapists attracted to psychodynamic, behavioral,cognitive-behavioral, or person-centered approaches to psychotherapy as-sociated with positions developed by Freud, Skinner, Ellis, and Rogers, re-spectively. A social systems model capable of unifying these diversetheoretical positions has been described by Pfadt (1990, 1991) and anumber of others have recognized the utility of a social systems perspectiveon psychopathology for psychotherapists working with cognitively impairedindividuals (Kaplan, 1988: Matson, 1984; Szymanski, 1994). By unifying di-agnostic, etiological, and treatment considerations within the same frame-work, social systems models helps psychotherapists to avoid redutionisticthinking that views psychopathology as the inevitable by-product of biologi-cal malfunctioning in persons with MR/DD. Success in working with pa-tients who have MR/DD demands a flexible in theoretical orientation andcreative use of psychotherapeutic methods throughout treatment. While the

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current evolution of the field prohibits a definitive description of the depthand breath of the various theories and methodologies, there are a numberof empirical findings, clinical insights and adaptations which have proveneffective. It is toward these innovations, understandings, and perceptionsthat we now turn our attention.

ADAPTATIONS OF STANDARD TECHNIQUES FOR PERSONSWITH MR/DD

Psychotherapists adapt their treatment approaches for all patients.Thus, adaptations for persons with MR/DD should not be viewed as par-ticularly cumbersome, if one has basic guidelines regarding the neededchanges in format. When working with this population, psychotherapistsmust be particularly attuned to adaptations related to cognitive and verballimitations, developmental level, and dependence needs (see Table I). Thefollowing guide reports the alterations most frequently noted in the litera-ture, upon which there is striking agreement (Hurley, 1989; Hurley et al.,1996; Nezu et al., 1992; Szymanski, 1980; Syzmanski and Kiernan, 1980;Szymanski and Rosefsky, 1980).

Table I. Major Adaptations of Psychotherapy Techniques

Adaptation

Simplification

Language

Activities

Developmental level

Directive methods

Flexible methods

Involve care givers

Transference/countertransference

Disability/rehabilitation approaches

Definition/example

Reduce usual technique in complexity; break downinterventions into smaller chunks, shorter lengthof sessions.

Reduce level of vocabulary, sentence structure, andlength of thought. Use short sentences; use simplewords.

Augment typical techniques with activities to deepenchange and learning. Add drawings, homeworkassignments.

Integrate developmental level into presentation oftechniques and material. Use games; assessdevelopment into relevant social issues.

Due to cognitive limitations, must be more direct.Outline treatment goals, progress, give extra"visual" guides.

Adjust usual techniques to suit cognitive level andlack of progress. Draw from other modalities.

Use family, support staff to help with change. Assignhomework or rehearsals at home with the help ofstaff or family

Attachments are stronger, quicker; therapist reactionssimilar to parental view. Therapists urged to bestronger in boundaries and to ensure peersupervision.

Issue of disability must be addressed with treatment.Therapists must raise issues and support positiveself-view.

Simplification

Because of the concrete nature of cognitive abilities among persons withMR/DD, all psychotherapeutic approaches must be simplified. The mostcritical alteration occurs in any verbal interaction, from simple greetings toactual verbal dialogue. This will be discussed in detail below. Adjustments ingeneral technique that involve simplification include the making of conceptsand critical points more concrete. For example, it is essential to be direct andorganized in the manner that psychotherapy is presented. In the first session,the psychotherapist must explain psychotherapy on a very simple level, in-cluding the format, what is to be accomplished, and how the plan will bedeveloped (Hurley and Hurley, 1986, 1987). Very frequently, session lengthis reduced for individual therapy to 30 min, and group sessions to 1 hr,whereas for individuals of normal intelligence length is typically 50 min and90 min respectively. Schneider (1986) reduced the number of persons in agroup from eight to five members. Cautela and Groden (1978) adjustedstandard training in muscle relaxation for systematic desensitization by re-structuring material and making it more concrete and repetitive. A numberof published reports have used various modification of this procedure to treatphobias quite successfully (Guralnik, 1973; Jackson, 1983; Jackson andHooper, 1981; Jackson and King, 1982; Luiselli, 1977; Mansdorf and Ben-David, 1986; Matson, 1981; Obler and Terwillinger, 1970; Peck, 1977; Sil-vestri, 1977; Waranch et al., 1981).

