Dan J. Tomasulo PhD., MFA, MAPP

The Healing Crowd

Positive Interactive-Behavioral Therapy (P-IBT)

Group Psychotherapy For People With Intellectual And Psychiatric Disabilities

Posted Aug 26, 2013

People with intellectual and psychiatric disabilities have typically been thought not to profit from insight oriented group therapy.  But there is mounting evidence to show that not only can people with these concomitant disorders find help through group therapy, they can actually flourish.  In other research that is emerging Positive Psychotherapy (PPT) is a strengths-based approach that is directly aimed at offering a more comprehensive perspective of a client and their life circumstances.  It is becoming known as an evidence-based standpoint that explores both strengths and weaknesses to achieve greater well-being and functioning.  In recent years techniques from PPT have been employed within the IBT format resulting in a treatment approach that is both easy for facilitators to learn --and effective.

Interactive-Behavioral Therapy (IBT) is the most widely used form of group psychotherapy for people with intellectual and chronic psychiatric disabilities. It uses a modification of theory and technique borrowed from other models in group psychotherapy and has evolved over the past twenty five years through work with individuals who are diagnosed with both intellectual disabilities (ID, the current preferred term for people diagnosed with mental retardation) and psychological disorders.  The model’s theoretical underpinnings, as well as many of its techniques, are drawn directly from psychodrama as originated by J. L. Moreno. As well as the work on therapeutic factors of Irvin Yalom, and the pioneering work of Martin Seligman, Chris Peterson, Tayyab Rashid, and Angela Duckworth.

The IBT Model – Modifications

A typical psychodrama session has three stages: (1) warm-up, (2) enactment, and (3) sharing. The three stages allow for group members to prepare for interactive role-playing, take part in an enactment of the issue being explored, and then reflect on the process just experienced. Due to the cognitive limitation of people with intellectual disabilities the traditional stages were unworkable, and a four-stage format was developed.  The four stages are: (1) orientation, (2) warm-up and sharing, (3) encounter, and (4) affirmation.

Stages

The Orientation Stage, helps people with cognitive impairment develop skills needed for successful group participation. Many people with intellectual disabilities are unfortunately accustomed to people not listening to them and will continue to talk whether others are listening or not.  They are also individuals who often struggle with secondary audiological and visual disabilities.

The Warm-up and Sharing Stage, invites members to deepen their level of disclosure and choose a protagonist. The warm-up and sharing stages from traditional psychodrama were combined into this second stage because the typical types of sharing in non-intellectually able adults were not possible with people with intellectual disabilities.  This stage, warm-up and sharing, allows for a shift from horizontal self-disclosure (typically person to person, but with little emotional content) to vertical self-disclosure (a more personal divulgence with more emotionally laden material).

The Enactment Stage, in which traditional psychodramatic techniques increase emotional engagement of the members (Hurley et al., 1996).  It is during this stage that role-playing and deep action methods are employed as primary means through which therapeutic factors (discussed below) are likely to be activated.Thisstage is the central feature of the IBT model, and techniques employed are modifications derived from psychodrama (reflecting issues unique to an individual's life) and sociodrama (issues which reflect a collective concern.) Prior to the development of the IBT, 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 facilitating therapeutic interactions.

The Affirmation Stage was designed to help members with intellectual disabilities who have difficulty with abstract thinking and cannot always relate analogous experiences from their own lives. The facilitators provide direct reinforcement for the emergence of any therapeutic factor displayed during the group that foster participation, and encourage members to provide affirmations to each other as well. This further encourages members to attend to each other and increases each member’s value in the eyes of his or her peers. Members take increasing interest in each other as a result and are more given to offer spontaneous support and to experience a healing sense of universality.

Empirical Validation

            The IBT model has been investigated over the past 20 years with some promising results.  Blaine (1993) tested the efficacy of an IBT group treating both intellectually disabled and non-disabled participants over 17 sessions.  Using a number of measures, she concluded that both types of patients showed significant positive change from the therapy, and interestingly, those subjects with intellectual disabilities demonstrated higher frequencies of most therapeutic factors (as identified by Yalom, 1995; Tomasulo, 1998; Yalom and Molyn Leszcz, 2005; and Razza & Tomasulo, 2005. In addition, each patient set goals for himself, and then evaluated himself with regard to how successful he felt he had been.  The final evaluations suggested that patients’ achievements of their interpersonal goals in therapy exceeded their expectations.  For an article on an updated review of the current research findings click here.

