Robert L. Morasky, Ph.D.
Therapy or counseling can be intellectually difficult for a person with a dual diagnosis. Nonetheless, it can be beneficial (Browning & Keesey, 1974; Foss, 1974; Halpern & Berard, 1974; Nuffield, 1986; Prout & Nowak-Drabik, 2003). Expert consensus guidelines (Rush & Frances, 2000) recommend that Client and/or family education as the treatment of choice for ten of eleven comorbid psychiatric disorders. Whether we call the treatment counseling, therapy, or education, a person with an intellectual disability (ID) engaged in such treatment may encounter substantial and, perhaps, difficult intellectual tasks.
The use of the term "intellectual disabilities" follows the model of the President's Committee on Intellectual Disabilities (formerly known as the President's Committee on Mental Retardation). The Committee adopted this term to "update and improve the image of people with disabilities who were formerly referred to as people with mental retardation and to help reduce discrimination against these citizens" (President's Committee for People with Intellectual Disabilities, 2006). The Committee also "sought to reduce the public's confusion between the terms mental illness and mental retardation and to remove the use of terms which resulted in faulty name-calling."
Counseling or therapy (C/T) for a person with a dual diagnosis may require more adaptation than would be needed otherwise. Such adaptation may be necessary before therapy begins or later if therapy stalls. Treatment providers need a strategy for adaptation. Prout and Strohmer (1998) described developmental adaptation in which language, goals, strategies, and tasks are adapted to the intellectual abilities of the client with mental retardation. Go slow, be concrete, repeat is a recommendation that is often applied to counseling and therapy with persons with an intellectual disability. Further advice seems appropriate, but what should it be?
A counselor/therapist would be well-advised to ask at least two questions in regard to undertaking C/T with a person with a dual diagnosis: What makes intellectual activity difficult? What intellectual activities are difficult? The Therapy/Counseling Adaptation & Planning Strategy (TCAPS) described herein is a conceptual and procedural means to help answer those questions and prepare for individualized C/T.
What makes an intellectual activity difficult?
If we can answer that question, we have the beginnings of a strategy for adapting not only C/T, but, also, vocational and life skills instruction for persons with ID. Four parameters commonly impact intellectual tasks: speed, number, abstraction, complexity. These will be discussed individually.
Fast to slow are the poles of a continuum of speed. When thought processes have to be done quickly, they become more difficult. That is why certain intelligence test items are timed. Faster performance gives higher scores. When the duration of exposure to a stimulus is short, memory storage is difficult, as is memory retrieval. When memory retrieval must be done quickly, the task is more difficult than if unlimited time is given. Speed is commonly accepted as a variable that makes intellectual activity demanding or difficult
Few and many are at opposite ends of this continuum. The more components one has to deal with, the more difficult the task. This is evident with memory. Also, decision-making becomes difficult when the number of available options increase (Tymchuk, Yokota & Rahbar,1990; Jenkinson, 1999). Consider how much more difficult it is to choose a meal from a large restaurant menu as opposed to the dining room that offers a single entrée.
Concrete is the opposite of abstract. Abstract concepts or attributes are generally intangible. That is, they cannot be detected by the senses. Concrete concepts or attributes are generally tangible or accessible to the senses. We can feel, see, hear, taste, and smell concrete phenomena, but not abstract ones. Abstract ideas are more difficult for the intellect to handle than concrete concepts. An abstract premise such as responsible people are highly regarded is much more difficult to work with logically than the more concrete statement, supervisors praise people who come to work on time.
Complexity is a topic that, in itself, is complex (Axelrod & Cohen 2000).
