In his paper, Sturmey (2005) stated that his purpose was to rebut the claims of efficacy of psychotherapy with individuals who have mental retardation made by Lynch (2004). It is not clear, however, that this is the main purpose because Sturmey concluded, based on the evidence supporting their effectiveness and efficacy, that behavioral interventions must remain the treatment of choice for people with mental retardation. The evidence he cited to support his arguments concerning the superiority of behavioral interventions over psychotherapy for people with mental retardation raises a number of issues that are explored below.
Efficacy and Effectiveness
The evidence to support the efficacy of psychotherapy for people with mental retardation is indeed limited. This is the conclusion reached in a number of recent reviews, critiques, and commentaries (e.g., Beail, 2003; Hatton, 2002; Prout & Nowak-Drabik, 2003; Willner, 2005). Unfortunately, Lynch (2004) appears to have conflated efficacy with effectiveness in relation to the evidence for psychotherapy for people with mental retardation cited by Prout and Nowak-Drabik (2003) and others. Efficacy research demands internal validity in order to evaluate how effective particular interventions are for specific, usually homogeneous, study samples; whereas effectiveness studies require external validity to demonstrate how generalizable treatment effects might be under routine care conditions in the wider population from which the sample has been drawn (Wells, 1999). Lynch (2004) and Prout and Nowak-Drabik (2003) are concerned with the effectiveness of psychotherapy for people with mental retardation for which there is a wealth of evidence, particularly cognitive–behavioral approaches (Willner, 2005). On the other hand, evaluations of behavioral interventions are almost exclusively conducted in highly controlled environments, with high staff ratios; therefore, the generalizability of these findings to nonsegregated settings is questionable (Scotti, Evans, Meyer, & Walker, 1991).
Mislabeling Cognitive Interventions
In their meta-analysis of psychotherapy for people with mental retardation, Prout and Nowak-Drabik (2003) included studies that, among other characteristics, involved direct face-to-face contact between the therapist and clients; aimed to assist clients in modifying their feelings, values, attitudes, and behaviors; and did not involve behavior modification. In Sturmey's (2005) critique of Prout and Nowak-Drabik's meta-analysis, he re-labeled a range of psychotherapeutic approaches as behavioral interventions. Consequently, in Sturmey's view, studies showing good outcomes for assertiveness, social skills, and problem-solving training become evidence for the efficacy of behavioral interventions. The cognitive and meta-cognitive skills training involved in the self-management and self-instructional techniques (e.g., self-monitoring, self-evaluation, self-reinforcement) underpinning the interventions in these studies were not acknowledged by Sturmey (2005).
What Works for Whom and for What?
The evidence set out by Sturmey (2005) to support his argument for superiority of behavioral interventions seems impressive. It is not clear, however, for what kinds of problems (behavioral, emotional, mental health), experienced by what type of clients (adult, child, with mild or severe mental retardation), and in what contexts (institutional, community) investigators have suggested these approaches are effective for. Studies providing evidence for the effectiveness of behavioral interventions have generally concerned high frequency challenging behaviors, such as self-injury and stereotypy (Didden, Duker, & Korzilius, 1997), involving people with severe and profound mental retardation (Scotti et al., 1991), and conducted in segregated settings (Carr et al., 2000). It has been proposed elsewhere that for mental health and emotional problems (e.g., anger dyscontrol) experienced by adults with mild mental retardation, cognitive– behavioral treatment is a more beneficial approach (Taylor, 2002). The potential advantage of these interventions is that they are self-actualizing in nature (i.e., they aim to help clients develop self-control over their emotional and behavioral problems). Promoting portable internalized control in order to facilitate transfer across situations is helpful when the target problem is low frequency, but high impact—as is often the case for aggressive behavior presented by people with mild mental retardation (Taylor & Novaco, 2005). There is emerging evidence that these approaches can be beneficial for a range of mental health and emotional problems experienced by people with mild mental retardation across a number of settings (Willner, 2005).
Example of Anger Dyscontrol
Anger dyscontrol, which is closely associated with aggression among people with mental retardation (Taylor & Novaco, 2005), is a good example to look at in more detail due to its prevalence and consequences for clients and people and systems supporting them. The evidence to support behavioral interventions for aggression in people with mental retardation is extensive (e.g., Carr et al., 2000; Lennox, Miltenberger, Spengler, & Efranian, 1988; Scotti et al., 1991; Whitaker, 1993). However, most studies showing the effectiveness of these approaches have involved contingency management techniques applied to people with moderate, severe, and profound mental retardation who exhibit high frequency aggression in segregated environments with high staff ratios (Whitaker, 1993). Thus, these approaches have been shown to be effective when applied to a small proportion of the mental retardation population in specific settings. Approximately 85% of people with mental retardation have mild mental retardation (American Psychiatric Association, 1994). In a narrative review, Taylor and Novaco (2005) reported that post-1985, there have been 19 published studies showing the effectiveness of cognitive–behavioral anger treatment involving people with mild mental retardation in a range of institutional and community settings. The majority of these studies are case and case-series reports, but 6 studies included control group comparisons that yielded significant between-group differences and moderate to large treatment effects (Lindsay et al., 2004; Rose, West, & Clifford, 2000; Taylor, Novaco, Gillmer, Robertson, & Thorne, in press; Taylor, Novaco, Gillmer, & Thorne, 2002; Taylor, Novaco, Guinan, & Street, 2004; Willner, Jones, Tams, & Green, 2002).
The above analysis indicates that at least for anger dyscontrol, the apparent weight of evidence supporting behavioral interventions is less impressive when applied to adults with mild mental retardation across a range of settings. For this majority constituency of people with mental retardation, cognitive psychotherapy would seem to be effective and, possibly, more beneficial in terms of psychological well-being.
Behavioral interventions have been shown, largely through single case experimental design studies, to be effective for a range of challenging behaviors exhibited by people with more severe levels of mental retardation in nonintegrated settings. The superiority of behavioral interventions over psychotherapeutic approaches for these types of problems among this relatively small proportion of the mental retardation population is unquestionable. However, behavioral interventions are less effective when applied to lower frequency, more complex behavioral problems (e.g., sexually aggressive behavior) characteristic of higher functioning individuals (Willner, 2005).
People with mental retardation are more likely to experience mental health and emotional problems than are individuals in the general population (Deb, Thomas, & Bright, 2001; Prosser, 1999). Very few studies of behavioral interventions have targeted the mental health needs of these clients (Didden et al., 1997), and behavioral approaches would appear to be of limited benefit to the majority of people with mild mental retardation who are vulnerable to a range of emotional problems (Stenfert Kroese, 1998). People with mental retardation have the same rights as others to access to psychological therapies that can help to relieve the distress experienced as a result of such problems. There is limited but growing evidence, including controlled trials, that cognitive–behavioral psychotherapy can be effective and of benefit to people with mental retardation experiencing emotional problems. In this regard it is probably both premature and unhelpful to promote the superiority of behavioral approaches at the expense of psychotherapy for these clients.
Author: John L Taylor, Dpsychol, Professor, Developmental Disability Psychology, Northumbria University, Cheviot House, Coach Lane Campus, Benton, Newcastle upon Tyne, NE7 7XA, United Kingdom. email@example.com