NADD Bulletin Volume III Number 6 Article 3

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The Interactive-Behavioral Model of Group Counseling For People with Mental Retardation and Chronic Psychiatric Illness

Daniel J. Tomasulo, Ph.D.

In recent years the Interactive-Behavioral Therapy (IBT) model of Group Psychotherapy has gained wide acceptance for use with people suffering from mental retardation, chronic psychiatric disabilities, and those with a dual (mental retardation/mental health [MR/MH]) diagnosis. The IBT model uses an abbreviated four-stage format to activate therapeutic factors through the use of action techniques. The remainder of this section will be devoted to the understanding of this model and its implications for use.

Despite the evidence of effectiveness and recommendations by researchers to use a group method, group psychotherapy for people with the above noted disabilities is usually not considered as a viable therapeutic modality. In addition group methods employed with chronic psychiatric populations have suffered from being little more than socialization or teaching forums. Those individuals suffering with a dual diagnosis with mental retardation and a psychiatric disability have usually been excluded from any dynamic or interactive group process at all.

Why Not Group?

Historically, the research on this matter showed that people with the above noted disabilities could not profit from insight oriented interactive therapy because they lacked specific cognitive abilities thought necessary for therapeutic change. To begin with, let us first focus on those with cognitive limitations. Although many clinicians have not regarded people with mental retardation as suitable candidates for any form of psychotherapy (Browning & Keesey, 1974; Hurley, 1989; Hurley, Pfadt, Tomasulo, & Gardner, 1996), there are many case reports on the effectiveness of individual psychotherapy (see Hurley, 1989, for a review) as well as for group psychotherapy (Daniels 1998; see Pfadt, 1991, for a review). Psychotherapy for people with mental retardation has been most effective when a directive style with structured sessions is used (Fletcher, 1984; Hingsburger, 1987; Hurley, 1989; Hurley & Hurley 1986; 1988; Hurley, Pfadt, Tomasulo, & Gardner,1996; Matson, 1985; Schramski, 1984; Tomasulo, 1992) Additionally, the use of active/interactive techniques stimulates more sensory and affective modes of learning than the verbal modality alone (Hurley, Pfadt, Tomasulo, & Gardner, 1996; Tomasulo, 1994). While this may be the primary reason that psychotherapy is overlooked as a treatment modality for people with mental retardation, there have been a series of erroneous assumptions on the part of practitioners. Consider the following major suppositions:

1.Since many developmentally disabled people are not verbal (or have difficulty verbalizing) they are thought to be unable to produce clues to regulating their behavior.

2.The secondary disabilities that often accompany people with mental retardation (short attention span, auditory and visual handicaps, seizure activity, etc.) are thought to provide insurmountable obstacles to interactive group therapy.

3.People with mental retardation are thought to lack the cognitive ability to profit from insight into the causes and consequences of their behavior.

4.Many practitioners understand the emotional disorders displayed by people with mental retardation as a side effect of a biochemical brain dysfunction. As such they feel there is little which psychotherapy can offer.

5.Somehow the emotional and behavioral problems of people with mental retardation are understood as being the result of mental illness or behavior disorders. With such elementary discrimination only psychopharmacological or behavioral treatments alone are sought. The use of psychotherapy to help ameliorate these problems is rarely considered.

Chronic Psychiatric Problems

People with chronic psychiatric problems have had more exposure to group treatment than people with mental retardation. However with the advent of the “Dual Diagnosis” awareness for people with MR/MH problems the need for improved treatment procedures in group therapy has been recognized (Nezu, Nezu, & Gill-Weiss, 1992). The use of action techniques for people with chronic psychiatric problems and inpatient psychiatric status has been well documented (Buchanan & Dubbs-Siroka, 1980; Buchanan, 1984; Cox et al., 1992; Spencer, Gillespie, & Ekisa, 1983; Starr & Weisz, 1989). The IBT format is an adaptation and enhancement of techniques and process known to be effective with people with mental retardation, chronic psychiatric problems, and those with a dual diagnosis.