While it can be viewed as a continuum between order and chaos (Waldrop, 1992 ), for the purposes of C/T with persons with ID a traditional continuum of simple to complex will suffice (Jenkinson, 1999). The difference between simplicity and complexity is the number of relationships encountered. Complex systems have more interrelated components than simple systems. In a simple task the components of the task stand alone, they are not related to each other in terms of sequence, location, or cause. In complex tasks the components may have any number of interrelationships. Whether to go to the mall, the bowling alley, or the YMCA would be a relatively simple decision. The intellectual challenge of making this decision becomes more difficult if relationships exist between the options. For example, going to the mall for the special sale means that your free pass to the bowling alley would expire (expiration date is today) and you might miss the open swim at the YMCA. Going to the bowling alley means that you would miss the last day of the special sale at the Music Box as well as the open swim at the YMCA. The relatively simple decision with three options becomes difficult because of the complexity caused by the relationships between options.
In answer to the question, What makes an intellectual activity difficult?, four parameters of difficulty can be offered: speed, number, abstraction, and complexity. Examples of how these difficulty parameters apply to C/T are useful; however, a quick look at the second question will make the subsequent application more meaningful.
What intellectual activities are difficult?
Memory, reasoning, generalization, decision-making, planning, and problem-solving are often given as difficult intellectual operations for persons with ID. While the list seems to be accurate, planning and problem-solving may depend largely on the initial four. A counselor/therapist working with a person with dual diagnosis needs to be aware of those four intellectual operations:
A person with dual diagnosis who is engaged in C/T may have to draw on visual, auditory, tactile, or any other type of memory. That is, the task may require that the person remember what an object looks like, what written words to look for, what different colors mean, or what sounds to which one should listen. Limitations on memory are well known (Miller, 1956). Both storage and retrieval of information can be impacted by all four of the difficulty parameters, speed, number, abstraction, and complexity.
A person with dual diagnosis may have to follow rules of deduction or induction in order to engage in C/T. Deduction may require that the person come to a conclusion based on a general statement and specific information. The structure of the general statement will often be if&ldots;then&ldots; Induction would require that the person come to a general conclusion based on several bits of specific information. Regardless of the degree of reasoning required, it can be made more difficult by the difficulty parameters.
C/T may require a person to make the same response to stimuli or situations that are similar, but different from the one encountered when learning the response. Generalization seems to rely on the ability to either: (a) recognize the attributes of a situation that make it like the sample situation encountered during learning, or (b) recognize the range of change in the attributes within which the response is still appropriate. Increases in speed, number, abstraction, and complexity all make generalization difficult.
Whenever the person has to make a selection from a set of options, he/she is engaged in decision-making. This is an area of particular difficulty for persons with ID (Hickson & Khemka, 1999; Hickson & Khemka, 2001). Experimental analysis of decision-making has uncovered many more steps to decision-making than identifying options and selecting from among them, but those two steps are basic to understanding decision-making. Like the other three operations, the difficulty associated with decision-making is increased when speed, number, abstraction, and/or complexity are increased.
How TCAPS Brings Difficulty Parameters and Intellectual Operations Together
Figure 1 presents the TCAPS matrix that results from joining the difficulty parameters with the difficult intellectual operations. Sixteen combinations of Difficulty Parameters and Cognitive Operations can be considered in order to minimize the difficulty of intellectual challenges. For every Operation that a person has to learn or perform, there are potentially four ways that the Operation could be intellectually difficult. That is, the operation of memory is more difficult when speed, number, abstraction, and/or complexity are increased. The same is true for the operations of reasoning, generalization, and decision-making. Not surprisingly, when speed, number, abstraction, and/or complexity are reduced, all of the Operations are made less difficult.
If service providers can adapt intellectual tasks so that they are less difficult, the service provided is more likely to be effective than if the adaptation did not occur. The questions a service provider should ask include: (a) Speed: How do I make certain that the person has adequate time to remember, reason, generalize or make a decision?; (b)
Number: Can the required remembering, reasoning, generalizing, and decision-making be performed with fewer parts or components?; (c) Abstraction: How do I rephrase or redefine the concepts in the task so that they are concrete?; and (d) Complexity: How do I reduce the relationships in the task so that it is less complex?
