Sturmey (2005) recently published a piece in this journal in response to Lynch (2004), which was also published in Mental Retardation. Sturmey aimed to rebut the “claims” of efficacy of psychotherapy with individuals who have mental retardation proposed by Lynch. Sturmey specifically criticized the work of Prout and Nowak-Drabik (2003), a meta-analysis of 92 studies cited by Lynch, and critiqued it from a variety of methodological and statistical perspectives. Indeed, meta-analysis of a large number of studies on any topic can be criticized from a variety of perspectives, yet we hope to learn about general trends. However, Sturmey's aim to rebut the article was not successful and his conclusions are erroneous.
Sturmey (2005) presented an exceedingly narrow conclusion without research evidence. In his concluding paragraph, he summarized his rebuttal as follows. First, there is an absence of well-conducted research on the effectiveness of psychotherapy. Second, there are many studies showing that behavioral interventions are effective. He then, however, concluded that behavioral interventions must be recommended because they are the only methods with research evidence of efficacy; thus, psychotherapy cannot be recommended. By his own scientific standards, his conclusions are not supported. In other words, if there are no long-term, well-controlled studies on the various forms of psychotherapy with this population, how can one conclude that psychotherapy is ineffective and not recommend it? If there are no rigorous studies on any particular form of psychotherapy showing that it is as good as, better than, or worse than behavioral techniques, how can we draw a conclusion? There are no rigorous studies directly comparing psychotherapy against a “behavioral intervention.” There are no rigorous studies with specific recommendations; for example, for what problems and for what subpopulation of people with mental retardation is Sturmey making his sweeping generalized recommendations that “behavioral approaches must remain the preferred treatment option for people with mental retardation” (p. 56)? His logic is flawed.
In his response Sturmey's (2005) used definitions of psychotherapy and behavioral intervention that are not accurate. Psychotherapy is a mental health treatment rendered in the forms of individual, group, and family settings. It is a treatment that is mental rather than physical and includes the use of relationship, suggestions, persuasion, reeducation, reassurance, and support as well as specific techniques, such as hypnosis, psychoanalysis, role play, cognitive restructuring, and instruction. Common psychotherapeutic approaches in the United States include: psychoanalytic, psychodynamic, interpersonal, psychodrama, cognitive–behavioral, behavioral therapy, and rational emotive behavioral psychotherapy. Sturmey referred to “traditional” psychotherapy, which does not actually exist.
Sturmey (2005, p. 55) criticized Lynch (2004), stating that Lynch was not correct for including the following methods as psychotherapy: assertiveness training, relaxation training, social skills training, and problem-solving training. Lynch was, however, correct because those techniques are very commonly used by mental health counselors, psychologists, and social workers, particularly those trained in cognitive–behavioral psychotherapy. They are not pure behavioral interventions. Cognitive–behavioral group treatment is often used to address social skills, assertiveness, and stress-management techniques, such as relaxation. These methods are employed for individual treatment or are used in a group format. The techniques are not behavioral interventions but are cognitive (mental) and behavioral (directive voluntary activities initiated by the patient). For example, when using relaxation techniques, psychotherapists spend sessions giving verbal instruction on relaxation, work with the patients by providing feedback as to how he or she is applying the method, and assigns “homework” (self-therapy) of practicing the technique. Then, the patient is helped to use relaxation in response to specific or generalized stressors and to apply it to generalized anxiety. Thus, this is not a behavioral intervention; it is a cognitive–behavioral form of psychotherapy. Further, the fact that these treatments have documented success provides evidence that people with mild mental retardation can benefit from other forms of psychotherapy because they can use the interpersonal relationship format, follow advice, accept feedback, and learn new ways of thinking and behaving as a result of this treatment.