The reality is that even if an astute and aware clinician were to recommend psychotherapy, the task of finding someone knowledgeable and competent to deliver such services would often be a difficult job. Although more and more providers are beginning groups and developing their group skills the reality is that group psychotherapy is the least often recommended and practiced form of treatment for people with mental retardation. One other reason why group therapy is the least used therapy for people with mental retardation (in addition to the ones listed above) may be that the dissemination of information on how to do such counseling was limited by the scarcity of research showing which method(s) were effective. This is to say that, although there may have been good indications that group therapy could be possible, the volume of such information was not sufficient to offset the assumptions of practitioners. The time has come for greater attention to be given to the group process. To begin with, using group counseling for people with mental retardation makes good clinical and economic sense. Consider the advantages of using a group format:

Advantages

1.The skills to run an effective group can be taught in a brief period of time (two to three months for a novice and considerably less for the more experienced).

2.In the same amount of time it takes to run a teaching based skill-training group (which evolved rather than a therapeutic group), a more richly interactive group can take place through facilitation rather than teaching.

3.More people can be served in a group counseling format than can be served through use of individual settings.

4.It can be argued that the treatment in a group is more effective than individual counseling.

5.On all pay scales the cost to an individual for group psychotherapy is cheaper than individual therapy.

6.Specific topics may target selected groups for particular problems (anger management groups, sex offender groups, bereavement groups, job readiness, etc.). In this way people with similar issues may gain support in ways not possible in individual counseling.

7.This kind of peer support is not limited to homogeneous groups. Interpersonal support from peers struggling with different issues is not available in any other format.

Role Playing

One of the longest-standing techniques in training, education, and therapy is role-playing. Role-playing is used in nearly every phase of human development to teach and model behavior. Parents use role play and children use it extensively during free play throughout early development. Within the field of counseling a more specific and elaborated use of role-playing has taken place through the development of Psychodrama (Blatner,1996).

Psychodramatic Methods: Psychodrama and Sociodrama

Psychodrama is an action-oriented therapy and technique, which endeavors to express a condition or offer a solution to a situation through the combined efforts of a group (Marineau, 1989). In fact, self-help groups and the systematic use of role playing in education and training are actually descendants of the psychodramatic method (Blatner & Blatner, 1988).

The use of role playing for training, education, simulation, dramatic presentation, skill development, and therapy is so pervasive that it is woven into the fabric of our society so seamlessly that it is barely recognizable as a science, art form, and acquired skill. Its natural process is at once so familiar and so agreeable that people use it in their programs without the slightest hesitation as to form. It is as though there is an attitude of: “ It’s only role-playing—I know how to do that.” As such the quality of most role-playing achieves adequacy—but the depth and breath of the use of active/interactive techniques is usually missed. The content in this article is designed to aid the reader in being able to add significantly to his or her role-playing repertoire.

While a fair degree of support for the use of role-playing exists, relatively few guidelines have been established for the development of role playing activities for potential leaders. This article will introduce the reader to the uses of role playing techniques, which have been particularly useful in helping individuals with developmental disabilities. Although role playing and psychodramatic techniques such as the double may be used in individual psychotherapy, this section will look at the ways in which these techniques may be used to enhance the dynamics of a therapy group for adolescents and adults with mental retardation and chronic psychiatric disabilities. In addition, we will examine the ways in which role-playing may be used to activate therapeutic factors within such a group.

Psychodrama is a particular type of group psychotherapy. It involves both theory and techniques. (In fact, Psychodrama is the original form of group work developed by the creator of the term “group therapy”, Jacob Moreno, M.D.) Over the years techniques from Psychodrama (reflecting issues unique to an individual’s life) and sociodrama (issues which reflect a collective concern) have been used with people with mental retardation. However, the primary use of role-playing was for role training. More specifically, these techniques were used almost exclusively for social-skills training rather than for the purpose of counseling. Teaching and training rather than facilitating therapeutic interactions were the aim of social-skill groups.

Social Skill Groups

The teachers in these groups fostered interaction between themselves and the participants rather than between and among the participants. Since the emphasis was on teaching a skill, the attention had to be focused on the teacher/trainer. In the Interactive-Behavioral format the emphasis is on interaction between the participants for the purpose of creating a therapeutic environment. As such there is a major shift from a teaching/training model to a peer support/interaction model, where behaviors having therapeutic value are reinforced as a way of strengthening viable group processes.

