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http://www.persee.fr/web/revues/home/prescript/article/psy_0003-5033_1975_num_75_2_28111
Effective Teaching Methods For People With Intellectual Disabilities
TAMMY REYNOLDS, B.A., C.E. ZUPANICK, PSY.D. & MARK DOMBECK, PH.D. MAY 21, 2013
Individuals with intellectual disabilities (ID, formerly mental retardation) benefit from the same
teaching strategies used to teach people with other learning challenges. This includes learning
disabilities, attention deficit/hyperactivity disorder, and autism.
One such strategy is to break down learning tasks into small steps. Each learning task is
introduced, one step at a time. This avoids overwhelming the student. Once the student has
mastered one step, the next step is introduced. This is a progressive, step-wise, learning
approach. It is characteristic of many learning models. The only difference is the number and
size of the sequential steps.
A second strategy is to modify the teaching approach. Lengthy verbal directions and abstract
lectures are ineffective teaching methods for most audiences. Most people are kinesthetic
learners. This means they learn best by performing a task hands-on. This is in contrast to
thinking about performing it in the abstract. A hands-on approach is particularly helpful for
students with ID. They learn best when information is concrete and observed. For example,
there are several ways to teach the concept of gravity. Teachers can talks about gravity in the
abstract. They can describe the force of gravitational pull. Second, teachers could demonstrate
how gravity works by dropping something. Third, teachers can ask students directly experience
gravity by performing an exercise. The students might be asked to jump up (and subsequently
down), or to drop a pen. Most students retain more information from experiencing gravity
firsthand. This concrete experience of gravity is easier to understand than abstract explanations.
Third, people with ID do best in learning environments where visual aids are used. This might
include charts, pictures, and graphs. These visual tools are also useful for helping students to
understand what behaviors are expected of them. For instance, using charts to map students
progress is very effective. Charts can also be used as a means of providing positive
reinforcement for appropriate, on-task behavior.
A fourth teaching strategy is to provide direct and immediate feedback. Individuals with ID
require immediate feedback. This enables them to make a connection between their behavior
and the teachers response. A delay in providing feedback makes it difficult to form connection
between cause and effect. As a result, the learning point may be missed.

Interventions for mental retardation often begin as early in life as possible, and typically
include a combination of social and practical skills training. People who suffer
from intellectual impairmentgenerally have a harder time learning things, and will need
extra help mastering practical life skills so that they can care for themselves more easily
as time goes by. Social skills therapy is also considered an important part of most
interventions for those with mental retardation, since the goal is typically to help the
person integrate into society and live a normal life. People with intellectual impairments
may have trouble grasping basic social conventions. They may need extra help learning
how to carry on normal conversations, respect others' personal space, and feel
confident in social situations.
With the help of interventions for mental retardation, most people suffering from this
developmental disorder go on to hold down jobs among unimpaired coworkers. They

are usually encouraged to share their homes with others, and are typically placed in
living situations that mimic the situations of their non-developmentally disordered peers.
Ad
Treating intellectual impairments such as mental retardation is usually begun when the
person is still a baby. Educational therapy can help the child learn important life skills,
even before school begins. Once the child has started school, interventions for mental
retardation typically involve allowing the child to interact frequently with all of his peers,
rather than segregating him in a classroom of other developmentally disordered
persons. The intellectually impaired student will need supplemental academic support,
since learning does not typically come easy to him. Frequent and prolonged repetition of
basic facts can help the student eventually learn them, and extra importance is usually
placed on those areas of knowledge that will have practical applications throughout the
person's life.
People suffering from developmental disorders often have trouble learning how to
interact properly with others, so social skills training is usually a crucial part of
interventions for mental retardation. Important social skills for those with developmental
disorders range from learning how to properly groom oneself, to how to behave in public
according to social convention, to how to understand figurative language and put
questions and statements in context. Social skills training for people with intellectual
impairments can involve education about what kinds of things are appropriate, and not
appropriate, to say to others, as well as when and how to initiate physical or eye contact
with others. Social skills, like academic skills, are typically practiced in a classroom
setting, and students are typically asked to perform social skills "homework" in real life
situations as well.
A novel programme of intervention - brief inpatient family intervention - was formulated to
impart the training skills to the parents of mentally retarded children to optimise the development
of their retarded child. During the period of this study. 106 mentally retarded children with
different socio-demographic backgrounds and degrees of handicap participated in this
programme, with encouraging results. The individualised management plan, spread over 2 weeks
of inpatient stay, included intensive counselling, training of the parents in techniques of
multisensory stimulation, speech, motor, and self-help skills training, behaviour modification and
medical management, as required. The programme could serve as a suitable model for
professionals working with the mentally retarded, to implement with limited resources.

