1. Cognitive-Behavioral Therapy for People with Intellectual Disabilities [ID] Valerie Gaus, Ph.D. gaus@optonline.net 631-692-9750

2. CURRENT TREND TOWARD USE OF PSYCHOTHERAPY FOR PEOPLE WITH ID 1990’s - present: Mental health treatment moved toward multi-modal, multi-disciplinary approaches to treatment planning Mental health treatment is taking place in community; growth of outpatient clinics designed to serve people with ID; psychotherapy is included as part of the array of healthcare services offered More authors are writing about psychotherapy approaches for people with ID (e.g., Butz, Bowling & Bliss, 2000; Lynch, 2000, 2004; Prout & Strohmer, 1994)

3. COMMON TRIGGERS FOR REFERRAL TO MENTAL HEALTH TREATMENT exposure to a traumatic event death of a loved one life stage transition stress (demands exceed coping capacity) – work or day program – family or residence – peers

4. PRESENTING PROBLEMS FOR PSYCHOTHERAPY anxiety depression loneliness social skill deficits problems with employment problems with dating poor judgment poor problem-solving ability

5. RATIONALE FOR USE OF COGNITIVE BEHAVIORAL THERAPY RATIONALE FOR USE OF COGNITIVE BEHAVIORAL THERAPY (see Kroese, B.S., Dagnan, D., & Loumidis, K. (Eds.), 1997, for a full discussion) Presenting problems in people with ID are often maintained by cognitive and social factors. Cognitive-behavioral therapy developed >30 years ago to address cognitive dysfunction in non- disabled people with mental health problems.

6. COGNITIVE FUNCTION INPUT Brain receives input from sense organs and filters out irrelevant data; also called “perception” PROCESSING Brain sorts, organizes, stores, compares, categorizes, foresees, plans, formulates using the incoming information OUTPUT Brain controls and produces output as a verbal statement or other behavior that is hopefully an adaptive response to the original input

7. COGNITIVE DYSFUNCTON Cognitive deficits: Information processing operations that are missing or working poorly Cognitive distortions: Errors in interpretation that involve faulty content of thoughts and can be associated with changes in mood and behavior

8. COGNITIVE DEFICITS INPUT – Problems with sensory perception – Inability to filter out irrelevant stimuli – Problems attending to relevant stimuli

9. COGNITIVE DEFICITS PROCESSING – Incorrect labeling or categorizing stimuli – Poor memory capacity or retrieval – Slow processing speed – Problems following a sequence – Problems comparing information – Problems with foresight or planning – Inability to use internal language or “self-talk”

10. COGNITIVE DEFICITS OUTPUT – Inability or poor use of language – Poor motor skills – Problems withholding output until processing is complete (impulsivity)

11. COGNITIVE DISTORTIONS Distorting the MAGNITUDE of a situation – Catastrophizing – Overgeneralizing – Dichotomous thinking (“black and white” or “all or nothing” thinking)

12. COGNITIVE DISTORTIONS Making the wrong ATTRIBUTION for a situation – Assuming the wrong intent for another person’s actions – Assuming the wrong locus of control in a given event

13. COGNITIVE DISTORTIONS Holding unrealistic EXPECTATIONS for a given situation – Expecting self to be perfect – Pessimism: expecting things to always go wrong

14. SOCIAL COGNITION The study of how people process and utilize information in social situations “Social cognition is the study of how people make sense of other people and themselves.” (Fiske & Taylor, 1984)

15. SOCIAL COGNITION 1) Analyze information coming from other people concerning their thoughts and feelings. 2) Generate expectancies about the overt behavior of others. 3) Draw inferences about the requirements of the social situation; how to behave in response.

