Welcome to Edition 228 of Institute Inbrief! In this edition’s featured article we review the use of positive interactive-behaviour therapy – a newer format for therapy which has produced positive outcomes for clients with intellectual disability.
Also in this edition:
- Latest news and updates
- Articles and CPD information
- Wellness tips
- Therapist Q&A
- Social media review
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Positive Interactive-behaviour Therapy for Intellectual Disability
Given that an estimated 60 percent of persons who have intellectual disability also experience severe communication deficits (AIHW, 2008), the literature on counselling this client group consistently refers to the importance of using “creative approaches” (WWILD, 2012, p 60) which allow the client to respond in both verbal and nonverbal ways. Thus, in addition to “talk therapy”, practitioners should consider employing drawing, music, puppetry, drama, and psychodrama.
In this article, we review the use of positive interactive-behaviour therapy – a newer format for therapy which has produced positive outcomes for clients with intellectual disability.
How the therapy works
This newer format for therapy comes highly recommended as a form of group therapy, especially for the over-half (57 percent) of the population with intellectual disability which is also diagnosed as having some form of psychiatric disability (AIHW, 2008). Positive interactive-behaviour therapy combines two approaches:
Positive psychotherapy (PPT), a strengths-based approach that offers a more comprehensive perspective of a client and their life circumstances. Because psychotherapy traditionally focused on symptoms, it was considered to be successful if the symptoms reduced. PPT, conversely, is becoming known as an evidence-based form of therapy that explores both strengths and weaknesses to achieve greater well-being and functioning. Instead of looking at what is “wrong”, it focuses on what is “strong”.
Interactive behaviour therapy (IBT), the most widely used form of group psychotherapy for people with intellectual and chronic psychiatric disabilities. It uses modified techniques from other psychotherapeutic approaches and has been evolving for about 25 years. Its theoretical underpinnings as well as some of its techniques originated with J.L. Moreno’s psychodrama, and it also incorporates the therapeutic factors of Irvin Yalom, as well as Martin Seligman and others (Tomasulo, 2013).
Positive interactive-behaviour therapy combines the two, through modifications of the typical psychodrama session, which has three stages: (1) warm-up; (2) enactment, and (3) sharing. Normally, the first stage would prepare group members for interactive role-playing. The second stage would see the enactment happen, and the third stage would be used for reflection on the role play. The cognitive limitations of people with intellectual disability made this format unworkable, so positive interactive behaviour therapy developed a four-stage model: (1) orientation; (2) warm-up and sharing; (3) encounter; and (4) affirmation (Tomasulo, 2013).
Looking more closely at the four stages, we can see that the orientation stage helps clients with intellectual and/or psychiatric disability gain the skills needed to participate successfully in a group; in addition to not always observing conversational rules, some people with intellectual disability also have visual and auditory problems.
In the warm-up and sharing stage, group members deepen their level of disclosure and choose a protagonist. In the enactment stage, the emotional engagement of the members is increased; typically it is here that role-playing and deep action methods are employed as primary means through which therapeutic factors are activated. A central stage, this third one employs modifications from psychodrama (drawn from individuals’ concerns) and sociodrama (mirroring collective concerns). This stage used to be used mostly for role (social skills) training, but with the development of IBT, has come to be used to facilitate therapeutic interventions.
The affirmation stage helps people with intellectual disability who, because of difficulty with abstract thinking, are unable to see analogies of group work to their own lives. Here the facilitators reinforce any therapeutic factors they see emerging and encourage members to give affirmation to each other as well. This has the added dimension of increasing group members’ status and value in each other’s eyes. As members become more interested in one another, they are more prone to spontaneously experience the universality that leads to increased support for other members (Tomasulo, 2013).