THE CO-OCCURRENCE OF mental illness with mental retardation/developmental disabilities

(MR/DD) has been referred to as dual diagnosis. It is estimated that as many as 30 to 40
percent of MR/DD individuals are dually diagnosed. Unfortunately, when a person with MR/DD
needs psychotherapy to treat the mental illness, it can be difficult to find a psychiatrist who is
comfortable working with the patient.

There are relatively few studies focused on psychotherapeutic interventions in the mentally
retarded (MR) patient. In 1982, Reiss, et al.,1 hypothesized that intellectual subnormality is such
a salient and obvious feature of the patient's presentation that accompanying emotional
disturbances are overshadowed. He coined the term diagnostic overshadowing to describe this
phenomenon and believes that diagnostic overshadowing leads to a failure to recognize and
subsequently treat the emotional and behavioral expressions of mental illness in the
developmentally disabled person.
Supportive psychotherapy is a form of psychotherapy in which the therapist plays an active role
in helping the patient improve his or her social functioning and coping skills.2 The emphasis of
the therapy is on improving behavior and subjective feelings rather than on achieving insight or
self-understanding and, as such, is particularly relevant when working with the mildly MR/DD
individual. Although there is limited literature on this, there are some small studies and case
reports summarizing the benefits of supportive psychotherapy for this population.2
The present case illustrates the use of supportive psychotherapy in a patient with recurrent
depression and mild mental retardation. It is used to illustrate the following topics: disability,
dependence, sexuality, grief/loss issues, advocacy and family support.
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CASE PRESENTATION: Psychiatric History and Diagnosis
Mr. B is a 30-year-old single man with mild mental retardation (I.Q.=65) and fluctuating
symptoms of depression and anxiety that date back to childhood. He was born to an intact
nuclear family, the first born of a male sibship of two. At the time of his birth, Mr. B was noted to
have hydrocephaly and was evaluated by neurosurgery. A decision was made not to place a
shunt or perform other invasive procedures, and his pediatricians followed his development
routinely. Medical records from that time were unavailable for review. Both Mr. B and his brother,
who is one year younger, reportedly progressed through all developmental milestones, although
of the two Mr. B was notably slower in acquisition of new skills relative to his brother.
Mr. B recalls being in regular classes through most of grade school; however, he distinctly
remembers taking a written test in the seventh grade and its outcome causing him to be placed
in special classes. Shortly after that exam, which also coincided with the time of his
grandmother's death, Mr. B recalls experiencing depressed mood, insomnia, anxiety, poor
concentration, overeating, and thoughts of suicide. He also reports a history of hearing voices
but cannot describe them further. His family members deny any previous knowledge of the
psychosis. Based on these symptoms, he was hospitalized at 12 years of age for approximately
one week, and was discharged with a diagnosis of major depressive disorder without psychotic
features.
Over the next several years, he experienced remitting and relapsing depression mixed with
anxiety episodes, which he experienced as fear of going crazy, physiologic arousal,
tremulousness, diaphoresis, and palpitations. Over the next several years, his outpatient