16. Success in a social situation requires a person to be able to extract meaning from: The general physical context of the interaction The nature of the social situation The speech of the other person The body postures of the other person The facial expressions of the other person

17. CBT History 1962 Ellis writes about “reason” in psychotherapy 1963 Beck introduces cognitive hypotheses for depression 1971 Meichenbaum and Goodman introduce self-instructional strategies D’Zurilla and Goldfried introduce problem solving therapy 1973 Ellis introduces Rational-Emotive Therapy 1976 Beck publishes Cognitive Therapy and the Emotional Disorders

18. WHY HAS CBT NOT BEEN APPLIED TO THE POPULATION MOST AT RISK FOR COGNITIVE PROBLEMS?

19. BASIC ASSUMPTIONS OF COGNITIVE BEHAVIORAL THERAPY (CBT) Cognitive activity (thoughts) affects behavior and emotions. Cognitive activity may be monitored and altered. Desired behavior change may be affected through cognitive change.

20. How is CBT similar to traditional behavior therapy? Both assume problems can be addressed by teaching people ways to change behavior Both assess outcome in measureable terms

21. How is CBT different than traditional behavior therapy? Differ in the view of HOW behavior may change Traditional behavioral approach assumes behavior is shaped by the environment - the link between behavior and environment is direct CBT takes into account the environment, but assumes that behavior change is mediated by cognitive change; there is a less direct link between environment and behavior

22. Environmental Event Behavioral Response Behavioral Response Environmental Event Cognitive Activity

23. 10 Principles of Cognitive Therapy (From Cognitive Therapy: Basics and Beyond, Judith S. Beck, 1995) 10 Principles of Cognitive Therapy (From Cognitive Therapy: Basics and Beyond, Judith S. Beck, 1995) 1. Cognitive therapy (CT) is based on an ever-evolving formulation of the patient and her problems in cognitive terms. 2. CT requires a sound therapeutic alliance. 3. CT emphasizes collaboration and active participation. 4. CT is goal oriented and problem focused. 5. CT initially emphasizes the present. 6. CT is educative, aims to teach the patient to be her own therapist, and emphasizes relapse prevention. 7. CT aims to be time limited. 8. CT sessions are structured. 9. CT teaches patients to identify, evaluate, and respond to their dysfunctional thoughts and beliefs. 10. CT uses a variety of techniques to change thinking, mood, and behavior.

24. ASSESSMENT Explore multiple factors (Gardner & Sovner, 1994). Is the presenting problem being maintained by…. medical factors? psychiatric factors? environmental factors? social factors? cognitive factors?

25. ASSESSMENT OF COGNITIVE FACTORS What cognitive deficits are maintaining my client’s problem? Therefore, what skills might I teach my client? What cognitive deficits are maintaining my client’s problem? Therefore, what skills might I teach my client? What cognitive distortions are maintaining my client’s problem? Therefore, what maladaptive thoughts and beliefs can be targeted and replaced to alleviate distress? What cognitive distortions are maintaining my client’s problem? Therefore, what maladaptive thoughts and beliefs can be targeted and replaced to alleviate distress?

26. COGNITIVE MODEL (From Cognitive Therapy: Basics and Beyond, Judith S. Beck, 1995) CORE BELIEF INTERMEDIATE BELIEF Situation -> AUTOMATIC THOUGHT -> Emotion

27. CORE BELIEF I am stupid INTERMEDIATE BELIEF If I don’t understand something the first time I try, it shows I can’t learn Situation -> AUTOMATIC THOUGHT -> Emotion New job -> I will never learn all of this -> Anxiety

28. ASSESSMENT Use of questions to elicit maladaptive beliefs Socratic questioning Downward arrow techniques

29. EXAMPLES OF CBT TECHNIQUES 1. Problem Solving 2. Assertiveness Training 3. Relaxation Skills Training 4. Cognitive Restructuring

30. PROBLEM SOLVING TECHNIQUES Based on work of D’Zurilla & Goldfried (1971) Teach person to break down a problem that is overwhelming and solve through small, manageable steps

31. PROBLEM SOLVING STEPS 1. Problem identification: 1. Problem identification: What is the concern? 2. Goal selection: 2. Goal selection: What do I want? 3. Generation of alternatives: 3. Generation of alternatives: What can I do? (Brainstorming- no idea is too silly at this step) 4. Consideration of consequences: 4. Consideration of consequences: What might happen for each alternative I listed above? 5. Decision-making: 5. Decision-making: What is my decision? 6. Implementation: 6. Implementation: Now do it and write down how it went. 7. Evaluation: 7. Evaluation: Did it work? If not, try another alternative.

