Christine Maguth Nezu and Michelle A Peacock

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Keywords: cognitive-behavior therapy, behavior therapy, mental retardation, developmental disabilities, dual diagnosis

Compared to the general population, individuals with mental retardation are at increased risk for developing behavioral, psychological, and emotional disorders. Characteristics associated with mental retardation such as deficits in social-cognitive processing ability and communication skills may negatively influence their ability to cope with stress and increase their vulnerability to developing psychopathology. Environmental factors often experienced by individuals with mental retardation that may also contribute to the development of psychopathology include poor learning opportunities, transient living situations, and staff turnover.

Until the nineteenth century, mental illness and mental retardation were treated as similar conditions, scientific interest being focused on mental illness with little attention directed toward patients with dual diagnosis (Nezu, Nezu, & Gill-Weiss, 1992). Despite the increased need for mental health services for this population during the normalization and integration movements in the 1970s, scientific recognition of co-occurring mental illness in persons with mental retardation did not occur until the 1980s. Despite this recognition, patients with mental retardation continue to be excluded from scientific studies that investigate the effectiveness of treatments for many psychological disorders (Nezu & Nezu, 1994).

People with mild to moderate mental retardation experience the same mental illnesses as the general population, although the manifestation of psychopathology may present somewhat differently as a function of the severity of the developmental disability (Nezu et al., 1992). Some mental disorders co-occur more frequently with mental retardation including personality disorders, severe behavior disorders, depression, and anxiety disorders (Nezu et al., 1992). Although a variety of cognitive-behavioral treatment strategies have been applied to address these disorders in non-handicapped populations, methodologically rigorous studies designed to investigate the efficacy of psychotherapy in persons with mental retardation are lacking.

Diagnosing a mental disorder in a patient with mental retardation is frequently complicated by deficits associated with developmental disabilities (e.g., speech impediments). Mental health professionals often lack professional training in mental retardation and hold a common misperception that patients with mental retardation are immune to psy-chopathology (Nezu & Nezu, 1994). Studies have demonstrated that clinicians tend to make biased judgments about psychiatric symptoms in patients with mental retardation attributing the symptoms to the mental retardation rather than the mental illness (Jopp & Keys, 2001). When this phenomenon of diagnostic overshadowing occurs, patients with mental retardation do not receive the services and treatment they need to improve their symptoms. In addition, these biases and misconceptions have resulted in the lack of "scientific attention to discovering and verifying effective outpatient treatments for developmentally disabled populations" (Nezu & Nezu, 1994, p. 34).

Prout and Nowak-Drabik (2003) reviewed 92 outcome studies conducted over a 30-year period that examined psychotherapy applied to persons with mental retardation and found only nine studies that met standard criteria for a meta-analysis. The meta-analysis results of these nine studies indicated that a variety of psychotherapeutic interventions (e.g., group, individual, skills training) provided moderate benefits and produced moderate changes in patients with mental retardation. Exploratory analyses revealed that techniques demonstrating the greatest degree of change tended to be interventions provided in individual therapy, clinic-based treatment settings, and treatments with a behavioral orientation. Based on overall findings, the authors noted that clinicians should consider psychotherapy for patients with mental retardation more often than is currently the practice.


In 2000 (Rush & Frances, 2000), practical clinical guidelines based on expert consensus and relevant research for treating persons with mental retardation suffering from major mental disorders were developed to assist clinicians in treatment decision making. Applied behavior analysis, managing the environment, and client and family education were the most highly recommended psychosocial treatments for many disorders including autism, attention-deficit/ hyperactivity disorder, conduct disorder, substance abuse and substance dependence, as well as target symptoms such as self-injurious behavior, aggression, and pica. CBT (e.g., anger management, assertiveness training, conflict resolution) was recommended as a first-line option for major depressive disorder, posttraumatic stress disorder, obsessive-compulsive disorder, and symptoms of anxiety. CBT was also recommended as a second-line option for bipolar disorder (manic phase), schizophrenia and other psychotic disorders, generalized anxiety disorder, conduct disorder, substance abuse or dependence, and adjustment disorder.

