Inpatient group therapeutic interventions for patients with intellectual disabilities Vilash Reddy Wright State University, USA

Journal of Intellectual Disabilities 2015, Vol. 19(1) 51–57 ª The Author(s) 2014 Reprints and permission: DOI: 10.1177/1744629514559314

Date accepted: 15 October 2014

Abstract Group therapy can be an effective mode of therapy, used on an inpatient unit, as it can allow patients to become allies in their journey to understand and overcome their mental health needs. The therapeutic principles discussed by Dr Irvin Yalom illustrate the significance and importance of group therapy, which was strongly incorporated into interactive behavior therapy (IBT) developed by Dr Daniel J Tomasulo. IBT is a type of group therapy, more action oriented, created to allow patients with intellectual disabilities (IDs) to better comprehend discussed topics, by designing and tailoring activities to meet their cognitive and linguistic capabilities. Additional details found in this article will illustrate the methods by which IBT is capable of meeting the needs of patients with ID. Such adjustments include shorter duration of activities to maximize concentration, proactive roleplaying involving the synergistic effort of all members of the group, and limiting the authoritative role of the therapist in a group environment Keywords intellectual disability, Tomasulo, IBT, group therapy, Yalom

Introduction Patients with intellectual disabilities (IDs) can be admitted to an inpatient psychiatric unit from their home environment, on a voluntary basis, but are more likely to be admitted based on the recommendations of the patient’s staff or family, due to acute changes in patient’s pattern of behavior. This collaborative effort, by various members of the patient’s support team, helps provide the treatment team with a global picture of the potential struggles that the patient is dealing with. They also help provide objective information, as the patients, based on the linguistic and

Corresponding author: Vilash Reddy, Department of Psychiatry, Wright State University, 3640 Colonel Glenn Hwy, Dayton, OH 45435, USA. Email: [email protected]

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Journal of Intellectual Disabilities 19(1)

cognitive capabilities, may not be able to express their symptoms or may lack insight into their behavior. In addition to medication management, on the inpatient unit, it is very important to help patients acquire skills, which can be used to deal with their underlying mental health needs. Therapy is one important mode of treatment that should be emphasized during hospitalization, by increasing a patient’s level of awareness about his/her condition and by helping the patients feel empowered, mitigating the feelings of helplessness through acquiring new coping skills, which can be applied in the future. However, based on limited resources, on the inpatient unit, individual therapy may not be feasible. An alternative option, which can be very beneficial in an inpatient setting, is group therapy. Group therapy is a type of psychotherapy that involves one or more therapists working with several patients at the same time. Groups can be as small as three to four patients; however, group therapy sessions generally involve 7–10 individuals (Lesczc and Yalom, 2005). The implementation of group therapy, for patients on an inpatient setting, can potentially improve compliance with treatment, by increasing a patient’s level of awareness and insight about their underlying symptoms and decreasing feelings of emotional isolation. Based on the type of staff available, group therapy can incorporate varying creative activities, including music and art therapy, which will increase participation and provide possible coping skills that a patient can utilize in the future (Montgomery, 2002). The number of staff involved in group therapy should be based on the level of assistance that patients of the group require to maximize that level of direct participation.

Structure of group therapy To help define the structure for group therapy, sessions should be held in a room that is exclusively dedicated to group therapy to minimize the level of unwarranted environmental distractions. One entrance/exit door is preferred to help the facilitator keep track of the participants. The best sitting arrangement for group therapy would be in a large circle, where the members of the group should be capable of seeing one another during the entire session and the therapist should sit along with the patients in the circle so that the therapist will not be viewed as an authoritative figure or the central focus of therapy (Lesczc and Yalom, 2005). A structured, daily schedule should be posted in the common patient area at the start of the day, with staff reiterating the various activities throughout the day to maximize participation. As group therapy is not mandatory on the inpatient unit, if possible, staff could offer words of encouragement or small items of appreciation to participating patients, which can include additional recreational privileges. This type of positive reinforcement will help increase participation in groups and help patients feel empowered in the process. Patients with IDs, based on prior experiences, are often told by an authority figure what to do in their life, so it is important to help maintain a level of autonomy for patients on the inpatient unit.