What the research says
People diagnosed with both intellectual and psychiatric disability were traditionally thought not to be able to profit from insight-oriented group therapy, but now research evidence is accumulating to show that they can benefit. Those with intellectual disability have long experienced “diagnostic overshadowing” (Reiss, Levitan, & Szyszko, 1982), in which any symptomatology (meaning, here: clinically significant symptoms) tended to be attributed wrongly to behavioural components of the cognitive deficit rather than any psychological condition. Over the last several decades, however, the IBT model has been investigated and some promising results are emerging.
In Blaine’s (1993) research testing the efficacy of an IBT group, both participants with intellectual disability and participants without it were treated over 17 sessions. Both groups showed significant positive change from the therapy, but the subjects with intellectual disabilities showed higher frequencies of most therapeutic factors. Similarly, Keller (1993) found the IBT format facilitated the rise in therapeutic factors. The IBT model has also shown to be effective in a study examining subjects with chronic mental illness (Daniels, 1998).
In another study, IBT was compared with behaviour modification techniques. The group exposed to IBT showed greater reduction in target behaviours, increased problem-solving skills, and earlier return to the community (Oliver-Brannon, 2000).
How to best use this therapy with clients who have intellectual disability
Tomasulo notes that the IBT method has been taught to “thousands of human service and mental health personnel via direct trainings and videotaped instruction” (Tomasulo, 2013), and was the focus of the APA’s first book on psychotherapy for people with intellectual disabilities (Razza & Tomasulo, 2005). As the need for psychological services for those with intellectual disability becomes increasingly accepted, there will be more publications like the DM-ID (Diagnostic Manual – Intellectual Disabilities) and the accompanying clinical guide to help clinicians reach an accurate diagnosis (Fletcher, Loschen, Stavrakaki, & First, 2007).
In June of 2013, the first certificate program in IBT was offered at Brock University in Ontario, Canada to help mental health practitioners work with people with intellectual and psychiatric disabilities (Tomasulo, 2013). These steps creating training and information for mental health practitioners will help to increase awareness of these client groups and their mental health needs and should ease the reluctance of such professionals to work with them.
Positive interactive behaviour therapy is arguably the already-enhanced therapy, as it combines elements of two therapies and has been customised for clients with intellectual disability.
AIHW (Australian Institute of Health and Welfare). (2008). Disability in Australia: Intellectual disability. AIHW Bulletin No. 67. Cat No. AUS 110. Canberra: AIHW. Retrieved on 8 December, 2013, from: hyperlink.
Daniels, L. (1998). A group cognitive–behavioral and process-oriented approach to treating the social impairment and negative symptoms associated with chronic mental illness. Journal of Psychotherapy Research and Practice, 7, 167–176.
Fletcher, R., Loschen, E. Stavrakaki, C., & First, M. (Eds.) (2007). Diagnostic Manual-Intellectual Disability (DM-ID): A Clinical Guide for Diagnosis of Mental Disorders in Persons with Intellectual Disability. Kingston, NY: NADD Press.
Razza, N. & Tomasulo, D (2005) Healing Trauma: The Power of Group Treatment for People with Intellectual Disabilities Washington, D.C., American Psychological Association.
Reiss, S., Levitan, G., & Szyszko, J. (1982). Emotional disturbance and mental retardation: Diagnostic overshadowing. American Journal of Mental Deficiency, 86, 567-574.
Tomasulo, D.J. (2013). The healing crowd: All about group therapy: what it is, why it works, and which group is right for you. Psychology Today. Retrieved on 1 January, 2014, from: hyperlink.
WWILD. (2012). How to hear me: A resource kit for counsellors and other professionals working with people with intellectual disabilities. WWILD Sexual Violence Prevention Association Inc: Disability Training Program. Department of Justice and Attorney General Building Capacity for Victims of Crime Services Funding Program. Retrieved on 3 December, 2013, from: hyperlink.
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How to close the expectation gap
The ‘happiness industry’ of books, therapy, courses, and conferences – often sold as ‘self-improvement’ resources – comprises $10 billion per year in the United States alone. Many of those who bought a book on how to be happy this year also purchased one last year. If the advice we’re getting is so sound, why can’t we get what we need and go away happy the first time? What’s getting in the way?
