NADD Bulletin Volume III Number 5 Article 2

Complete listing

Modifying Psychotherapy for Individuals With Mental Retardation

Christopher Lynch, Ph.D.

Introduction

Psychotherapists who provide services for individuals with a dual diagnosis adhere to two general concepts. First, we believe that individuals with mental retardation can suffer from mental illness. Second, we believe that such individuals can benefit from psychotherapy. The first concept has been strongly supported (e.g., Matson & Frame, 1986; Mulcahy, 1992; Sovner & Hurley, 1983), and few would argue that individuals with mental retardation can not also have a bona fide mental illness. The idea that individuals with a dual diagnosis can benefit from psychotherapy has, thus far, primarily been supported through individual case studies and our own clinical experience. However, there has been some research conducted on this issue and preliminary data from a review of efficacy studies (Prout & Nowak-Drabik, 1999) provides additional support for this belief.

Although clinicians in the field believe that psychotherapy can be effective for the client with mental retardation, they do acknowledge that such psychotherapy often needs to be modified. Such modifications are required to accommodate for a client’s cognitive and developmental weaknesses. Although many clinicians realize that modifications are often necessary, there are few clear guidelines on how this is to be done.

The Match Model

During assessment and treatment formulation, I use a heuristic model which I term MATCH. These letters stand for Memory, Attention, Thinking Skills, Communication, and Higher Order Cognition. The MATCH acronym serves as a reminder that I need to “match” my techniques with a client’s cognitive and developmental profile.

The MATCH model is a conceptual tool and not a quantitative assessment instrument. Formal assessment from qualified professionals may assist a clinician in understanding a client’s strengths and weaknesses. However, in addition to any formal testing, I make use of the MATCH model by asking questions which help me to assess the possible need for treatment modifications. Various modifications are then considered based upon a client’s cognitive and developmental strengths and weaknesses.

Memory

In this area, consideration is given to how well a person can encode and recall information. Effective use of memory is an important aspect of psychotherapy. Often, we require clients to report on recent events and emotionally salient issues. Clients also have to remember when to use techniques. Questions/possible solutions include:

Can the client effectively encode therapeutic recommendations? In other words, when you present a technique or concept is your client accurately storing this information for later use?

If not, then consider:

•checking for retention (make sure the client has retained the concept or technique by having him or her repeat the concept or demonstrate the technique back to you)

•repeating information (repetition can bolster ability to encode information)

•presenting the information in different ways (e.g. visually as well as orally)

•presenting the information in meaningful ways (e.g. relate techniques and concepts to a specific problem in a client’s life)

Can the client effectively recall long term information? In other words, can a client accurately recall the answers to such questions as “Did you have a good week?” or “When did your depression begin?”

If not, then consider:

•having the client write down information (e.g. use of journals, “feelings” charts)

•increasing communication with caregivers (with proper consent) for acquiring or confirming information

•reviewing past records (especially for very long term information)

•telling the client beforehand what information you will be asking for during the next session

Can the client effectively remember to use techniques?

If not, then consider:

•enlisting caregiver’s help in prompting and reminding the client to use techniques

•using written or pictorial reminders such as a chart

•calling on the phone to check if using technique when required

•anticipating upcoming situations when technique may be useful

Attention

Difficulty with attending during session is a frequent occurrence in my work with individuals who have mental retardation. Attention deficits can make it difficult to process information. Also, if a client can not remain on topic, then it is difficult for the clinician to obtain accurate information. For this area, I consider the following question and solutions:

Can the client effectively attend during the session?

If not, then consider:

•shortening length of the session

•providing breaks

•using novel and fun techniques

•exerting more effort to establish and maintain eye contact

•minimizing distractions (e.g. turn phone off, close the blinds)

Thinking Skills

In this area, the model refers to a client’s ability to reason and problem solve. Such skills can greatly enhance a client’s ability to accurately understand social and emotional issues. In this area, I also consider the ability of a client to understand therapeutic and emotionally relevant concepts. For this area, I consider the following questions and solutions:

Can a client effectively reason and problem solve?

If not, then consider:

•spending time working on the process of problem solving (e.g. determining what the problem is, generating potential solutions, choosing solutions, evaluating outcomes)

•teaching reasoning skills as they relate to real-life situations

•enlisting caregiver’s assistance in helping to apply reasoning and problem solving skills in the natural environment

Can a client accurately understand concepts presented in therapy?

If not, then consider:

•teaching concepts in concrete terms

•checking for comprehension of a concept before assuming that a client has grasped it

•making concepts relevant to recent, real-life situations

Communication

Communication is an important aspect of psychotherapy. It is important to consider a client’s ability to express him or herself and to understand what the psychotherapist is saying. Questions/possible solutions include:

Can a client understand you?

If not, then consider:

•speaking slower (but still fluently)

•using visual aides to assist with communication

•checking for comprehension before assuming that a client has understood you

Can a client effectively express him or herself?

