Do you really believe that the sciences would ever have originated and grown if the way had not been prepared by magicians, alchemists, astrologers, and witches whose promises and pretensions first had to create a thirst, a hunger, a taste for hidden and forbidden powers? Indeed, infinitely more had to be promised than could ever be fulfilled in the realm of knowledge. (Nietzsche as cited in Paradi, 2002, p. 240)
The purpose of this response is to rebut with intense nonscientific vigor, the assertion by Sturmey (2005) that the acknowledged absence of methodologically adequate studies of “traditional psychotherapy” for individuals with mental retardation (Lynch, 2004; Prout & Nowak-Drabik, 2003) justifies the conclusion that behavioral supports “must remain the preferred treatment option for people with mental retardation” (Sturmey, 2005, p. 56). I also object to Sturmey's implication that it is in the best interest of individuals with mental retardation and emotional distress (arising from mental illness or a myriad of other life sources as comprehensively detailed by Lynch, 2004), to label social skills training, problem-solving training, relaxation exercises, and assertiveness training as “behavioral methods,” distinct from traditional psychotherapy.
Integrated biopsychosocial models are based on the premise that behavioral and emotional challenges faced by individuals with mental retardation represent the dynamic influence of biomedical (including psychiatric and neuropsychiatric), psychological, and social factors. Best practice features of these models incorporate the role and magnitude of effects of biomedical and psychosocial vulnerability, instigating and maintaining variables in understanding emotional distress. These models highlight the need to identify skills and related emotional/ motivational supports required by individuals to cope effectively. They encourage an enhancement of competency, build on strengths, and acknowledge the need for environmental change to accommodate need and accommodation in a proactive manner. They encourage us to translate the multiple modalities of influence on an individual's life into a paradigm that may assist us in understanding, stressing that our understanding of the distress of others will evolve over time. These models encourage the development and implementation of multimodal support plans, with the recognition that mental health consists of both the presence of personal contentment and the relative absence of psychological distress (Griffiths, Stavrakaki, & Summers, 2002).
As allies and providers of support to individuals with mental retardation and emotional distress, we do not know what works best from a psychotherapeutic perspective. We barely have an inkling of understanding of the efficacy of psychotherapy from a scientific perspective for individuals without mental retardation (Wolpe, 1993). I have had the privilege, however, of working with many therapists and clinicians committed to supporting individuals with mental retardation and emotional distress. My colleagues and, more importantly, the individuals whom I have supported have taught me numerous things. (a) Many individuals with mental retardation are, at times, in grave need of emotional support. (b) All sectors of professional support are underfunded and staff members are grossly undertrained. This reality challenges individuals who are providing support to modify the format of their respective theoretical modalities in order to optimally meet the needs of individuals with mental retardation (Lynch, 2004). (c) I have learned that a systemic lack of training negatively affects treatment outcomes and should be considered an obstacle to accurately measuring the benefits of specific treatment modalities offered to individuals with mental retardation (Beasley, 2004). (d) Advice and training is available to assist willing participants to learn to modify their support approaches. (e) “The absence of evidence for efficacy is not evidence of ineffectiveness” (Beail, 2003, p. 471). Rather, inadequate outcome measures and a lack of effort to even attempt to measure outcomes due to the stigmatization and discrimination experienced by all individuals with mental retardation are more likely explanations for our current lack of knowledge in this area. Practice-based evidence, versus evidence-based practice, exists and should and does inform the clinical efforts of many committed therapists (Beail, 2003). (f) I have learned that self-advocates with mental retardation and autism spectrum disorders are available (although they are proceeding with self-preserving caution) to assist professionals to improve on our efforts to reduce the intensity of emotional distress experienced by individuals with mental retardation during their lifetimes (Shore, 2004).
Support should be dictated by need. The value of available support is difficult to measure with scientific outcome variables. Practice-based evidence does suggest that psychotherapeutic support, if offered with respect and compassion to individuals with mental retardation, can be life-enhancing. Learning to love yourself after being repeatedly raped by a family member and/or careprovider; seeking peace after experiencing repeated failures of attachment, personal, social, and cultural dislocation; moving from community to institution and, hopefully, back to community; grieving the loss of your biological family; and adjusting to opportunities for new roles and responsibilities after a lifetime of being punished for attempting to be yourself will not be helped by behavioral methods or traditional psychotherapy. As people privileged to walk alongside individuals with mental retardation during their life paths and as professionals in the field, we have no right to perpetuate turf wars or “await the evidence.” We need to proceed, with caution and hope, but proceed and find our way as the evidence follows (or not).
During her journey with her autistic son. Valerie Paradi (2002) asked, “How will I hear my son's voice if it's entangled in such a legacy of wartime fear, cultural misogyny, and ideological posturing?” (p. 70).
Author: Robert King, MD, Consultant Psychiatrist, Assertive Community Treatment Team for Individuals With Developmental Disabilities, Royal Ottawa Hospital (Brockville Division), Brockville, Ontario K6V 5W7. Robert.King@NBPH.MOH.GOV.ON.CA