Psychodrama and Sociodramatic theories (Steinberg & Garcia, 1989; Blatner & Blatner, 1988) offer the most widely accepted format for facilitation role playing techniques within a group setting. The use of these techniques in groups for people with mental retardation has been modified to accommodate the unique needs of this population. The Interactive-Behavioral group therapy (IBT) model (Razza & Tomasulo,1996a; Razza & Tomasulo,1996b; Razza & Tomasulo,1996c; Tomasulo, 1992, 1994; Tomasulo, Keller & Pfadt, 1995) uses a 45- to 60-minute, four-stage format to facilitate the use of action techniques for people with mental retardation. The four stages are: 1) orientation, 2) warm-up and sharing, 3) enactment and 4) affirmation.

Zen and the Art of I-B Group Therapy

In the classic book Zen and the Art of Motorcycle Maintenance, Robert Pirsig noted that the Japanese instructions for assembling a particular object start with the sentence (I am paraphrasing): “To begin assembly one must have the right attitude.”

This is very much the case with the IBT (and perhaps group therapy in general). The facilitator must begin the group with the right attitude. This is to say that your intention is to help others interact with each other at every level possible. Try to clear yourself of other issues and distractions prior to beginning the group and rededicate yourself to the above intention. If you can maintain this intention the obstacles will seem less drastic, the unexpected more easily coped with, and the reciprocal joy you find greater.

Stages

The four stage format of the Interactive-Behavioral model uses a 45-minute to one-hour time slot. On some occasions this time slot may be even shorter. It uses this brief format for four reasons:

1.The condensed time demands reduces the possibility you will exhaust the members’ abilities to remain physically and emotionally present.

2. The time frame keeps the co-facilitator(s) more focused on their task.

2.The shorter meeting time than traditional groups fits into the schedules of most hospitals, agencies, residences, vocational settings, and schools.

3.If you are billing 3rd party payment, it provides a standard and acceptable time period for reimbursement.

The model combines theoretically sound techniques for activating therapeutic factors from the field of Psychodrama (e.g., Tomasulo, 1994) with some modifications specific to people with dual diagnosis (e.g., the orientation and affirmation stages). The four stages of this model are: 1. orientation, 2) warm-up and sharing, 3) enactment and 4) affirmation.

Stage 1: Orientation and Cognitive Networking

In a group for individuals with mental retardation, many secondary disabilities as well as the primary cognitive deficits inhibit interaction between members. For this reason the facilitator works to engage the members in “cognitive networking” during the initial orientation stage. Having members repeat what was said to them, turn toward the person speaking, acknowledge what was said, and/or in some way participate in the group process through interaction is the goal of this first stage. If the members fail to attend to each other, any other therapeutic, corrective, or instructional goals within the group will not be realized. Additionally, the orientation stage provides a familiar beginning signal for the members to help them realize the group has begun. This stage was designed to help with the initial difficulty encountered in establishing a group with the potential for therapeutic factors to emerge. Poor eye contact, difficulty with short-term recognition or memory, impaired hearing, delayed responding, confusion, echolalia, inattention, distractibility, speech impediments and hyperactivity are just some of the obstacles to interaction between members. It therefore becomes a primary function of the facilitators to stay focused on the development of cognitive networking between the members. This is a direct effort to establish basic interactions between and among the group’s members by having them repeat, acknowledge or otherwise support what another member in the group said. Physically orienting towards the person speaking, looking at them, and echoing back what was heard are central elements to the activity. This process begins in the orientation stage but will continue throughout the group. Without such rudimentary interaction there is a diminished opportunity for therapeutic factors to emerge and be reinforced. As such, the orientation stage is characterized by the facilitator(s) assisting members in interacting with each other participating in the group process. This is the goal of this first stage. If the members fail to attend to each other, any other therapeutic, corrective, or instructional goals within the group will not be realized.