If not, then consider:

•using alternative means of communication (e.g. writing)

•enlisting the help of someone who may be able to translate

•allowing more time to express self

•consulting with a speech/language specialist

Higher Order Cognition

In this area, the model pertains to what is often referred to as executive functions. Such functions have an impact on goal completion and, as noted in Sohlberg and Mateer (1989) include such activities as “goal selection, planning, initiation of activity, self-regulation or self-monitoring, and use of feedback” (p. 237). Such activities are crucial for the successful implementation of many therapeutic techniques, and relate to the ability to choose when to implement techniques, how to set and remain cognizant of goals, and how to constructively use feedback to determine if techniques are being effective. For this area, I consider the following question and solutions:

Can a client effectively use higher order cognitive skills to implement techniques, set goals, and use feedback?

If not, then consider:

•working on ability to plan (e.g. when do you think you will use a technique?)

•working on self-monitoring ability by using concrete activities (e.g. a “feelings” chart)

•helping the client to related specific techniques to more long-term, global goals

•encouraging metacognition: the ability to think about one’s own thinking

Case Illustration

(Names and demographic information have been altered to disguise patient identity)

Laura came to my office as a 25 year old female with mild mental retardation and seizure disorder. Laura was having frequent interpersonal conflicts with staff. A consideration of Laura’s cognitive strengths and weaknesses revealed the following: Memory was severely impaired. This was particularly true for long-term memory. Laura would frequently have difficulty remembering staff instructions or upcoming events. Consequently, she would exhibit confusion and misinterpret information. Not only did this interfere with the psychotherapy process, it also created significant friction with staff, since they believed that Laura was purposely twisting information. Attention was a relative strength for Laura and this helped her to absorb material presented during sessions. Thinking skills were somewhat impaired. Laura seemed to have difficulty grasping some of the more abstract concepts presented in therapy and did not effectively approach problem solving tasks. Communication was a relative strength and an asset for the process of psychotherapy. Higher order cognition was impaired and Laura often had difficulty relating specific techniques to more global therapeutic goals.

Modifying psychotherapy for Laura heavily involved compensating for her impaired memory. To help compensate for this impairment, I encouraged Laura to write down important information (e.g. instructions from staff). We also practiced using a calendar for remembering important dates and appointments. Laura was also encouraged to keep a journal to be used for writing down emotionally-salient issues and events on a daily basis. In Laura’s case, consulting with staff was crucial, and I worked to help staff understand that Laura’s failure to accurately understand instructions was not intentional. By understanding this, staff exerted more effort to present information in ways that would enhance Laura’s recall.

The model also suggested that I work on thinking skills. In this respect, I presented abstract concepts in terms that were meaningful for Laura. In addition, I used repetition in the presentation of concepts. We also worked specifically on problem solving skills. In this regard, I presented Laura with problem solving worksheets and had staff assist her in completing these sheets whenever she presented them with an interpersonal conflict.

Higher order cognition was addressed by helping Laura carefully consider when to apply techniques. Each session we would discuss the upcoming week, and prepare for situations which may call for a therapeutic strategy. In this area, we also worked on keeping concrete records of progress (e.g. the number of times she kept or lost her temper) and we discussed global treatment goals during every session.

Laura responded positively to treatment and the number and severity of interpersonal conflicts with staff decreased significantly. By carefully considering Laura’s cognitive and developmental profile, I was able to effectively modify techniques in ways which contributed to the treatment success. In Laura’s case, providing consultation to staff with regard to Laura’s cognitive profile also had a direct effect on treatment success.

Summary and Conclusions

Although individuals with mental retardation can benefit from psychotherapy, modifications are often required to achieve treatment success. The MATCH model can serve as a heuristic tool to help clinicians modify psychotherapy in ways that take an individual’s cognitive strengths and weaknesses into account. Briefly, the MATCH model encourages a clinician to consider an individual’s Memory, Attention, Thinking Skills, Communication and Higher Order Processing. By considering these ability areas, a clinician is in a better position to modify techniques in ways that will optimize treatment success.

Certainly, cognitive ability is not the only factor to consider when conducting work with individuals who have mental retardation. Just as with individuals who do not have a developmental disability, clinicians need to consider a host of factors including family history, medical status, personality characteristics, environment, the presence of a mood or thought disorder, and motivation when developing and delivering mental health services.

References

Matson, J. & Frame, C. (1986). Psychopathology among mentally retarded children and adolescents. Beverly Hills, CA: Sage.

Mulcahy, M. (1992). Evaluation of treatment in the psychiatry of mental retardation. International Journal of Mental Health, 21, 77-94.

Prout, H. T. & Nowak, K. M. (1999, November).

The effectiveness of psychotherapy with persons with mental retardation: Status of the “research”. Paper presented at the annual conference of the National Association for the Dually Diagnosed, Ontario, Canada.

Sohlberg, M. M. & Mateer, C. A. (1989). Introduction to cognitive rehabilitation:Theory and practice. New York: Guilford Press.

Sovner, R. & Hurley, A. D. (1983). Do the mentally retarded suffer from affective illness? Archives of General Psychiatry, 40, 61-67.

For further information, please contact:

Christopher Lynch, Ph.D.
Developmental Disabilities Center
Mountainside Hospital
1 Bay Avenue
Montclair, NJ 07042