Steven Altabet, Ph.D.
The TEAM Centers Inc.
This paper was inspired by a personal shift in perception as much as the development of specific therapeutic techniques. In fact, many of the therapeutic techniques that will be discussed here were a product of graduate training. I was trained in Cognitive-Behavior Therapy and spent much of my internship and other practical experience administering techniques such as Rational Emotive Therapy (Ellis, 1973), as well as other Behavior Therapy techniques including Systematic Desensitization (Wolpe, 1969), and Progressive Muscle Relaxation (Jacobson, 1939) to people without significant cognitive impairment. The techniques were pretty straight forward and I did not have to deviate much from the standard procedures to have the desired effect on the people whom I saw. Then came graduation, and with it the time to find a 'real job.' In searching for opportunities to begin my professional career I found more opportunities to work with individuals with special needs than those without cognitive impairment. Therefore, I decided to go where there was market place demand.
My first job after graduation was at a center for children with cerebral palsy. After getting married I moved to Tennessee and got a job in a developmental center. I had learned some behavior analysis techniques while in undergraduate training and was able to develop those techniques well enough to perform adequately in these positions. Still, I felt that there was something missing. For one thing, I spent the better part of seven years learning a completely different set of therapeutic techniques that were not being used, but most importantly, I realized that while the behavior analysis techniques were effective in controlling the problem behaviors I was being asked to reduce, the responsibility for improvement fell primarily on the support staff. With the individual having little responsibility for his/her own emotional well being, they seemed to show little self satisfaction when there was behavioral improvement. In addition, the treatment focused solely on behavior change without addressing the emotions associated with the behavior. This is when that shift in perception took place.
People with cognitive impairment experience emotions, just like those without cognitive impairment, but the psychological treatment we provide for them does not address emotional functioning. This needed to change. The remainder of this paper focuses on that attempt.
Adaptation of Cognitive-Behavioral and Behavior Therapy Techniques
An article in the January/February 2005 edition of the NADD bulletin indicated that psychotherapy interventions were underutilized in people with Intellectual Disability and were deemed "moderately effective" in helping with mental health issues (Prout, 2005). I believe that psychotherapy can be just as effective for people with cognitive impairment (e.g. autism, intellectual disability, etc.) as they are for the general population if it is broken down to a level that is consistent with their cognitive abilities. Prout and Strohmer (1994) indicated that individuals who are most likely to benefit from direct psychotherapy services have a minimum of a 6-7-year-old cognitive level. That would translate to an adult or older adolescent with mild to moderate mental retardation. While they also mentioned that individuals functioning below this cognitive level are not likely to benefit from direct therapeutic intervention, my experience leads me to believe that these individuals can benefit from a more indirect form of intervention. The following section describes the methods that I use in teaching individuals with cognitive impairment how to gain awareness of their emotional responses and how to control or change a negative emotional state.
Recognition of emotional states is an important aspect for learning coping skills. Even though individuals with cognitive impairment may have difficulty accurately labeling different emotional states, they do not show any difference from people without cognitive impairment when it comes to discriminating between pleasant and unpleasant emotions (Owen, Browning, & Jones, 2001). Early sessions focus on teaching individuals to recognize four basic emotional states (happiness, sadness, anger, and fear). This recognition is done through the teaching of physical symptoms associated with these physical states (e.g. changes in heart rate, breathing, muscle tension, etc.), as well as personal situations that are frequently associated with the different emotions. This is usually done through demonstrations, discussion, exercises, games, visual aids, imitation, music, using a mirror, and even biofeedback if applicable. For those with more severe cognitive impairment caregivers are taught to recognize signs of emotional distress in the people they assist, as well as situations that may cause them distress. While there are general physical signs of distress, people are taught to recognize the specific physical signs that apply to their personal mood states. More cognitively aware individuals may be taught how to recognize certain cognitive statements or situations, people and activities that correlate with different emotional states.