Stage 2: Warm-Up & Sharing

In the warm-up and sharing stage the facilitator invites the members to speak about themselves within the group. This is a process-driven group, and as such, the content of their presentations is of less importance. In other words, the facilitator’s concern is with the dynamics of the group, not necessarily what is being said by the participants. The facilitator’s job is to pay attention to the nature of the interactions between the various members. During this second stage the group members take turns making their self-disclosures, and the cognitive networking begun in the orientation stage is continued. For example, the facilitator may ask the member who has just finished speaking to select the next member to go. In this way, members are again encouraged to pay attention to and interact with each other rather than with the facilitator exclusively. Following this level of participation the facilitator will then ask the members if any of them has a problem to work on in the group. It is during this deeper level of sharing that the members will experience a greater sense of emotional involvement within the group. The group becomes more cohesive, and the stage is set for action to take place.

The second stage of the group ushers in more intimate interactions between members. This is referred to as the warm-up and sharing stage because we are “warming-up” to the enactment. We are “warming-up” to being together and learning from each other. For more than a year the author worked with dozens of comedians at the New York City Improv. Prior to going on stage the more seasoned comics would spontaneously walk, talk, and act silly. They were preparing for their performance by getting themselves into a state of readiness. You notice before an athletic event the athletes stretch, bounce and slowly get themselves ready for participation. They try to get themselves prepared to perform at a level of competency that may not be attainable without a warm-up. Even your computer gets itself ready for the tasks at hand. A preparation is necessary for maximum effectiveness. In watching other groups being run there is often too little time given to readiness. Group leaders start with an agenda and content when the members are too often ill-prepared. In the warm-up and sharing stage the facilitator invites the members to speak within the group. As mentioned this is a process-driven group, and as such, the content of their presentations is of less importance. In other words, the facilitator’s concern is with the dynamics of the group. Has everyone had a chance to speak? Who has chosen whom to speak after him or her? Who has accurately heard what was said? Each of these concerns far outweigh the content of the group. Indeed the message/content of your group will be lost without sufficient preparation of the participants. The facilitator’s job is to pay attention to the nature of the interactions between the various members. During this second stage the group members take turns making their self-disclosures, and the cognitive networking begun in the orientation stage is continued. For example, the facilitator may ask the member who has just finished speaking to select the next member to go. In this way, members are again encouraged to pay attention to and interact with each other rather than with the facilitator exclusively. Following this level of participation the facilitator can then ask the participants to share something from their week. Once each person has had a chance to go, the facilitator will then ask the members if any of them has a problem to work on in the group. It is during this deeper level of sharing that the members will experience a greater sense of emotional involvement within the group. The group becomes more cohesive, and the stage is set for action to take place.

Stage 3: Enactment

It is during the enactment stage that techniques such as role playing and the double are used. The issues presented in the warm-up and sharing stage are formulated into characters with the help of the facilitator. Although only certain group members may take part in the enactment, the entire group’s focus of attention is on the action taking place. (The action technique “The Double” will be not be discussed in this article.) The enactment stage is the central feature of the Interactive -Behavioral model. All of the features of the enactment stage are modifications derived from the field of Psychodrama (Tomasulo,1994).

It is during the enactment stage that techniques such as role playing and the double are used. The issues presented in the warm-up and sharing stage are formulated into characters with the help of the facilitator. Although only certain group members may take part in the enactment, the entire group’s focus of attention is on the action taking place. Of the four stages, the Enactment Stage is the core focus of the group. Within the Enactment Stage a number of techniques are used to stimulate interaction between group members. One of the most useful of those techniques is the double (Tomasulo,1994). Broadly stated, a double is a role played by one or more group members as they give voice to the feelings and thoughts of another member who is struggling with a given problem. The use of the double can be a tremendous asset in groups for people with mental retardation, chronic psychiatric illness and dual diagnoses. There are a number of other techniques, which are used during the enactment stage. Among these, are the empty chair, role reversal, and mirror.

Stage 4: Affirmation

Finally, in the affirmation stage the facilitator validates the participation of each of the members in the group. This is done with specific attention to the therapeutic factors (Bloch & Crouch, 1985; Yalom, 1995). Each member is verbally acknowledged for his or her interactive contributions to the group. Specifically if someone displays a trait which is interactive and reflective of a therapeutic factor, it will get reinforced. The reinforcer identifies (in concrete terms) the interaction between one member and another via a therapeutic factor. This reinforces the member’s new social skills by noting what was done that has therapeutic value. It also has the added benefit of helping the affective intensity of the enactment stage to slow down. The cognitive networking begun in the Orientation stage continues throughout the four stages. This helps to insure the fact that what is being worked on is being taken in by the participants. In general terms, the orientation as well as the warm-up and sharing stages are relatively tedious for the facilitators. The task of weaving together the fabric of thoughts and words is often not very stimulating. This however is the foundation upon which nearly everything else in group must rest. The time invested into these two stages is necessary for any return to be realized in the second half of the group.