James, whose diagnoses are Impulse Control Disorder and Mild Mental Retardation, is seeing a therapist for help with anger management. A behavioral functional assessment with informants who know James revealed that he often attributes incorrect intentions to caregivers when they make requests, give directives, or set boundaries. The incorrect attributions lead to anger which has resulted in agitation and aggression. One aspect of James view of the world seems to be that everyone is out to get him, and he needs to get them first. The therapist plans to use cognitive behavioral therapy to deal with James world view, thoughts, and behavior. She adapted the therapy using TCAPS. The adaptations will be discussed in the following section.
Operation - Generalization/Parameter Abstraction
Anger is abstract and, therefore, difficult for James to recognize across many different settings. By identifying his usual features of anger, the concept can be made relatively concrete. Eight features were identified including loud voice, increased large motor movements, talking so fast he spits, swearing, clenched teeth and hands, frowning, tension in arms and neck, and the desire to hurt someone.
Operation - Memory & Generalization/Parameter Number
The initial eight features of James anger were too many for James to remember or to generalize, so she reduced it to clenched teeth and hands, frowning, tension in arms and neck, wanting to hurt someone/something.
Operation - Memory/Parameter Abstraction
The features of James anger, clenched teeth and hands, frowning, tension in arms and neck, and desire to hurt someone, were still too abstract for James to remember. After trying to describe these features in concrete terms, she decided that line drawings showing the features would be more concrete. Desire to hurt someone was shown graphically as two people confronting each other, one having a thought bubble with him/her hitting the other person.
Operations - Generalization & Reasoning/ Parameter Complexity
Requiring that all or certain selected features of anger be present in order to call it anger seemed too complex. And, the deductive reasoning that James would have to do to recognize that he was angry was made more difficult by the complexity. The therapist realized that James often frowned and had tense arms and neck when simply watching movies on television. She thought of defining anger as either frowning or tense arms and neck and either clenched teeth and hands or wanting to hurt someone/something. This may have been most accurate, but obviously too complex. She finally decided that two features, clenching teeth and hands and wanting to hurt someone/something were sufficient to identify most of the occasions when James was angry and aggressive.
Operation Decision-making/Parameters Number & Abstraction
During a later stage of therapy desensitization was used to reduce James anger and aggressive responses when given requests or directives. The options that seemed feasible for James to use were: (a) Go to his room to cool off, (b) Take eight deep breaths, (c) Recite a mantra that he learned and practiced often, I want to be quiet, calm, and gentle, (d) Find the house manager and talk with him about the incident, and (e) Ask the person, Could you say please? or Could you ask me nicely? Of course an unspoken option was to get angry and ascend the Escalation Spiral (Morasky, 2006). During in vitro and in vivo desensitization procedures James would have to select from among these options and respond accordingly. The therapist realized that five possible replacement behaviors were too many, and the most concrete would work best. During treatment James practiced using only Could you say, please? and Could you ask me nicely? when the therapist presented requests and directives that stimulated anger in the past.
Operation Decision-making/Parameter Speed
Some of the stimuli presented by the therapist were more suited to Could you say, please? than Could you ask me nicely? and vice versa. So, James had to decide which one to use. At the same time he was experiencing a degree of anger which made decision-making even more difficult. A quick response was not necessary initially. However, the therapist wanted him to eventually respond quickly in order to compete with his anger that flared up quickly. For several sessions she encouraged and praised deliberate memory retrieval and decision-making. After several sessions James reduced his response latency without prompting.
The preceding examples show how therapy can be made less intellectually difficult using TCAPS. If psychotherapy is the treatment of choice for a person with a dual diagnosis, then the therapist needs to focus on adaptations related to intellectual difficulty. The intellectual operations of memory, reasoning, generalization, and decision-making can be cross-referenced with difficulty parameters of speed, number, abstraction, and complexity to identify potentially difficult therapeutic tasks. Of course, TCAPS is not applicable to every therapy and/or every client. However, reducing the intellectual difficulty where possible will allow therapists to increase the range and effectiveness of therapeutic treatments available to persons with a dual diagnosis.
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