Sturmey (2005) insisted that rigorous scientific evidence is required to recommend psychotherapy. By doing so, he chose to ignore other reviews and evidence for the effectiveness of many forms of psychotherapy used with people who have mental retardation (Butz, Bowling, & Bliss, 2000; Hurley, Pfadt, Tomasulo, & Gardner, 1996; Hurley, Tomasulo, & Pfadt, 1998; Nezu, Nezu, & Gil-Weiss, 1994). Further, he ignored the numerous clinical case reports, papers, and books on using individual, group, and family psychotherapy for people with mental retardation. In 2000, Fletcher, Hurley, and Bellordre published a bibliography on psychotherapy for this population within a book on psychotherapy. They cited over 300 publications. Since that time, there have been many more reports and books on psychotherapy for this population. For example, I recently reported on the use of a cognitive– behavioral approach for agoraphobia and panic disorder in a man with Down syndrome (Hurley, 2004). This is the preferred choice of treatment for all patients with this disorder, regardless of intelligence level, and it worked well with little modification for my patient. Razza and Tomasulo (2005) recently published a book on group psychodrama psychotherapy for people with mental retardation who have posttraumatic stress disorder and a trauma history. In their classic volume, Szymanski and Tanguay (1980) forcefully supported psychotherapy, and this book is as fresh today in this area as the day it was published. The American Academy of Child and Adolescent Psychiatry developed the Practice Parameters for the Assessment and Treatment of Children, Adolescents, and Adults with Mental Retardation and Comorbid Mental Disorders, and work group members recommended psychotherapy (Szymanski, King, & the Work Group on Quality Issues. et al., 1999).
By beginning the title of his rebuttal with “Against,” Sturmey (2005) chose the strongest possible negative position on psychotherapy as a form of treatment for people with mental retardation. His paper may be used by agencies as “proof” that psychotherapy is ineffective and, thereby, cause further limits in access to mental health treatment for people with mental retardation. For example, it is possible that the Center for Medical Services in the federal government will revise the Medicare regulations to prevent all people with mental retardation from receiving these services. State governments may find that psychotherapy is not medically proven and prevent Medicaid reimbursement of psychotherapy services. Private insurance companies could then prevent psychotherapy services for people with mental retardation because these treatments would be considered “experimental” and not a valid form of care.
I currently use psychotherapy to treat a large number of people with mild mental retardation and have done so for more than 30 years. I am an expert in this field and a cognitive–behavioral psychotherapist as well. I find that many patients with mild mental retardation respond very well to psychotherapy and that it is responsible for improvement as well as mental stability. How would Sturmey suggest I use “behavior interventions” to treat the following problems in my patients.
A woman married for 10 years whose husband has lost sexual interest in her?
A woman whose child was taken away by social services and is suffering grief and guilt?
A woman who experiences anxiety and panic attacks at work when asked to do new tasks because she feels inadequate?
A man whose parents died suddenly in a car accident, leaving him to live alone?
A married couple with increasing conflict in their relationship due to financial hardship?
Finally, Sturmey (2005) did not advocate a need for research on all forms of psychotherapy. In 1989, I published such a paper calling for research on psychotherapy. I agree with Sturmey that funding of such research has not occurred and will probably not be forthcoming. Despite this lack of scientific research, it is imperative that clinicians continue to treat people with mental retardation using psychotherapy when it is appropriately indicated.
Within the past 20 years, however, significant development has occurred. The literature base has grown substantially and a greater sense of cohesiveness has been obtained through conferences, trainings and the efforts of professional organizations. … However, there are some current concerns that the field will need to address … fiscal constraints … and demonstrating the effectiveness of psychotherapy for individuals with mental retardation through empirically rigorous research. (p. 402)
Further, Lynch (2004) himself, while citing the Prout and Nowak-Drabik (2003) study, stated that the authors themselves “acknowledged that many of the studies were poor in terms of methodological rigor or design” (p. 402). What, then, did Sturmey (2005) need to rebut so vigorously?
Finally, Sturmey's (2005) title is certainly very unfortunate. He might have instead titled his rebuttal “A Call for Rigorous Research on Psychotherapy With People Who Have Mental Retardation: A Response to Lynch.”
Author: Anne D. Hurley, PhD (email@example.com), Harvard Vanguard Medical Associates, 230 Worcester St., Wellesley, MA 02481; and Associate Clinical Professor of Psychology, Tufts University