diagnoses included recurrent major depressive disorder without psychotic features and panic
disorder without agoraphobia.
Following this diagnosis, Mr. B underwent trials of three selective serotonin reuptake inhibitors,
most recently paroxetine. Mr. B reported minimal benefit from the antidepressants, but admitted
that he actually had not taken them as directed. Instead, he had become accustomed to taking
the medication on an as needed basis when his anxiety worsened. Mr. B had never previously
undergone a course of psychotherapy but was receptive to this prospect.
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KEY POINT: Making the Diagnosis
In general, there may be conceptual, speech, and language barriers when attempting to record
a history from an individual with mental retardation/developmental disability. If the MR (mental
retardation) is severe or profound, the individual may be nonverbal or have no usable language
(e.g., echolalia). Patients such as Mr. B who are in the mild to moderate range of MR will
typically be verbal, but may speak in concrete terms; they may not report, question, or interpret
psychiatric symptoms the way an individual without intellectual disability would. For example,
they may report awareness of their own normal thinking processes as auditory hallucinations.
On the other hand, MR persons certainly may suffer from auditory hallucinations, but may not
recount the experience in those words. Mr. B experienced symptoms and signs consistent with
depression and panic disorder, but expressed his chief complaint as, I'm afraid of losing my
friends, and he could not answer or elaborate upon questions such as, Who are the important
people in your life? and What are your goals in long-term relationships?
Collateral data sources and serial interviews were needed to finalize the diagnosis. With proper
informed consent in place, both Mr. B's parents and brother were questioned regarding Mr. B's
history of psychiatric illness. Interestingly, all four accounts provided important yet sometimes
conflicting information, possibly due to different perspectives and different concepts of mental
illness. For example, when describing the hospitalization, the patient and the patient's brother
clearly recall the presence of psychosis (auditory hallucinations), but both parents adamantly
denied that the patient was ever psychotic.
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KEY POINT: Reference Material for Help With Psychiatric Diagnoses in Dual-Diagnosis
Patients
The possibility for the future publication of a companion manual to the Diagnostic and Statistical
Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) for use with the MR
client is being discussed. A committee supported by both the National Association for the Dually
Diagnosed (NADD) and the American Psychiatric Association (APA) is currently convening to
propose such a manual, which will support the use of behavioral equivalents of diagnostic
criteria for each psychiatric disorder in the MR/DD person. This manual is due out in 2006. For
example, depressed mood as a symptom of major depressive disorder will also list the
relevant behavioral equivalents: sad facial expression, flat affect or flat facial expression,

laughing or smiling rarely, frequent crying or appearing tearful, and persistent whimpering,
whining, or complaining.3
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KEY POINT: Adjunctive Pharmacotherapy
Presently there are no identified best practices specific to the MR population; therefore, as of
now, the best practices that exist for the general population should be applied. Treatment with a
selective serotonin reuptake inhibitor (SSRI) is an appropriate intervention for depression in this
population, but attention to compliance issues is imperative in a treatment of a patient, such as
Mr. B, who possesses an intellectual disability and who self administers medication. Fluoxetine
(a daily or weekly dosing schedule) can be considered because of the long half life, which could
provide some protection from noncompliance. Family intervention (with reminder phone calls
from parents) was added in order to remind the patient when to take the medication both for
therapeutic benefit as well as to lower risk of a withdrawal syndrome and future noncompliance
based on those symptoms.
At the time of the initial assessment, Mr. B shared that he had also been taking a sedative at
bedtime to treat initial insomnia. This was discouraged. In general, sedatives and
benzodiazepines should be avoided where possible in the MR/DD population, as there is more
potential for oversedation and anterograde and retrograde memory difficulties. Additionally, this
population has a higher prevalence of pulmonary morbidity and mortality, which could be
exacerbated by the respiratory side effects of these medications.4Finally, there are reports of
paradoxical stimulation with the use of benzodiazepines in this population.5
In the case of Mr. B, psychotherapy was indicated because of ongoing relationship and
disability/dependence issues and unresolved bereavement issues. Medication also was
indicated because of the severity of depression, prominent neurovegetative signs, and a
decrement in social and occupational functioning.
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KEY POINT: Life Transitions and the Recurrence of Depression
At the time a family receives news that a child has mental retardation or a developmental
disability, there begins a process of grieving as the family realizes that developmental stages
may not be achieved or may be delayed. Each expected life transition may bring renewed grief
or loss for a MR individual and the family (e.g., when not achieving developmental milestones,
upon entering school, at the onset of adolescence, when others graduate from high school,
attempting to gain independence from the family, at the time of peers' or siblings' marriages,
when peers or siblings have children, and when parents anticipate their own deaths).
These milestones were especially significant in Mr. B's situation, since he had a sibling close in
age. In the early years, the brothers were in similar classes at school, which made Mr. B feel on
schedule and also provided him with his brother's social support in the educational setting. He
recalled multiple instances when his brother advocated for him by including him in social