            Keller (1993) also found that IBT encouraged the emergence of therapeutic factors. The IBT model has also been found to be effective with another chronic population:  people with chronic mental illness.  Daniels (1998) tested the IBT model with a group of chronically mentally ill adults who carried diagnoses of schizophrenia or schizoaffective disorder.  Multiple clinical rating scales were administered to measure changes in social functioning and negative symptomatology.  Three hypotheses were tested, and each was supported by the ensuing data.  Specifically, it was found that: 1) IBT increases the overall social competence of people with chronic schizophrenia or schizoaffective disorders; 2) IBT improves the negative symptoms that are often associated with poor treatment outcome for people diagnosed with schizophrenia or schizoaffective disorders; and 3) IBT facilitates the emergence of those therapeutic factors found to enhance social competence in people with chronic schizophrenia and schizoaffective disorders.  Note that both Blaine (1993) and Daniels (1998) did not limit their research to people with intellectual disabilities.  Daniels’ study suggests that the IBT model may provide a viable forum for people with chronic mental illness, whose treatment programs often include group psychotherapy.

            The IBT model was also studied by Carlin (1998), who explored its value in helping individuals with intellectual disabilities cope with bereavement and a study by Oliver-Brannon (2000) compared IBT with behavior modification techniques in treating subjects with dual diagnoses of mental retardation and psychiatric disorders.   The study suffers from small sample size and non-random assignment, but data collection revealed that subjects in the IBT group, compared with the behavior modification controls, evidenced greater reduction in target behaviors, increased problem-solving skills, and earlier return to the community. 

            In a doctoral dissertation Lundrigan (2007), designed a questionnaire based upon Seligman’s 1994 Consumer Reports survey of client satisfaction with mental health services (Seligman, 1995). She administered the survey to 40 IBT clients, all of whom were dually diagnosed. Clients reported feeling helped by their participation in IBT groups, as evidenced by their responses to the questionnaires and in the in-depth clinical interviews in which a percentage of the subjects participated. Of the 40 clients who were surveyed, 34 (85%) felt that they had been helped by therapy.  It is of note that this figure corresponds closely to the 87% satisfaction rate found in Seigman’s Consumer Reports study. Additionally, twenty-one (52.5%) of IBT participants’ felt they had been helped a great deal by therapy. The high degree of satisfaction reported in the questionnaire lends support to the presence of the therapeutic factors in IBT groups identified by Blaine (1993), Daniels (1998), Keller (1993) and Razza & Tomasulo (2005). These therapeutic factors are considered a robust measure of the therapeutic value of a group. Here is where there is a direct fusion of the IBT and PPT models.  The signature strengths that underlie PPT have been aligned and articulated with the therapeutic factors.  In fact many of the original therapeutic factors (e.g., hope, altruism, and interpersonal learning) are nearly verbatim descriptions of some of the character strengths as proposed by Peterson and Seligman,(2004).

Interest in the area of mental health and intellectual disabilities has grown in recent years.  There has been a historical distinction between research and practice in mental health, and research and practice in developmental disabilities, has resulted in a dearth of clinical understanding of people who suffer with both (Fletcher, Loschen, Stavrakaki, & First, 2007a). Studies indicate a great variability in estimates of psychiatric disorders among the developmentally disabled (Caine & Hatton, 1998; Cooper, Smiley, Morrison, Williamson, & Allan, 2007). Estimates of psychiatric disorders vary as much as from 25% to 40%, while some go as high as 80% of this population (Caine & Hatton, 1998). A recent population-based study of over 1,000 people (Cooper et al, 2007), designed to overcome some of the sampling biases and limitations of earlier studies, found that over one-third of people with ID met DSM-IV-TR criteria additional clinical diagnosis.

People with ID have long been subjected to what Reiss referred to as “diagnostic overshadowing” (Reiss, Levitan, & Szyszko, 1982), i.e., “the tendency on the part of professional to attribute symptomatology to the retardation itself.” In other words, clinically significant symptoms have been misunderstood as mere behavioral components of cognitive deficits” (Razza & Tomasulo, 2005).