The expectation gap
This article looks at “the expectation gap”: the often unconscious expectations that most of us carry about what we might be, have, or do which are in excess of what everyday reality can deliver. These expectations cannot all be met, and the width of the gap is the measure of our unhappiness. We look at three aspects: imagining, comparing, and remembering.
1. Imagining: the ‘could be’ gap. Creating this gap with our human ability to visualise, we experience our imaginings as greater than reality. We have a comfortable home, but imagine the mansion we’d like. We have a decent relationship, but fantasise about that perfect romance with the beautiful, adoring stranger. We have a solid career, but find ourselves thinking that we’d be happy if only we could make it to the upper rungs of management, and so on.
2. Comparing: the interpersonal gap. With this, we experience that our situation is never as good as others’. Look at the Smiths. They don’t just have the new house like we do; they also have a recreational vehicle, membership at a prestigious golf club, and an international holiday every year. Or we cast a covetous glance at Jane, who really seems to have it all together: interesting work, a lovely family, and she still finds time to exercise regularly and volunteer for the local charity. We moan; “What’s wrong with me? Why am I not able to do all that?”
3. Remembering: the inter-temporal gap. Opposite to imagining, we remember what we did have before in the ‘good old days’. “Life was easier as a student”, we say, forgetting the many all-nighters to get assignments in and constant hunger from being broke. “My old job was more interesting,” forgetting the deplorable work conditions. The problem with remembering is that we do it selectively, expecting life to be rewarding in the same ways that it used to be, regardless of how bad the rest of life was then, and making ourselves unhappy when it is not.
How to take action: letting go of the expectations
What to do? An internet search into happiness and expectations yields advice to surrender expectations in order to gain happiness. Research shows that lowered expectations (in the sense of entitlements, not in the sense of standards we set for ourselves) means greater happiness, and that what we focus on grows. What does that mean? Current thinking reflects both scientifically-based studies as well as spiritually-based reflections. The confluence of those two yields a few widely-held (but not always easy-to-follow) pieces of advice.
For Gap 1: gratitude and generosity. You want more in your life? Focus with gratitude on what you do have, so that you are attractive to greater good flowing to you. Along these lines, generosity (in the form of service and philanthropy) are reliably proven to increase happiness. Let go of negative thoughts about what could be; grateful altruism is a winner.
For Gap 2: no comparisons and treasure your connections. The positive psychology folk are clear that comparisons with others are problematic if we choose our reference group unwisely. That is, we make ourselves unhappy by expecting to be as well off as some group with whom any comparison is unfair to ourselves. Even better, let go of comparing and cherish your interpersonal connections. It is our quality relationships with others and the social support we derive from (and contribute to) them that ultimately make us the happiest. We best appreciate what we have when we do not expect to have what some (presumably better off) person has.
For Gap 3: be optimistic, and enjoy the present moment with compassion. Happiness researcher Ed Diener notes that happy people see possibilities, opportunities, and success. They see the future with optimism and find the positive aspects of the current situation. Letting go now of expectations to recreate past conditions ushers in the means to savour the present moment fully, and to view others with compassion.
We can’t solve the endemic problem of discontent in this little article, but what we can do is reflect on whether we really need to maintain the illusory controls, seen in our many rigid expectations for life, that guarantee our unhappiness
Written by Dr Meg Carbonatto B.S., M.A., and Ph.D.
This article was originally published in Asteron Life’s Balance Blog. AIPC regularly contributes to Balance’s wellbeing blog category.
A Case Using Brief Psychodynamic Therapy
Wendy is a 54 year old woman who has two adult children and has been married for twenty-nine years. Her husband, Steve, has recently and unexpectedly informed her that he no longer loves her and that he wants a divorce. Wendy was shocked to hear this, and she now reports that she is constantly crying and feels extremely anxious. Wendy has not told anyone about this situation, although she and Steve have agreed to explain his decision to their children within the week. In this scenario, the counsellor will be using a brief psychodynamic approach.