activities and integrating Mr. B into his social network. At the time of the separation into special
classes in middle school, this support came to an abrupt halt. Mr. B's brother was later
transferred to a different high school, having been accepted into a specialized school with
advanced academic programs.
Subsequently, when his brother began college, got married, and experienced the birth of his first
child, Mr. B experienced renewed grief/loss with each development. It was during these periods
of transition that Mr. B's depressive symptoms resurfaced. Chronolog-ically, he was slightly
older than his brother, and Mr. B, identifying himself as the first born child, felt a family obligation
to marry, to have children, and to do everything my parents expect from an adult child. With
every step taken by his brother and peers, Mr. B felt he was further and further behind, and
consequently the depressive symptoms would resurface.
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PRACTICE POINT: How to Help the Depressed MR Person Through Difficult Transition
Periods
During these difficult transition periods, effective supportive psychotherapy interventions with Mr.
B were as follows: 1) using the supportive and structured trusting, confiding, emotional
relationship to boost the patient's morale; 2) actively suggesting more adaptive responses to
stress, and reinforcing those responses during therapy; and 3) using the structured treatment
setting to provide an aura of safety, predictability and sanctuary during these stressful periods,
and increasing the session frequency temporarily.2
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PRACTICE POINT: Grief and Loss Issues in the Dually Diagnosed
As was previously mentioned, at approximately the same time Mr. B was placed in special
classes in middle school, his maternal grandmother died. Mr. B had an extremely close bond
with his grandmother and did not feel that he played an active role in the funeral services. In
fact, he was kept from them by his family because of his mental retardation. Mr. B's own mother
reacted to the loss by isolating herself from other family members and characterized her
mother's death to Mr. B as the loss of the person closest to me.
In another era, Mr. B would not have lived to experience this loss. The average life expectancy
for the MR person in the 1920s was nine years of age. By the 1990s, life expectancy for that
population had increased to between 50 and 60 years. Currently, the life expectancy
approaches that of the general population, except when there are multiple disabilities, cerebral
palsy, Down's syndrome, or severe levels of cognitive impairment.4,6
MR/DD persons now commonly live in the community instead of living in specialized institutions.
They suffer the losses of parents, grandparents, primary caretakers, siblings, and pets, and
often lose their community housing in the process, especially if the loss was that of the last
remaining parent.7 As in Mr. B's case, MR persons historically have been excluded from
attending funeral services of family members.

