People with intellectual disabilities (ID) were in the past believed unlikely to benefit from psychotherapy. Mental health and disabilities professionals now recognize this to be a misunderstanding of the capabilities of people with cognitive disabilities to gain skills and reduce symptoms of emotional disorders through therapy.
Contributing to this misunderstanding was “diagnostic overshadowing”, the belief that behavioral and emotional challenges resulted directly from a person’s cognitive impairment. Diagnostic overshadowing caused professionals to miss symptoms of anxiety, depression, PTSD and other mental health disorders. Instead of recognizing the same symptoms observed in people without ID, problems that can be diagnosed and effectively treated were “overshadowed” by the presence of intellectual disability.
As researchers studied the mental health needs of persons with ID, the rates of mental disorders such as anxiety and depression were described through epidemiological studies. Risk factors for mental disorders in people with ID were identified including genetic, medical/biological, and environmental factors.
According to the National Association for Dual Diagnosis (NADD), estimates vary considerably of a person with ID experiencing a co-occurring mental health disorder. Many professional believe the rate to be about thirty to thirty-five percent. Researchers have also documented the lifetime risks of adverse events for persons with ID including abuse experiences and the effects of social stigma, reduced opportunities and marginalization.
Establishing the co-occurrence of mental health disorders in individuals with ID has led to more specific treatment approaches. The American Association for Intellectual and Developmental Disabilities (AAIDD) and NADD promote effective treatment through research, advocacy and training. Increased understanding of genetic syndromes associated with ID have added to our understanding of dual diagnosis and treatment. Progress in psychotherapy research and practice has occurred in tandem with important contributions of applied behavior analysis toward increasing of skills and reducing problem behaviors.
Effective mental health services for people with ID requires specialized skills and understanding of psychological, biological, and social-cultural dimensions of intellectual and developmental disorders. NADD identifies five areas of competency that clinicians seeking to work with ID clients can develop, including assessment, psychotherapy, positive behavior supports and effective environments, assessment of medical conditions, and psychopharmacology. NADD offers a clinical certification program for clinicians who wish to identify and demonstrate competency in these core areas.
Dr. Robert Morasky, in a 2007 article published in the NADD Bulletin (Vol. 10, No. 3), presents examples of modifications to make psychotherapy effective for people with ID. Dr. Morasky asks clinicians to look at what makes an activity like psychotherapy intellectually difficult. He suggests changes to traditional therapy when working with ID clients to account for differences in memory, ability to reason and generalize, problem solve, plan and make decisions. Therapists can increase effectiveness by adjusting the pace of therapy and the number of ideas or themes addressed, use basic rather than abstract concepts, and reduce complexity. Collaboration with family members and residential or day program caregivers enables practicing of skills learned in therapy in natural and familiar settings.
With appropriate modifications, psychotherapy for people with ID is helpful and empowering for clients. An excellent source book for clinicians, Psychotherapy for Individuals with Intellectual Disabilities, edited by Dr. Robert Fletcher (2011), is available from NADD Press. This volume includes discussions of adapting Dialectical Behavior Therapy by Drs. Margaret Charlton, Eric J. Dykstra and Marvin Lew. Dr. Theodosia Paclawskyj describes modifications to Behavioral Relaxation Training. Drs. Daniel J. Baker and E. Richard Blumberg illustrate adaptations to Positive Psychology approaches, including how ten practical techniques from Positive Therapy can be applied to people with ID.
Many additional resources and publications offer guidance on best practices for therapy with ID clients. Places to start include websites for NADD (www.thenadd.org) and AAIDD (www.aaidd.org). For additional resources or information, feel free to contact me.
Jerrold C. Edelberg, PhD, NADD-CC
(207) 773-7993 ext. 20