Language

Persons with MR/DD all have verbal limitations that span from minorto very significant. Even for the person with a mild level of disability, verbalskills are concrete and vocabulary is less mature. For a person with mildMR/DD, vocabulary may be within the 10-year old or lower equivalent,and the psychotherapist must be vigilant in simplifying his or her level ofvocabulary words. For example, words such as reflect, manage, emotion, andmotivation might be far too complex. Thus, verbal dialogue must be trans-lated, transformed, and adjusted to the patient's level of understanding.Similarly, complex sentence structure must be avoided, and most impor-tantly, psychotherapists must work with short sentences, giving one thoughtat a time, with pauses so the person can assimilate the information. Ludwigand Hingsburger (1987) suggested that psychotherapists use initial sessionsto develop a working "therapeutic" vocabulary that will be used in treat-ment (Ludwig and Hingsburger, 1987). In this way, there will be a mutualunderstanding with which to proceed to the therapeutic work.

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Persons with MR/DD have a limited length of verbal retention (e.g.,a memory span of 4 numbers for mild mental retardation versus 7 for thenormal intelligence adults) (Wechsler, 1991). Because of this, only a shortspan of information can be digested at one time. Thus, short, simple sen-tences should be used, with breaks and time for the person with MR/DDto absorb the information, think about it, and respond.

Psychotherapists must be very sensitive to the dilemma of the personwith MR/DD who is used to not understanding a great deal of conversation.They are not likely to interrupt and ask for clarification or to indicate inany manner than the conversation is too complex. Thus, the psychotherapistmust often check for understanding and offer ongoing clarification as amatter of course.

Activities

Activities are a natural augmentation strategy to assist in the thera-peutic process. Whereas some techniques are specifically action-oriented(such as psychodrama and play therapy), many psychotherapy approachesare more verbally oriented, or insight-oriented. Experienced psychothera-pists working with patients with MR/DD have consistently found that nomatter what modality one is working in, that addition of activities-supportenhances treatment. This can be in the form of homework assignments,letters, pictures to bring home after a session, and other vehicles that willhelp the person with MR/DD have a full understanding of the issues andways of enhancing his or her personal growth and use of new learning (Hur-ley, 1989; Hurley and Sovner, 1991; Jackson, 1983; Lindsay et al., 1992;Page, 1986; Sternlicht, 1966).

Developmental Level

Persons with MR/DD often have not developed beyond the chrono-logically younger individual in important areas of functioning. Some factorsto consider within the developmental framework are egocentricity, concreteoperational functioning, and limited ability to take the perspective of theother person. Psychotherapists must include assessment of developmentallevel from various perspectives in their individual evaluation of the personwith MR/DD. Developmental level is relevant in terms of comparisons tocognitive level, for example, the language and reasoning may be similar tothat of a 4-year-old child or a 10-year-old child. Developmental level mustalso be assessed with regard to social-adaptive behavior, and in terms oflifespan development from the viewpoint of Erickson and Maslow (Dosen,1990). For example, the adult with MR/DD, although at age 35, could be

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struggling with issues of independence typical of a 14-year-old (Gilson andLevitas, 1987).

Psychotherapists have also advocated that techniques appropriate forthe younger child may suit the adult with MR/DD. Sternlicht (1965, 1966,1977) asserted that the use of nonverbal techniques was essential for allpersons with MR/DD (e.g., using balloons, mirrors, and noisemakers). Playtherapy and art therapy have also been used extensively with adults whohave MR/DD (Baum, 1990; Hellendoorn, 1990; Jakab, 1969; Leland andSmith, 1962, 1965; Page, 1986). The use of child-oriented techniques is notuniversally accepted. However, the adaptation of some techniques withina more adult-oriented framework for adults with MR/DD has been seenas useful from a practical viewpoint.