In the past, it was assumed that the MR/DD patient did not experience death in the same way
as the general population and that they were not affected by such losses. In fact, 72 percent of
institutional staff in the Hollins study7 felt that clients had not been affected in any way by
bereavement. However, they did observe increased scores of aberrant behavior in the bereaved
group after losses, which we now know clearly indicated the significant and disturbing impact of
the loss of an important attachment figure. In the past, only 16 percent of bereaved clients had
the opportunity to visit their loved ones' graves or locations where ashes had been scattered.7 It
is now understood that MR/DD persons who have been allowed to attend the funeral services of
significant others are considerably better at processing the loss appropriately and moving on
with their lives.7
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PRACTICE POINT: Processing Death and Loss with the MR Person
It may be helpful to understand how a MR person experiences loss if one takes into account the
stage of development of that person. According to Piaget,8 the sensorimotor stage would be the
level of cognitive ability of a profoundly MR person (developmental age 0 to 2 years). The loss
experience for such an individual would be one of expectation that the lost object will return
(e.g., constantly unfulfilled expectation).8,9
The pre-operational stage could be said to represent severe/ moderate MR (developmental age
2 to 7 years); in this stage, fantasy and magical thinking may be used. The patient may ask
questions such as: How will the loss affect me? Who will understand me now? Who will take
care of me? Who will be my friend? Who will give me things?9
Concrete operations could be said to represent moderate/mild MR (developmental age 7 to 11
years). This patient can understand clear and specific explanations of loss and death but will
tend to take things literally.9 For example, Mr. B (who only as an adult has achieved this level)
did not fully understand commonly used statements, such as passed away, gone to heaven,
and your grandmother is now looking over you. In supportive psychotherapy, the effective
intervention to help him resolve his bereavement was to utilize concrete terms, such as death
and died, allow him to verbalize his feelings of sadness, and to encourage him to fully
participate in any memorial services.10 He also benefited from making a memory book with
pictures and art, and this activity provided him with a tangible object commemorating the lost
loved one.
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PRACTICE POINT: Quality of Life Indicators
Dual diagnosis individuals are people, and as such they desire the same things from life as
individuals in the general population do: stable relationships, safe housing, symptom control,
quality medical care, financial stability, and occupations where they are contributing,
accomplishing, creating, and achieving goals.11

Mr. B's quality-of-life indicators included housing, finances, and his occupational setting. He
described his housekeeping job as boring and did not feel challenged. Also, he felt an increase
in anxiety whenever he was required to talk with his supervisor, no matter what the content of
the exchange, because he feared authority figures and felt controlled by them. He was
especially fearful when requesting time off work, despite the fact that he had accumulated many
weeks of available leave; this was actually the result of a request by Mr. B for time off during the
Thanksgiving holiday being denied by his supervisor. Mr. B was encouraged to ask his
supervisor for a few new duties and a small raise, and he was given a note endorsing these
changes. His job description and wages were upgraded almost immediately. He was
encouraged to ask his supervisor why leave had been refused last Thanksgiving. When the
reasoning was re-interpreted to him correctly (he was told that his services had been very much
needed during the holiday period), he experienced a boost to his morale, and he readily asked
for and received a brief vacation before assuming his new duties.
Mr. B lived independently in a small apartment, which was his preference, and was able to
afford his monthly bills (rent for subsidized apartment, utilities, groceries, etc.), but previously
had little spending money. This frustrated him at times and he felt it to be an obstacle to meeting
new friends. His small wage increase gave him more spending flexibility and facilitated his
ability to engage in more social activities.
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KEY POINT: Accessing Services in Both the MR and MH Systems for the DuallyDiagnosed
One reason Mr. B was so poor is that he accessed no services from the MR/DD system in his
area, despite being entitled to them. This was partly due to his ability to secure employment
unaffiliated with MR/DD, but also because his family did not acknowledge his mental retardation
as such and take advantage of those services. His condition was referred to by family as a mild
learning disability which should be overcome. As a result, when Mr. B attended several
functions sponsored by MR/DD, he concluded that he wasn't as bad off as those people and
did not come back. At the same time, like many mildly retarded persons, he felt inferior to coworkers in his occupational setting. Although there were opportunities for social networking
through both mental health and mental retardation systems, Mr. B was not involved in these
programs because he was told by his family that he was not retarded and not mentally ill. As
a result, he also was not receiving social security or disability payments (despite his eligibility
through both the MR and MH systems), nor did he have a job coach, vocational rehabilitation, or
case management, for the same reasons.
Without directly challenging Mr. B's assumptions about his condition or his family, the
psychiatrist facilitated access to a supported educational program, job coaching, and case
management.12,13,14 This was done by acknowledging that Mr. B was in fact not as disabled as
some of the other patients; therefore, Mr. B could mentor other lower functioning MR individuals,
serve on an advisory board, and perform other activities related to the MR/DD board that were
truly needed by others, while at the same time accessing needed services for himself.