Behaviour and Solution Focused Couple Therapy
The practice of couple therapy has been encouraged to incorporate a more scientific model of practice and the use of research to inform the style of therapy most appropriate to use (Whiting & Crane, 2003). As a result, the discipline of couple and family counselling is moving to an evidence based focus. A number of theoretical frameworks have attempted to conceptualise dyadic relationships. Some of these theories have become foundations for the interventions that have become common in couple’s therapy today. Some of the models and theories include the strategic model, emotion focused therapy, solution focused therapy, behaviour theory and attachment theory.
Q&A with Toula Gordillo (Clinical Psychologist)
Q. What can we learn from the Indigenous culture about passing on important counselling and psychological information?
A. The Australian Aboriginal and Torres Strait Islander communities can teach non-Indigenous individuals a lot about passing on important information to younger generations... if we care to listen. What is the one thing that all ages, cultures, communities, genders, socio-economic groups have in common? We all relate to stories and images. They are universal, non-culturally specific and can be used to deliver important historical, social/cultural and psychological information in the same way as Indigenous oral traditions passed on important ecological information for thousands of years. Non-threatening, yet still very powerful, stories and images can be used to deliver cognitive behaviour therapeutic principles, and other evidence-based information, as part of Story Image Therapy & Tools (SITT)™. This form of therapy utilises modified Dreamtime stories, among other modern and historical stories, to deliver important psychological skills and strategies through Story Image Tools (SIT-2). (For more information, see www.talktoteens.com.au).
Non-confrontational stories and images allow the young person to develop insight, creating opportunities for catharsis and internalisation of psychological messages. As in the Indigenous culture, individuals can learn through identification with the characters in the story, thereby depersonalising a situation and enabling an opportunity for cognitive reframing in the hands of a skilled therapist or counsellor. Specific tools, such as stories, 3D objects, posters etc. can be used to accompany the story to further reinforce the message.
Science is beginning to support the effectiveness and longevity of Indigenous oral traditions, particularly in relation to the Australian coastline. It may well be the same for psychological information that needs to be effective in helping to create sustainable changes in past and future generations. Best of all, stories and images can be delivered via oral, written or digital traditions - making them current and relevant to present generations. Counselling and psychological information can be delivered via Indigenous stories, enabling Indigenous and non-Indigenous clients to learn more about the Indigenous culture through the stories and information.
Science and narrative are complementary methods of obtaining and delivering information, a combination that the Indigenous culture has learned well. It is incumbent upon all therapists and counsellors, Indigenous or non-Indigenous, to ride the twin horses of richness (obtained through stories) and rigour (obtained through the science). Oral, written and digital traditions can send important messages to our children, youth and adults in all cultures. Stories and the subsequent images that are created in a person’s mind, can be incredibly powerful ways of creating behavioural change or delivering important information. Our Indigenous community understand the benefit of stories and images, and have done since the Dreamtime. The culture is built around stories and images and all individuals, Indigenous and non-Indigenous, could learn from this.
Toula Gordillo is a Clinical Psychologist, AIPC private assessor/tutor and regular contributor for Institute Inbrief. Toula has an extensive work history as a Clinical Psychologist, Teacher, and Guidance Officer. For more information, visit www.talktoteens.com.au.
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Have you visited Counselling Connection yet? There are over 650 interesting posts including case studies, profiles, success stories, videos and much more. Make sure you too get connected (and thank you for those who have already submitted comments and suggestions).
Stress-free Health Management: A Natural Solution for Your Health
When faced with reviewing books relating to stress management and natural therapies there can be some degree of scepticism involved as many texts tend to tout the adage that their way is the only way to health and well-being. Stress-free health management: A natural solution to your health by Jenetta Haim does not fit this mould.
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"It seems to be important to believe people to be good even if they tend to be bad, because your own joy and happiness in life is increased that way, and the pleasures of the belief outweigh the occasional disappointments."
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