Use of Directive Style

The structure of a directive style is helpful to people who have cog-nitive limitations. Structure is provided by meeting at a regular time, withthe same person, by rigidly defining the time limit of the session, what willhappen, with accompanying pictures or visual cues that emphasize thestructure. The directive style outlines the process. It is essential that eachtherapeutic session has an organization that is clear and concretely pre-sented to the person with MR/DD (Hurley, 1989; Hurley and Hurley, 1986,1987; Fletcher, 1993).

Tact and diplomacy are useful for persons of normal intelligence. Forpersons with MR/DD, however, a more direct, but caring, style will be help-ful. "How are you feeling?" is a typical way the psychotherapist may elicitthe referral problem from the person of normal intelligence, expecting "Ifeel depressed, I can't do anything at work." as a response. The personwith MR/DD might respond "Fine" because that is the expectation, or thatis what he or she knows to say to that question, totally missing the purposeof the question. Instead, the psychotherapist might state "Your socialworker told me you hit people at home." Thus, the approach is more directand helpful in getting to the therapeutic material.

Flexible Methods

Psychotherapists must be flexible in approach to the person withMR/DD. Cognitive limitations, developmental delay, dependence on caregivers, and social rejection throughout society are all aspects of adjustingany techniques, whether it be adjusting a more psychoanalytic approach orcognitive-behavior therapy approach. Length of session, communicationaround appointments, therapy contracts, and consent need to be adjusted

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and flexibly approached throughout the treatment. Lindsey et al. (1993),for example, describe modifications of cognitive therapy of depression forpersons with mental retardation which included a structured form for moni-toring negative thoughts and rating the intensity.

Flexibility on the psychotherapists' part also affects interpretation andtiming. Patience is usually necessary, and therapists must avoid seeing slowor little progress as "resistance." Throughout psychotherapy, the patientmay need breaks, changes in psychotherapy routine, or adjunctive inter-ventions not typical of the normal intelligence patient. For example, manyindividuals with mild MR/DD may be quite capable of participating in long-term psychodynamic psychotherapy. At many points, however, the patientmay need direct assistance in some aspect of his or her life, which requiresspeaking to care-givers or family members. The psychotherapist would or-dinarily not intervene in such a way, but when treating the patient withMR/DD, arrangements must then to made to facilitate the needed com-munication in some way, using a co-therapist or other available staff.

Involve Care Givers

When treating children, the involvement of the care giver is essentialin the treatment. Most adults with MR/DD have full- or part-time caregivers-support persons, including family members, personnel from educa-tional, vocational, residential, protective, or state agencies. These supportstaff are an invaluable resource that can help to accelerate the therapeuticwork by embedding treatment into the person's daily routines and socialecology (Sarason, 1953; Hurley, 1989; Lowe et al., 1990). For example,Mansdorf and Ben-David (1986) assisted a moderately delayed boy withsevere grief reaction to the death of his brother. The family was instructedto verbalize and rehearse appropriate behaviors at home, and praised theboy for performing therapeutic tasks.

When involving care givers or support staff, the psychotherapist must becareful about boundaries, confidentiality, and reporting of information abouttreatment. Information conveyed to support staff and care givers should bepositive, and openly conveyed in the presence of the person. The psycho-therapist must assess that support staff and care giver have the capacity tobe therapeutic, as their own personal problems, or employment conflict, maylimit their ability to help the client positively (Nezu et al., 1992).

Transference/Countertransference

Transference is the reaction by which the patient responds to the psy-chotherapist as if he or she is another figure from life, e.g., reacting to the

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therapist as if he or she were a mother or father. Similarly, the psycho-therapist responds to the patient with countertransference, or as if the pa-tient was a son or daughter. Training in psychotherapy extensively addressesthis reaction, which, if unaddressed, leads to a problematic involvementand loss of distance and objectivity in the professional nature of the work.It is generally agreed that persons with MR/DD can display transferencereactions that are more rapid, pronounced, and primitive than those seenin the general population (Levitas and Gilson, 1987, 1989; Szymanski,1980). Rather than being problematic, the strong transference reaction maymake psychotherapy particularly effective with this population.