Principles of group therapy In The Theory and Practice of Group Psychotherapy, Dr Irvin D Yalom (2005) discusses the key therapeutic principles that illustrate the benefit of group therapy for patients.  Introduction of hope: a group will consist of individuals at different stages of the treatment process. The journey for recovery will seem less daunting if patients are able to witness

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53 others who are coping and recovering, allowing those in the beginning of the process to feel more hopeful. Togetherness: being a part of a group, with similar experiences, helps each individual understand and recognize that they are not alone or isolated in dealing with their mental illness. In addition, it helps the individuals understand they are accepted and valuable for who they are. Empowerment: patients have the ability to help one another by sharing their experiences and by increasing the level of awareness of group members. Safe haven: group therapy can be a safe haven for patients to allow them to discuss their issues and experiences, in a nonjudgmental, neutral environment. Mirroring: patients participating in group therapy can be capable of mirroring positive behaviors and actions of a therapist to provide them with more tangible ways to communicate and address underlying issues. Practice: through repetition, patients will be able to practice how to apply their newly acquired techniques, which can alter their behavior in a positive fashion. Through repetition, habitual actions may develop into an underlying mentality that the patient can develop. Interpersonal learning: through reflection, individuals can better understand themselves and their experiences. The knowledge they acquire can allow them to understand the meaning of events in their lives. Purification: the act of sharing feelings or experiences in a group environment can be beneficial. An individual can release his/her suppressed emotions, which reduce his/her level of pain, guilt, or distress. Suppression of emotions can cause physical and psychological tensions within each individual. Confidence: as group members are capable of sharing their feelings and emotions, it can help individuals increase levels of self-esteem and confidence.

Tailoring group therapy for patients with ID It may have been thought for years that patients with ID may not benefit from insight-oriented group therapy to help address their mental health issues due to potential cognitive limitation that hinder therapeutic intervention. However, there is increasing evidence and literature over the past 20 years, illustrating that such individuals can benefit from therapy if the therapeutic interventions are designed to better fit these individuals’ needs and capabilities (Razza and Tomasulo, 2005). Psychotherapy for patients with ID is more effective if it was focused on the use of active/interactive techniques that stimulate learning than a verbal modality alone (Psychology Today, 2013). According to the literature, interactive behavior therapy (IBT), developed by Daniel J Tomasulo, is the most widely used form of group psychotherapy for individuals withID, chronic psychiatric issues, or dual diagnosis (Razza and Tomasulo, 2005). The central focus of IBT is altering the nature and methods of therapy being conducted to meet the needs of individuals with ID, as expressive and/or receptive language can be reduced or limited, for certain individuals (Gardner et al., 1996).

Importance of role-playing Role-playing is used in nearly every phase of human development to teach and model behavior. It is a fundamental concept that is reiterated in IBT to help enrich the therapeutic experience, which

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Journal of Intellectual Disabilities 19(1)

has been coined psychodrama (Marineau, 1989). Psychodrama is an action-oriented therapy and technique that allows expression of a condition or offers a solution, to a particular situation, through active participation in a collaborative group environment (Marineau, 1989). This collaborative approach conducted in an IBT format places an emphasis on the interaction of participants in the group rather than the interaction between the patient and facilitator, as the facilitator should provide guidance on the direction of therapy (Razza and Tomasulo, 2005).

Structure of the IBT model The interactive–behavioral model, which is conducted in a four-stage process, uses 45 min to 1 h time slots for therapy sessions. The reduced time demands are beneficial to maximize participation, as patients are more physically/emotionally present, limiting the levels of exhaustion or inattention (Razza and Tomasulo, 2005).

Four stages of IBT Stage 1: Orientation The goal of the facilitator is to create a stable environment for participants with cognitive impairment to develop skills needed for successful group participation, to focus on creating an environment where each individual is capable of experiencing his/her feelings and emotions, without interruption, as patients with ID are unfortunately accustomed to people not listening to them or talking over them. The facilitator should continue demonstrating skills of actively listening to participants and redirecting members on the importance of paying attention to one another and maintaining good eye contact (Psychology Today, 2013).

Stage 2: Warm-up and sharing The goal of the facilitator is to invite members to talk about themselves within the group. It is important that each facilitator pays attention to the interaction of members within the group to help maximize the therapeutic experience. Each member of the group should take turns disclosing his/ her experiences relating to the topic discussed. Interaction among peers is preferred rather than interaction with the facilitator to maximize group adhesion. It can also be beneficial for the experience to be interactive, as one member selects another member to continue sharing his/her experiences (Psychology Today, 2013).

Stage 3: Enactment The goal of the facilitator is to help implementing techniques such as role-playing to help drive the therapeutic experience for each patient through direct or indirect participation. The issues or topics that were discussed during the warm-up/sharing experiences are formulated into characters through the collaborative effort of participants and facilitator (Marineau, 1989). One type of role-playing technique has been coined ‘‘the double,’’ in which one or more group members will voice the feelings and thoughts of another member who is struggling with a given problem. Various styles of enactment selected by the therapist can be used such as mirroring, role reversal, doubling, and so on. The therapist can also allow participants to select which type of enactment they wish to do (Psychology Today, 2013).