The readiness of the members of the group to take part in the action portion of the group allows them to have greater concentration, presence, and emotional involvement. In this way the format and process of the Interactive-Behavioral model lends itself toward creating an opportunity for a “teachable moment” when the participants are able to take part in a way that allows for learning to take place.

The Affirmation stage signals the end of the group and serves to slow down the emotional build-up that has taken place during the session. The primary concern of a facilitator is to attend to the emotional needs of the individuals being served in the group. If the facilitator is concerned that the issues dealt with during the session have impacted the participants in such a way that they may need more time to absorb the elements of the session, they may be helped by providing additional affirmations. An affirmation helps members identify those components of their participation which are directly tied to therapeutic factors and other interactive features which pertain to their emotional growth. Most often the affirmation stage signifies the need to close down the emotional aspects of participation and allow members to return to their normal routine in a neutral or positive attitude. Towards this end the emotional involvement in the group usually peaks during the enactment stage and plateaus during the affirmation stage.

This is different than other models of group therapy where action methods are used. There is what is known as the” Hollander Curve”. The Hollander Curve has a bell-shaped format that has a “warm-up” stage as the firsthand of the curve; the enactment stage as the highest peak of intensity and emotional involvement; then finally the “sharing” stage which happens during the final stage of the session and is indicated by the downward slope of the right side of the bell-shaped curve. Additionally there is a spiral format, which has a funnel-shaped form to it. This model identifies the intensity of the session located in the center core of the funnel. The beginning of the session is on the perimeter then the session moves to the center core. Finally after the core of the session has been reached you bring the group back to the perimeter. These models are helpful in understanding group dynamics. The necessary modification for the IBT model is that as facilitators we must be mindful of the fact that the groups may stir emotions, which may not be expressed in this population. As such you want to assure that you are providing an opportunity for each member to “decompress” from the group experience if need be. In these matters it is always better to err on the side of being too cautious. If you suspect that someone is having leftover feeling from the group, be certain to help them connect to an individual counselor, a staff person or teacher who can be helpful. Of course, you also may provide some counseling for them yourself.

The IBT model provides a structure for group work for people with dual diagnosis. Modification of established methods from psychodrama and sociodrama combine with standard theory and practice of group psychotherapy to create a supportive therapeutic atmosphere.

References

Blatner, A.(1996). Acting-In. New York: Springer Publishing.

Blatner, A. & Blatner, A. (1988). Foundations of psychodrama history, theory, & practice. New York: Springer Publishing.

Bloch, S. & Crouch, E. (1985). Therapeutic Factors in Group Psychotherapy. New York: Oxford University Press.

Browning, P. L. & Keesey M. (1974). Outcome Studies on counseling with the retarded: A methodological critique. In P. L. Browning (Ed.), Mental Retardation (pp. 306-317). Springfield, IL: Charles C. Thomas.

Buchanan, D. R. & Dubbs-Siroka, J. (1980). Psychodramatic treatment for psychiatric patients. Journal of the National Association of Private Psychiatric Hospitals, 11, 27-31.

Buchanan, D. R. (1984). Program analysis of a centralized psychotherapy service in a large mental hospital. Journal of Group Psychotherapy, Psychodrama & Sociometry, 37, 32-40.

Cox, M., Taplin, O., Berry, C., Roine, E., Meyer, M. A., Hewish, S., & Saunders, J. (1992). Drama in custodial settings. In M. Cox (Ed.), Shakespeare comes to Broadmoor: “The actors are come hither”: The performance of tragedy in a secure psychiatric hospital. London: Jessica Kingsley.

Daniels, L. (1998). Cognitive-behavioral and process oriented approach to treating the social impairment and negative symptoms associated with chronic mental Illness. J ournal of Psychotherapy Research and Practice, 7, 167-176.