Psychotherapists must be prepared to often review the limits of ther-apy. Clarifying the psychotherapeutic relationship in clear, concrete termswill help the person maintain a working relationship. Otherwise, the patientmay quickly see the therapist as a "friend," or possible romantic partner.Countertransference issues for psychotherapists working in MR/DD aresimilar to those that arise in pediatric settings. Rescue fantasies, overpro-tection, and ridicule of the parents are common pitfalls.

These are the objective countertransference issues. The subjectivecountertransference issues are those issues the therapist may not be intouch with while working with a patient. These issues are hallmarked byrepetitive feelings the therapist has but may not be able to understand. Asan example, if the therapist repeatedly finds himself avoiding a member ina group or feeling frustrated during an individual session with a patient,the repetition should serve as an opportunity for the therapist to discussthe issue with a supervisor or in peer supervision. Often the repetition ofa reaction without understanding its cause is an indication of an uncon-scious countertransference which needs to be brought to light. In the ab-sence of a supervisor the use of a peer supervision group may be anexcellent way for people to explore these dynamics. When psychotherapiststreat a patient with MR/DD, such reactions are quick and strong, acceler-ated by the patients' dependence needs. In addition, the psychotherapistis challenged to work through his or her own feelings about disability anddifferences. As noted earlier, working with this population challenges usto expand the depth of our own humanity by being open and available topeople who have been devalued by society and not deemed capable of fullparticipation in reciprocal human relationships.

Disability/Rehabilitation Approaches

The mental health psychotherapist must take a strong and positive ap-proach to disability issues, as cognitive limitations are a disability that chal-lenges personal and intellectual growth as well as independence in

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adulthood. With the disability also comes social stigmatization, social re-jection, and many failure experiences (Wright, 1983). Unlike other disabili-ties, however, people with MR/DD cannot independently ascertain whyothers are responding negatively to them. They do not assume that publicsocial rejection is due to disability; whereas, for example, a man in a wheel-chair may perceive that he is being treated differently due to his obviousdisability. The person with MR/DD often concludes that he or she is a"bad" person. Szymanski and Rosefsky (1980) stated that, upon finding outthat they are just "slow" in certain developmental areas, many individualswith MR/DD react with relief. Reiss and Benson (1984, 1985), and Blotzerand Ruth (1995) reported that disability issues inevitably arise during thecourse of counseling and psychotherapy and must be addressed.

Psychotherapists must promote a strong and positive approach to dis-ability. The person with MR/DD must be helped to understand the dis-ability while also appreciating their abilities. Thus, while one cannot read,one may be able to cook well or dance well, have friends, or take publictransportation. Within this framework, the person is also separated fromtheir skills and talents, appreciating their worth as a human being. Sinason(1986) has written on the unconscious defenses the person with MR/DDuses against the trauma of having this handicap, and uses a psychoanalyticapproach to address these issues. A capacity-based approach is a definingcharacteristic of person-centered planning (Pfadt and Holburn, 1996) andshould make for a mutual alliance between advocates for this approach toproviding services for people with MR/DD, and psychotherapists interestedin developing a positive approach to disability.

ESSENTIAL ELEMENTS OF THE PSYCHOTHERAPEUTIC PROCESS

The techniques and adaptations reviewed certainly comprise a full"tool-box" for the psychotherapist who is interested in working with pa-tients who have MR/DD. Although techniques and adaptations are criti-cally important to successfully treat the patient with MR/DD, the mostcritical variable is the establishment of a therapeutic relationship. Psycho-therapy can be broadly defined as "the formalized exchange between oneor more therapists and one or more patients for the purpose of attaininga defined clinical goal. It is an event which can be described in terms ofstructure, process, and content" (Nuffield, 1986; p. 201). Viewed from thisperspective, the task of the psychotherapist is to establish a triadic rela-tionship among the three elements so that the essential ingredients neces-sary for a successful psychotherapeutic endeavor are actualized for anindividual or group of people, with specific problems, under a particularset of circumstances.