Tomasulo and Razza have conducted studies on the existence of the therapeutic factors identified by Yalom in the Interactive Behavioral Therapy groups (Razza & Tomasulo, 2005). Yalom’s extensive studies on group therapy identified 11 therapeutic factors (Yalom, 1995).  Tomasulo and Razza examined the presence of these factors along with three additional therapeutic factors at work in the IBT groups. The factors include 1. acceptance and cohesion, 2. universality, 3. altruism, 4. installation of hope, 5. guidance, 6. catharsis, 7. modeling, 8.self-understanding, 9. learning from interpersonal action, 10. self-disclosure, 11. corrective recapitulation of the primary family, 12. existential factors, 13. imparting of information, 14. development of social skills.

            The IBT model has been written about extensively in Mental Health Aspects of Intellectual Disabilities (Razza & Tomasulo, 1996, a, b, & c; Tomasulo, 1994, 1997, 1998; Tomasulo, Keller, & Pfadt, 1995), as well as in edited volumes on intellectual disabilities (Jacobson & Mulick, 1996; Wiener, 1999; Fletcher, 2000).  It is the subject of Action Methods in Group Psychotherapy (Tomasulo, 1998), and as previously mentioned, was the focus of APA’s first book on psychotherapy for people with intellectual disabilities ( Razza & Tomasulo 2005). It has been taught to thousands of human service and mental health personnel via direct trainings and videotaped instruction (Tomasulo, 1990).  It has been recommended as a valuable means of treating adults with intellectual disabilities who are at risk for suicide (Kirchner & Mueth, 2000).

            There is a slow, but growing awareness among mainstream clinicians of the need for psychological services for people with intellectual disabilities.  This has been evidenced by the publication of the DM-ID Diagnostic Manual – Intellectual Disabilities and the accompanying clinical guide (Fletcher et al, 2007).  This two-volume set is published by the National Association for the Dually Diagnosed in conjunction with the American Psychiatric Association in an effort to help clinicians reach an accurate diagnosis within the DSM-IV-TR. The section on Posttraumatic Stress Disorder (Tomasulo & Razza, 2007) was informed by our work with IBT groups, which grounded clinical understanding of how trauma may manifest in people with intellectual disabilities.  People with intellectual disabilities as they remain one of the largest yet most underserved populations (Monday Morning, 2002)  IBT was described in: Healing Trauma:  The Power of Group Treatment for People with Intellectual Disabilities. American Psychological Association’s first book on psychotherapy for people with intellectual disabilities.

            In June, 2013 the first certificate program in IBT was offered at Brock University in Ontario, Canada, to help practitioners work with people with intellectual and psychiatric disabilities.  Others sites and times for certification are being planned.  For more information on the P-IBT model check here.

Further reading:

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

Blaine, C. (1993).  Interpersonal learning in short-term integrated group psychotherapy.  Unpublished master’s thesis:  University of Alberta, Canada.

Carlin, M.  (1998).  Death, bereavement, and grieving:  A group intervention for bereaved individuals with cerebral palsy.  Unpublished doctoral dissertation:  Long Island University, C.W. Post campus.

Cooper, S.A., Smiley, E., Morrison, J., Williamson, A., & Allan, J. (2007).  Mental ill-health in adults with intellectual disabilities: Prevalence and associated factors. British Journal of Psychiatry, 190, 27-35.

Caine, A., & Hatton, C. (1998). Working with people with mental health problems. In E. Emerson, C. Hatton, J. Bromley, & A. Caine (Eds.), Clinical psychology and people with intellectual disabilities (pp. 210–230). Chichester, England: Wiley

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.

Duckworth, A. L., Steen, T. A., & Seligman, M. E. P. (2005). Positive psychology in clinical practice. Annual Review of Clinical Psychology, 1, 629–651

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.

Hurley, A.D.,  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 (pp. 371-378).  Washington, DC: American Psychological Association.

Hurley, A.D., Tomasulo, D., & Pfadt, A.  (1998).  Individual and group psychotherapy approaches for person with mental retardation and developmental disabilities.  Journal of Developmental and Physical Disabilities, 10 (4), 119-123.

Keller, E. (1995).  Process and outcomes in interactive-behavioral groups with adults who have both mental illness and mental retardation.  Unpublished doctoral dissertation:  Long Island University, C.W. Post campus.