Operant Procedures

Treatment strategies based on the principles of operant conditioning include token economies, time out from reinforcements, differential reinforcement schedules, extinction, and overcorrection. These strategies have been effectively utilized to treat a wide range of disorders in patients with mental retardation such as eating disorders, anxiety disorders, depression, phobias, self-injurious behaviors, and aggression (Nezu & Nezu, 1994). For example, reinforcement (e.g., small prize) for attending weight loss meetings as well as losing weight was successfully used as one component of a self-monitoring behavioral weight loss program (Fox, Haniotes, & Rotatori, 1984).

Operant procedures are frequently used as part of multicomponent treatment strategies. For example, verbal reinforcement for socially appropriate statements was implemented as part of a social skills training protocol aimed at improving interpersonal functioning among mentally retarded adults (Matson & Senatore, 1981). Social reinforcement is often utilized as an additional learning strategy in conjunction with other treatment procedures such as assertiveness training (e.g., Nezu, Nezu, & Arean, 1991), relaxation training (e.g., Calamari, Geist, & Shahbazian, 1987), and social problemsolving training (Nezu et al., 1991).

Respondent-Based Procedures

Interventions based on respondent or classical conditioning procedures have also been found to be effective in the treatment of a variety of symptoms and disorders including decreasing avoidant behaviors, aggressive behaviors, and disruptive behaviors in persons with profound to mild mental retardation. For example, Calamari et al. (1987) investigated the efficacy of a progressive muscle relaxation training procedure combined with auditory electromyo-graphic (EMG) feedback, modeling, and reinforcement procedures in comparison to a control group among devel-opmentally disabled persons. Their results indicated that people with developmental disabilities learn to relax and benefit from a multicomponent relaxation training intervention, regardless of their level of intellectual and adaptive functioning (i.e., participants ranging from profound to mild range of mental retardation benefited).

Social Learning Approaches

Social learning strategies have been demonstrated as effective approaches for decreasing psychiatric symptoms and maladaptive behavior, as well as improving interpersonal skills and overall quality of life in persons with mental retardation (Nezu & Nezu, 1994). These interventions include social skills training, assertiveness training, problemsolving training, modeling, and self-reinforcement. Matson and Senatore (1981) compared the effects of social skills training, which involved techniques such as modeling and role-playing, to traditional psychotherapy and no treatment in outpatients with mild to moderate mental retardation. The results suggested that social skills training aimed at specific target behaviors was more effective than traditional psychotherapy or a no-treatment control condition for enhancing interpersonal functioning. Some reduction in performance was revealed at a 3-month follow-up, suggesting the need for maintenance therapy to sustain treatment gains.

Nezu et al. (1991) empirically investigated the effects of two cognitive-behavioral interventions, social problemsolving training and assertiveness skills training, in 28 adults with mild mental retardation and co-occurring mental illnesses. Diagnoses in addition to mental retardation consisted of anxiety disorder, schizophrenia, intermittent explosive disorder, adjustment disorder, and various personality disorders. Participants were randomly assigned to one of the following three conditions: (1) 5 weeks of problem-solving training followed by 5 weeks of assertiveness skills training, (2) 5 weeks of assertiveness skills training followed by 5 weeks of problem-solving training, or (3) a wait-list control condition. In comparison to the wait-list control group, at 5 weeks and posttreatment, participants in both treatment groups demonstrated significant reductions in aggressive behavior, psychiatric symptomatology, and feelings of distress. In addition, results revealed increases in assertiveness skills, problem-solving skills, and adaptive behavior.

Other studies have found positive results that focus on skills that enhance interpersonal functioning. For example, in comparison to a wait-list control group, participants with moderate to borderline mental retardation who received social skills training with an emphasis on dating skills demonstrated improvement in heterosocial interactions and social-sexual knowledge (Valenti-Hein, Yarnold, & Mueser, 1994). The results of this study, however, did not reveal reductions in social anxiety. Mildly mentally retarded adults have also benefited from assertiveness training provided in a group setting that consisting of focused instructions, modeling, behavioral rehearsal, and response feedback (Gentile & Jenkins, 1980). The results indicated increased use of appropriate verbal responses (i.e., making requests and refusing unreasonable requests).

Social learning treatment approaches have also been demonstrated to be effective in weight reduction programs for adults with mental retardation. For example, Fox et al. (1984) produced significant weight loss in adults with mental retardation through a behavioral weight loss program that included self-control strategies such as modeling, self-monitoring involving pictorial stimuli, self-reinforcement, increased physical activity, and reduction of food intake.

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