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Regardless of style and technique, it is the professional and consistenthelp of a person who is trusted, with whom you can be yourself withoutfear of reprisal, judgment, that makes psychotherapy work for people. By"just being with" the other person, the psychotherapist provides the essen-tial ingredient for supportive change. The importance of this human contactcannot be over-emphasized. In traditional psychotherapy the therapist muststruggle with a wide array of issues which may include his or her capacityto "be present" with the person he or she is working with. Overcomingsuch difficulties requires reflection on the therapists' part to understandinfluences such as "countertransference" and "identification with the pro-jection" as causal features in the barrier to therapeutic availability. Whilethese and other dynamic features are still worthy of reflection for the thera-pist (as will be discussed below) what is perhaps even more important isthe therapists' ability to expand his or her level of compassion and toler-ance. This is to say that the range of disabilities presented by a personwith MR/DD may challenge the therapist to expand the depth of his orher humanity.

Content vs Process

Content is the most important vehicle for teaching, that is, conveyinginformation. In psychotherapy, however, the process is the most importantelement. Thus, it is not what is said that is so important to growth andchange, but the reciprocal relationship between parties in the communica-tion process. As an example, in group psychotherapy the underlying "thera-peutic factors" (see Table I) reflect those elements which have therapeuticvalue emerging from interaction between and among members (Yalom,1985; Bloch and Crouch, 1985). These factors serve as a barometer forgauging potency of psychotherapy. Neither the style or content, nor thetheoretical orientation of the group facilitators and members, are as im-portant as the underlying process. Many persons with MR/DD have beensubjected to many group-teaching/didactic experiences, and while valuable,these have not afforded personal growth and understanding as a centraloutcome.

Support vs Skills Training

The support received through the process of psychotherapy is essential,rather than specific skill training in any area. Historically, social skills train-ing groups emerged following a belief that people with MR/DD could notprofit from a dynamic group experience, or had a small improvement , orthat mental health issues were irrelevant to the population. Thus, a "special

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education-skills training" approach was deemed as most valid (Benson,1986, 1992; Benson et al., 1986; Bregman, 1985; Castles and Glass, 1986;Gardner et al., 1983; Griffeths, 1990a,b; Kelly and Christoff, 1985; Matsonand Senatore, 1981; Nezu et al., 1991; Turner et al, 1978; Valenti-Hein,1990). As a result, the "training" model and social skill training paradigmbecame widely used. Although the social skills model is useful in manycontexts, such training groups are not structured for therapeutic growth.The teaching or training model certainly has an important role to play inthe development of specific skills, its pre-eminence as an intervention pre-cluded the evolution of a peer support model. Recent advances in the useof peer support as well as supportive individual psychotherapy will be dis-cussed later.

Action Methods vs Verbal Methods

Action methods include techniques from psychodrama, art therapy,play therapy, music therapy, and other creative and interactive therapies.As early forms of psychotherapy were verbal and analytic by nature thetraining of therapists was heavily influenced by the use of these procedures.It is not until the late 1960s that alternate forms of psychotherapy makea significant impact in the United States.

Because psychoanalysis is often used as the prototype for psychother-apy, the early emphasis was on verbal ability on the part of the psycho-therapist and patient. As later forms of therapeutic encounters emerged,they were primarily verbal and psychodynamic in nature. A major innova-tion was heralded by Jacob Moreno, who promoted psychodrama as wellas group psychotherapy. The psychodramatic approach is active rather thanpassive, focuses on movement, rather than lying on a couch, and focuseson encounter or an interaction with people rather than an analysis ofthoughts and feelings by the therapist. Thus, the birth of action methodswas in direct contrast, and perhaps even in reaction to, the "Talking Cure."These innovative therapeutic techniques were very helpful for those thatcannot benefit well from verbal methods, including not only patients withMR/DD, but also persons of lowered educational levels, learning disabili-ties, and chronic mental illness. Action methods not only provide a greateropportunity for emotions to be expressed and "acted out" in a safe atmos-phere, but also stimulate more sensory modalities than the verbal methodsalone (Tomasulo, 1994; Tomasulo et al., 1995). As the secondary disabilitiesinvolve such impairments as auditory, visual and attention deficits, the useof methods which stimulate a wider variety of sensory processes seems notonly prudent but also necessary. For example, you are likely to rememberscenes from plays and movies from years ago, but may not recall the details