Kirchner, L., & Mueth, M. (2000). Suicide in individuals with developmental disabilities. In R. Fletcher (Ed.), Therapy approaches for persons with mental retardation (pp. 127–150). Kingston, NY: NADD Press.

Lundrigan, M. (2007).  Interactive Behavioral Therapy with intellectually disabled persons with psychiatric disorders:  A pragmatic case study.  Unpublished doctoral dissertation:  Graduate School of Applied and Professional Psychology, Rutgers University, New Brunswick, NJ.

Marineau, R. F. (1989).  Jacob Levy Moreno, 1889-1974.  London:  Routledge.

Monday Morning: A newsletter of the New Jersey Developmental Disabilities Council. (2002). Surgeon General releases report on health disparities and mental retardation. Copy Editor, 8(6).

Oliver-Brannon, G. (2000). Counseling and psychotherapy in group treatment with the dually diagnosed (mental retardation and mental illness—MR/MI) (Doctoral dissertation, The Union Institute, 2000). Dissertation Abstracts International, 60(10-B), 5230

Peterson, C., & Seligman, M. E. P. (2004). Character strengths and virtues: A handbook of classification. New York: Oxford University Press.

Rashid, T., & Ostermann, R. F. (2009). Strength-based assessment in clinical practice.Journal of Clinical Psychology, 65, 488–498.

Razza, N., Tomasulo, D (2005) Group Dynamics in the Treatment of People with Intellectual Disabilities: Optimizing Therapeutic Gain Mental Health Aspects of Developmental Disabilities Ment HealthAspects Dev Disabil 2005;8(1):22-28

Razza, N., Tomasulo, D (2005) Healing Trauma: The Power of Group Treatment for People with Intellectual Disabilities Washington, D.C., American Psychological Association

Razza, N. (2008)  Meeting the Needs of People with Intellectual Disabilities. New Jersey Psychologist, Fall 2008

Reiss, S., Levitan, G., & Szyszko, J. (1982). Emotional disturbance and mental retardation: Diagnostic overshadowing. American Journal of Mental Deficiency, 86, 567-574.

Seligman, M., The Effectiveness of Psychotherapy: The Consumer Reports StudyAmerican Psychologist, December 1995, Volume 50, Number 12, pp. 965-974

Seligman MEP, Rashid T, Parks AC (2006). Positive psychotherapy. American Psychologist.2006;61:774–788

Tomasulo, D. (1998) Action methods in group psychotherapy: Practical aspects. Philadelphia:  Taylor & Francis.

Tomasulo, D. (1999a) Getting to Hope: Role-playing in the Treatment of Denial, Resistance and Shame Mental Health Aspects of Developmental Disabilities. Vol. 2, No.4 1-9.

Tomasulo, D. (1999b). Group Therapy for People with Mental Retardation: The Interactive Behavioral Therapy Model. In Wiener, D. Editor. In Beyond Talk Therapy: Using Movement and Expressive Techniques in Clinical Practice. Washington, DC: American Psychological Association.

Tomasulo, D. (2000) Group Psychotherapy for People with Mental Retardation In Fletcher, R (Ed.) Therapy Approaches for Persons with Mental Retardation. (pp. 65-85) Kingston, NY, NADD Press

Tomasulo, D. (2006) Group Psychotherapy for People with Intellectual Disabilities: The Interactive-Behavioral Model Journal of Group Psychotherapy, Psychodrama and Sociometry Vol.59, #2.

Tomasulo, D.,J. and Razza, N.J (2007). Posttraumatic Stress Disorder (2007). In Fletcher, R., Loschen, E., Stavrakaki, C., & First, M. (Eds.). Diagnostic Manual -- Intellectual Disability (DM-ID): A Textbook of Diagnosis of Mental Disorders in Persons with Intellectual Disability. (Chapter 21) Kingston, NY:NADD Press.

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

Yalom, I., Leszcz, M  (2005).  The theory and practice of group psychotherapy (5th ed.). New York:  Basic Books.

 Wilner, P. (2005). The effectiveness of psychotherapeutic interventions for people with learning disabilities: A critical overview. Journal of Intellectual Disability Research, 49(1),73-85.

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