Go to:
PRACTICE POINT: Relationships
Mr. B had some recurring themes in his relationship difficulties. He tended to be submissive and
passive, which resulted in frustration and an increase in his symptoms of depression and
anxiety. He also had self-esteem problems and poor self confidence, which caused him to make
poor decisions in relationships and attempt to continually please others. This in turn resulted in
poor boundaries with both men and women, and these difficulties were compounded by his
limited insight and judgment. Mr. B expressed a goal of being able to voice his opinions with
confidence and be accepted as a person by both platonic friends and potential significant
others.
Using supportive psychotherapy, the therapist became active and directive in helping Mr. B
improve social functioning and coping skills. In general, the goals of supportive psychotherapy
include the following: a) promoting a supportive therapist-patient relationship; b) enhancing the
patient's strengths, coping skills, and capacity to use environmental supports; c) reducing the
patient's subjective distress and behavioral dysfunctions; d) achieving for the patient the
greatest practical degree of independence from his or her psychiatric illness; and e) fostering
the greatest possible degree of autonomy in treatment decisions for the patient.2
In therapy, Mr. B has learned how to maintain appropriate boundaries in a relationship but still
maintain the relationship. For example, when the therapist ran late for an appointment, Mr. B
learned how to assert his legitimate needs and rights in an appropriate manner and learned that
the relationship was not threatened by him doing so.
Mr. B began to practice limit-setting and appropriate boundaries with his family and learned that
this was safe to do within these stable and supportive relationships. The therapist also made the
therapy safe by extending to Mr. B the option of not answering questions when it did not feel
comfortable and by giving him specific responses to use when these situations arose in other
circumstances and relationships. For example, Mr. B described a chronic problem of giving
others too much information, even when he felt the questions were personal or intrusive. He
gave examples of his male friends and co-workers requesting updates on his dating relationship
or information concerning his finances, and he stated, I always feel like I have to answer their
questions. Often, Mr. B felt vulnerable and exposed in these relationships, but was not sure
how to proceed and again feared the loss of his friends. He was able to utilize some of the
responses learned in therapy to improve these relationships and have his own needs met.
The therapy setting was also utilized for addressing sexuality and issues of romantic
relationships. Like Mr. B, often individuals with MR aren't exposed to sexual education, and it is
common for family members and others to ignore this aspect of the MR individual's adult life.
However, Mr. B (like many other MR persons) was interested in having romantic relationships
and perhaps having children and wanted guidance about these matters.
One night, while out with his friends, Mr. B was introduced to a woman, and without his consent
the male friends set up a date for him with her. He went out with this woman several times.

The girlfriend ended the relationship with him after just two weeks of dating. He felt pressured
by her to engage in sexual intercourse, and gave in despite his better judgment. When he
admitted his remorse to her for engaging in sexual intercourse, an argument ensued wherein
she told Mr. B she no longer wanted to see him. The problems that Mr. B experienced in the
romantic relationship also involved boundary issues and inability to be an advocate for self. The
therapist confronted these issues directly and encouraged Mr. B to voice his opinion and state
his preferences within the safety of the therapy setting and to explore his goals in a romantic
relationship.
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SUMMARY
The Clinical Manual of Supportive Psychotherapy's goals of supportive psychotherapy can be
implemented in the treatment of persons who are mentally ill and MR. These goals are as
follows: reducing behavioral dysfunctions, reducing subjective mental distress, supporting and
enhancing the patient's strengths, coping skills and capacity to use environmental supports,
maximizing treatment autonomy, and achieving maximum possible independence from
psychiatric illness.2
Supportive psychotherapy is an eclectic form of psychotherapy that is widely practiced in
multiple settings and service delivery systems. It is an effective mode of therapy for the dualdiagnosis patient who meets inclusion criteria and is motivated for treatment. The most frequent
goals of the therapy focus on reducing behavioral dysfunction and subjective mental distress, as
well as supporting existing adaptive coping skills while maximizing autonomy and
independence. These goals are especially relevant to the dual-diagnosis patient who has
struggled with issues of disability and dependence and who may have limited experience with
interpersonal relationships and social networks. The working alliance formed in the supportive
psychotherapy will provide the necessary forum in which these issues can be addressed and
processed.