32. ASSERTIVENESS SKILLS TRAINING Teach person to express needs and desires express anger in adaptive ways say “No” in adaptive ways state opinions and contradictions appropriately confront authority figures Based on Bergman (1985)

33. ASSERTIVENESS SKILLS TRAINING One strategy for identifying needs is to use Talk Blocks (Innovative Interactions, 2000)* helps individual to identify feelings but also identify separately what is he or she needs in order to cope with or solve problem Identifying is prerequisite for expressing * www.talkblocks.com

34. ASSERTIVENESS SKILLS TRAINING Talk Blocks (Innovative Interactions, 2000)* I FEEL frustrated I NEED to be listened to * www.talkblocks.com

35. ASSERTIVENESS SKILLS TRAINING To teach expression of wants and needs, focus on “I” statements. One useful tool is the “Use Your I’s” game (Western Psychological Services, 2002)

36. ASSERTIVENESS SKILLS TRAINING The “Use Your I’s” game (Western Psychological Services, 2002) promotes the following formula for an assertive statement: I feel …..when …..because…..I want ….. I feel angry when you change my appointment without telling me because I am an adult and I want to make my own appointments, please.

37. RELAXATION SKILLS TRAINING Based on Goldfried & Trier (1974), Cautela & Groden (1978) Variety of methods which teach self-control over arousal associated with stress and anxiety can be done through progressive muscle exercises with breathing control or can be done through guided imagery and breathing control

38. COGNITIVE RESTRUCTURING Based on Ellis (1962, 1973) and Beck (1976). Variety of methods which teach how to recognize maladaptive beliefs how to challenge maladaptive beliefs how to replace maladaptive beliefs with more adaptive ones

39. ABC Model

40. ABC Model: Restructuring “B”

41. COGNITIVE RESTRUCTURING METHODS FOR PEOPLE WITH ASD The Thought Chain Social Stories (Carol Gray, 1995) Comic Strip Conversations (Carol Gray, 1994)

42. THE THOUGHT CHAIN Gaus, 2000

43. My roommate asked me to clean up crumbs from the counter top. I will be homeless, soon!

45. SOCIAL STORIES

46. My name is Julie. I see Dr. Gaus in therapy every week. Today I am going to see her in a new place

47. I might get to the clinic early. I get nervous when I have to wait. I also get bored if I have to wait. I feel better if I eat a snack or candy

48. Sometimes there is candy in waiting rooms. Candy that is displayed in a dish on the coffee table or counter is for people to take. This is “public food.”

49. Candy that is not displayed publicly on the coffee table or counter is “private food”. People keep “private food” in their drawers, cabinets, pockets or purses.

50. People feel offended when they are asked to give away their “private food”. Sometimes when people feel offended, they hide those feelings.

51. I will bring a book with me. If I have to wait, I can read my book. I will bring some Lifesavers in my purse. If I have to wait, I can eat some of my Lifesavers.

52. COMIC STRIP CONVERSATIONS

53. Spoken words - things we say out loud. Thoughts - things we say silently to ourselves.

54. Comic Strip Conversations Symbol for “Listen”

55. Comic Strip Conversations “What would you like him to hear?”

56. Comic Strip Conversations “What would you like to hear from him?”

57. GUIDELINES FOR USING CBT FOR PEOPLE WITH ID Teach the individual how to recognize, challenge and slow down the process of maladaptive thought processes. Teach the individual to more accurately “read” the behavior of others and to re-conceptualize social situations. Teach concrete skills to increase ability to cope with stress. Maintain a balance between the provision of structured activities and empathy in the sessions. Use visual material to illustrate points, as they tend to learn more effectively from symbols and pictures, despite their verbal strengths.