Fletcher, R. (1984). Group therapy with mentally retarded persons with emotional disorders. Psychiatric Aspects of Mental Retard Review, 3, 21-24.

Hingsburger, D. (1987). Sex counseling with the developmentally handicapped:The assessment and management of seven critical problems. PsychiatricAspects of Mental Retardation Reviews, 6, 41-46.

Hurley, A. D. (1989). Individual psychotherapy with mentally retarded individuals: A review and call for research. Research in Developmental Disabilities, 10,261-275.

Hurley, A. D. & Hurley, F. J. (1986). Counseling and psychotherapy with mentally retarded clients: I. The initial interview. Psychiatric Aspects of Mental Retardation Reviews, 5, 22-26.

Hurley, A. D. & Hurley, F. J. (1988). Counseling and psychotherapy with mentally retarded clients: II. Establishing a relationship. Psychiatric Aspects of Mental Retardation Reviews, 6, 15-20.

Hurley, A., Pfadt, A., Tomasulo, D., & Gardner, W. (1996). Counseling and psychotherapy. In J. Jacobson & J. Mulick (Eds.), Manual of diagnosis and professional practice in mental retardation. Washington, D. C.: American Psychological Association.

Marineau, R.(1989). Jacob Levy Moreno 1889 - 1974 Father of Psychodrama, Sociometry and Group Psychotherapy. New York: Tavistock Routledge.

Matson, J. L. (1985). Biosocial theory of psychopathology: A three factor model. Applied Research in Mental Retardation, 6, 199-227.

Nezu, C. M., Nezu, A. M., & Gill-Weiss, M. J. (1992). Psychopathology in persons with mental retardation: Clinical guidelines for assessment and treatment. Champaign, IL: Research Press.

Pfadt, A. (1991). Group psychotherapy with mentally retarded adults: Issues related to design, implementation and evaluation. Research in Developmental Disabilities, 12, 261-285.

Razza, N. & Tomasulo, D. (1996a). The sexual abuse continuum: Therapeutic interventions with individuals with mental retardation. Habilitative Mental Healthcare Newsletter, 15, 19-22.

Razza, N. & Tomasulo, D. (1996b). The sexual abuse continuum: Part 2. Therapeutic interventions with individuals with mental retardation. Habilitative Mental Healthcare Newsletter, 15, 84-86.

Razza, N. & Tomasulo, D. (1996c). The sexual abuse continuum: Part 3. Therapeutic interventions with individuals with mental retardation. Habilitative Mental Healthcare Newsletter, 15, 116-119.

Schramski, T. (1984). Role playing as a therapeutic approach with the mentally retarded. Psychiatric Aspects of Mental Retardation Review, 3, 26-32.

Spencer, P. G., Gillespie, C. R., & Ekisa, E. G. (1983). A controlled comparison of the effects of social skills training and remedial drama on the conversational skills of chronic schizophrenic inpatients. British Journal of Psychiatry, 143, 165-172.

Starr, A. & Weisz, H. S. (1989). Psychodramatic techniques in the brief treatment of inpatient groups. Individual Psychology: Journal of Adlerian Theory, Research & Practice, 45, 143-147.

Steinberg, P. & Garcia, A. (1989). Sociodrama: Who’s in Your Shoes?. New York: Praeger Publishers.

Tomasulo, D. (1992). Interactive-behavioral group counseling for people with mild to moderate mental retardation (Two videos). New York: YAI National Institute for People with Developmental Disabilities

Tomasulo, D. (1994). Action techniques in group counseling: The double. Habilitative Mental Healthcare Newsletter, 13, 41-45.

Tomasulo, D., Keller, E., & Pfadt, A. (1995). The Healing Crowd. Habilitative Mental Healthcare Newsletter, 14, 43-50.

Yalom, I. (1995). Group Psychotherapy (4th edition). New York: Basic Books.

For further information:

Daniel J. Tomasulo, Ph.D.
723 North Beers St., Suite 2B
Holmdel, NJ. 07733
732-264-9501; e-mail tomasulo@worldnet.att.net.

(Note: This excerpt is from Dr. Tomasulo’s book, Action Methods in Group Psychotherapy: Practical Aspects (1998). Philadelphia: Accelerated Development, and is reprinted with permission from the publisher.)