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of a conversation last week. In much the same way, using such action meth-ods as role playing has the effect of helping members of a group attend,learn, and recall relevant material presented during the group. These ex-periential methods are extremely effective and useful for persons withMR/DD.

Therapeutic Growth and Group Psychotherapy

Because of the strong therapeutic value of groups on many levels,group psychotherapy is an extremely important treatment modality for per-sons with MR/DD. For people of normal intelligence, the growth experi-ence of groups has caused the development of legions of self-help andsupport groups, the first and most famous being AA (Alcoholics Anony-mous). Groups provide much therapeutic benefit that does not depend onintellectual capability. Whereas many psychotherapeutic approaches de-pend, to some extent, on cognitive skills (e.g., cognitive-behavior therapy,rational emotive therapy, psychoanalytic therapy), group treatment can beeffective for all levels of MR/DD.

As discussed previously, the past 15 years has seen an awareness ofthe effectiveness of the group modality, but mainly as a "training" formatfor specific skill development. There is a need for a shift from "training"group approaches to a more interactive and therapeutic counseling format.In doing this the emphasis on evaluating the acquisition of a particularskill with an individual in the group remains an important criteria for de-termining the effectiveness of the group process. However, the exclusivefocusing on specific skill development often neglects the rich potential toprovide generalized support (not limited to specific skill acquisition) on-go-ing encouragement, a sense of belonging, hope, and other (re)habilitativeelements that accompany a positive group experience. This transformationis from content-driven skill-oriented groups, to those which are focused onprocess. This shift would seem to require that a type of concurrent validitybe established. By this we mean to take what has been accomplished ingroup therapy in general and extrapolate from these findings that whichto look for in groups targeted for people with MR/DD. This approach hasbeen identified by Pfadt (1991) as a primary vehicle for making group psy-chotherapy available to persons with MR/DD.

The shift toward group counseling from skill training groups may re-quire that the content of the group become secondary to its process. TableII describes the therapeutic factors at work in all group psychotherapy, asposited by Yalom (1985) and Block and Crouch, (1985). A therapeutic factoris defined as a component of group therapy that positively benefits a mem-ber's condition. This improvement conies as a result of actions by the group

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facilitator, the members, and the individual. Therapeutic factors are per-haps one of the most respected measures of any group's viability and areobserved in group psychotherapy with patients who have MR/DD.

Another promising development is the use of the Interactive BehavioralModel (Tomasulo, 1992). This model describes a process taken from well-established principles in group psychotherapy which have been modifiedfor people with MR/DD, and allows the groups' process to also be usedwith various curricula. As an example, the Interactive Behavioral Modelhas been used in anger management, AIDS awareness training, relationshipcounseling, sexual abuse avoidance training, mental health counseling, vo-cational readiness, behavior management, travel training, independent liv-ing readiness, sex education, socialization, educational readiness,parent-child education, birth control, advocacy groups, and others. Such abroad base use of the model would seem to indicate that the four-stageprocess of the group is more essential to the functioning of the group thanthe content. The presence of therapeutic factors within the group sets thestage for corrective work to be done.

The evaluation of the effectiveness of group therapy is arguably themost difficult of all therapeutic validation efforts (Pfadt, 1991). Process andoutcome research is greatly hampered by issues surrounding criteria, mean-ingful dependent variables, and proper methodology. Indeed the difficultyin assessment of psychotherapy has been related by Nuffield (1986) to beattributed to the following conditions: "The fuzzy and poor description ofthe therapeutic process, the inadequate description of the context, the fail-ure to describe the inter current events that may be important, and thelack of objective outcome measures that are meaningful and that can beconsidered to be empirically valid" (p. 227).