Following emotional recognition, a series of coping skills are taught to help them learn to calm themselves and make appropriate choices. Different relaxation exercises are reviewed including deep breathing, muscle tension and relaxation and visual imagery. In addition everyday activities which the person finds relaxing are explored as a way to supplement the relaxation exercises. For more impaired individuals a relaxation assessment is done with the person and caregiver to help determine what relaxation techniques and activities can be provided for them.
Once calming techniques have been mastered (the person can correctly perform the relaxation procedures upon request without modeling or correction), then other cognitive-behavioral techniques are also explored to help the person learn to cope with an upsetting situation. Depending on the level of cognitive functioning, these techniques may include assertiveness and problem solving. For people with cognitive impairment these techniques need to be broken down to there most basic elements in order for them to be understood and utilized effectively. For example, with assertiveness the key concepts are to talk about your feelings ("I feel <emotion> when you <action>"), to say 'no' in a respectful way (e.g. No thank you or Can I do something else?), and to ask for help when you need it). Problem solving involves thinking of multiple ways to remedy a situation and thinking of the potential consequences before one acts. These techniques are practiced frequently through demonstration, role play, and games until the person can begin to use these techniques without much prompting. In most cases the people I have worked with continued to need some prompting with these techniques so they are explained to the caregiver so they can prompt and reinforce the use of these outside of sessions. For those with more severe cognitive impairment the care giver will need to do this type of thinking for them, although alternative ways of communication can be developed to help the person express their needs and preferences.
Toward the end of the treatment period, the person and caregiver are given a series of cue words to help them remember what they have learned and prompt them to use the techniques. The general cue words are easy to recognize and remember (e.g. Stop, Relax, Think), but more personally significant cue words are developed as needed. It has been demonstrated previously that even individuals with severe intellectual disability are able to respond to cue words during relaxation training (Lindsay, Fee, Michie, & Heap, 1994). These techniques can be used on their own, but are often most effective when included as part of a comprehensive behavior and mental health support plan.
Summary and Conclusions
In summary, the main notion of this paper is that traditional behavior therapy techniques can be used for people with cognitive impairment if the techniques are broken down to a level consistent with that person's understanding level. While I have not been doing this long enough to produce substantial behavior data, analysis of specific cases have shown a reduction in aggressive and destructive behaviors when the techniques are used consistently. Regular practice of calming and coping techniques is important for their use during times of need. Regular practice (when the person is calm) will help increase familiarity for the person and the caregiver, and will make it easier to prompt and implement when the person needs calming. One thing that needs to be stressed is that these are most effective when used during periods of mild to moderate agitation. Once the person is severely agitated, other behavior management techniques will be needed to ensure the person's safety so early recognition of distress is very important in using these techniques.
I look forward to collecting some hard behavioral data and eventually publishing some research on the effectiveness of these techniques with this population. I strongly encourage others to do the same so we can dispel the myth that people with cognitive impairment cannot benefit from psychotherapy or mental health treatment.
Ellis, A. (1973). Humanistic psychotherapy: The rational emotive approach. New York: McGraw-Hill.
Jacobson, E. (1939). Progressive relaxation. Chicago: University of Chicago Press.
Lindsay, W. R., Fee, M., Michie, A., & Heap, I. (1994). The effects of cue control relaxation on adults with severe mental retardation. Research in Developmental Disabilities, 15, 425-437.
Owen, A., Browning, M., & Jones, R. S. P. (2001). Emotion recognition in adults with mild-moderate learning disabilities: An exploratory study. Journal of Learning Disabilities, 5, 267-281.
Prout, H. T. (2005). Dual diagnosis in children and adolescents: Issues and opportunities. The NADD Bulletin, 8, 3-7.
Prout, H. T. & Strohmer, D. C. (1994). Issues in counseling and therapy. In D. C. Strohmer & H. T. Prout (Eds.), Counseling and psychotherapy with persons with mental retardation and borderline intelligence (pp.1-19). Brandon, VT: Clinical Psychology Publishing Co.
Wolpe, J. (1969). The practice of behavior therapy. New York: Pergamon Press.