Given the difficulties in assessing the therapeutic outcome describedby Neuffield (1986), the strategy recommended by Pfadt (1991) is worthconsidering. This involves a logic similar to validating an experimental de-sign, where the internal validity is first established (in this case by deter-mining that conditions related to the process of psychotherapy have beenactivated) before examining the external validity of the experiment (theextent to which outcome can be generalized to other contexts). This ap-proach was utilized by identifying therapeutic factors in group psychother-apy described by Yalom (1985) and Block and Crouch (1985) as theyemerged in the context of an on-going psychotherapy group with adultswith mild MR/DD using the Interactive Behavioral Group format. A recentstudy (Tomasulo et al., 1995) examined the presence of eight therapeuticfactors in an Interactive-Behavioral group using inter-rater reliability of ex-perts in group therapy which were videotaped. Twelve sessions run weeklywith both a high functioning group (Mild MR/DD) and a low functioning

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group (moderate MR/DD). The results showed the presence of all eightof the therapeutic factors. In addition, ratings demonstrated that membersgenerally became more interactive with one another over time as depend-ency through interaction lessened with the facilitator.

FUTURE DIRECTIONS

For decades, psychotherapists have worked with people who haveMR/DD and found the treatment productive. There are ample writings andreports from enthusiastic psychotherapists about the effectiveness of thistreatment. As summarized earlier, psychotherapists have developed generaladaptions of preferred techniques to suit the cognitive and developmentallevel of persons with MR/DD. These have included alterations based oncognitive limitations, such as a general simplification of approach, alteringlanguage patterns to match linguistic level, using a variety of action-ori-ented activities, and maintaining flexibility in treatment approach based onthe patient's response. Other adaptations are based on development-de-pendence, and these include close assessment of developmental level, in-volving care giver staff in treatment, as well as significant heightenedproblems with regard to transference-countertransference issues. Last, psy-chotherapists must be aware of disability issues as they related to self-ac-ceptance and positive self-attitude. Many psychotherapists using the rangeof available techniques agree remarkably on these general adaptions thatcan be made and will serve to make psychotherapy a useful vehicle of sup-port and change for persons with MR/DD.

For those psychotherapists who practice using a behavioral or cogni-tive-behavioral model, treatment effectiveness has been documented, as thisapproach itself lends to measuring of behavioral maladjustment and changeafter psychotherapy. The use of variants of systematic desensitization/andresponse prevention for anxiety and phobias has been shown to be as ef-fective as that done with patients with normal intelligence. Lesser reportedwork on the use of cognitive-behavioral therapy for depression has alsobeen successful, when appropriately modified.

The prominence of the group-training model has also been challengedas more psychotherapists have become convinced that group psychotherapymay be more important to generalized personal growth. While group train-ing is invaluable for skill acquisition, it does not provide the personalgrowth that a psychotherapeutic group format can provide.

People with MR/DD suffer the full range of psychiatric disorders andprobably do so at a rate higher than that of the general population. TheMR/DD service systems are generally aware of this situation, but address itthrough habilitation planning, supports, and behavioral consultation. There

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is a critical need for psychotherapists to step forward and treat patients withMR/DD. In the distant past, third-parry reimbursement has been a problem,but as many persons with MR/DD may have Medicare/Medicaid benefits,insurance should not be a significant barrier at the present time. Thus, thewillingness to treat those in need, and stretch already established psychother-apy skills should propel psychotherapists to work with this population.

Why is it, then, that the majority of psychotherapists do not feel com-fortable treatment patients with MR/DD? Several factors may be at work,such as poor health insurance payor, or (unfortunately) prejudice. We be-lieve, however, that most psychotherapists would gladly treat patients withMR/DD, with encouragement and basic instruction regarding how they mightadapt their present therapist-skills to work effectively with this population.

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