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Stage 4: Affirmation The goal of the facilitator is to validate and acknowledge the effort of each of the participants involved in the group by reflecting on important highlights of the session, qualities, or characteristics of individuals involved that helped maximize the quality of therapy, and acknowledge the level of interaction between individuals, which helped to make the group more cohesive. The period of the session helps individuals to identify components of participation that are applicable to the therapeutic goals of the session and applicability in their own life (Psychology Today, 2013).

Benefits of IBT approach The style and techniques used in IBT are not only beneficial for patients with an ID but can also be utilized for patients with chronic mental illness, such as schizophrenia and depression as well as those with a dual diagnosis. The therapeutic goal is to increase the overall social competence of such individuals and increase each patient’s insight into his/her condition (Daniels, 1998). The technique of IBT can be applicable to addressing particular mental health issues, such as anxiety, depression, and psychosis, which can help patients to address their underlying pathological issues through a therapeutic modality (Mental Health Reviews, 2005).

General topics to discuss with inpatient population In addition to IBT, staff involved should focus on educating patients on topics that are important for mental and physical well-being, including nutrition, sleep hygiene, psychotropic education, and exercise. 1. Education on proper nutrition: it is important to discuss with patients the importance of quality nutrition and what types of food/beverage are beneficial for each patient’s medical health. In addition, it is important to address topics such as proper portioning of meals, monitoring calorie intake, and type and quality of nutritional items. Patients are often misinformed and/or not educated about the importance of quality nutrition, which can have benefits on mental and physical health, to limit or hinder the likelihood of developing conditions such as diabetes and heart disease. 2. Education on sleep hygiene: it is important for patients to understand the importance of structuring their life to allow them to maximize the quality of sleep and the duration that they sleep for, as it can be beneficial for mental health. Therapists should discuss topics such as limiting caffeinated beverages before evening, restricting bedroom activities for sleep/ sexual activities (limited stimulating activities such as TV, eating, and reading), possibility of incorporating relaxation techniques before sleep to reduce internal tension, and educating patients on leaving the bedroom if unable to maintain sleep. It is also important for the therapist to focus on establishing a consistent regimen in which patients should limit oversleeping, as this can be a counterproductive process. 3. Education on sleep medications: inadequate quality of sleep (nighttime restlessness, inability to fall and/or stay asleep, and early morning awakening) can have direct effects on any psychiatric condition the following day, as the brain is unable to feel rested and calm. It is important to address topics related to sleep medications, such as residual sluggishness and (grogginess) and to educate patients on being watchful of oversedating effects of medications. It is particularly important to educate patients who self-administer medications about

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Journal of Intellectual Disabilities 19(1) the ill effects of over medicating with sleep medication. It is also important to discuss with patients to lookout for possible side effects with particular medications, such as parasomnia with Ambien. 4. Psychotropic education: based on patients’ cognitive capabilities, the therapist should discuss with patients the importance of continuity of medication use, the type of psychotropic meds, and the potential side effects or withdrawal symptoms. In addition, harmful effects that patients experience should be discussed with their service providers. Pictorial diagrams or illustrations can be helpful for all patients, particularly those with receptive cognitive impairment. 5. Benefits of exercise: exercise, particularly aerobic exercises, for at least 30 min to 1 h, daily, can be a beneficial outlet to dissipate internal tension, which can exist with regard to the etiology of psychiatric illness. Exercise can have physiological effects on the body, as it can reduce the level of stress hormones, including cortisol, as well as stimulate the production of endorphins, which are natural mood elevators as well as pain relievers (Anderson and Shivakumar, 2013). This concept has been vocalized by athletes, as a ‘‘runner’s high’’, in which euphoric feelings are felt after an extended period of exercise. It is important for staff to screen patients who would be appropriate to participate in physical activities to limit the likelihood of injury. If patients had physical limitations, exercises could be altered to allow varying levels of participation within a group. It would be beneficial for patients to be capable of participating in exercise groups 20–30 min, hopefully three times a day, according to staff availability. Also outdoor activity, due to increased exposure to sunlight, would be beneficial for patients to naturally increase their level of vitamin D. 6. Relaxation skills: it is important for a therapist to help patients address the physical tension that exists, as this is one among a constellation of symptoms of anxiety. A therapist can incorporate techniques such as progressive muscle relaxation or deep breathing; however, the level of communication among staff should be focused on meeting the cognitive abilities of each patient. Simpler terminologies or directions regarding the exercises, as well as ongoing reiteration, are beneficial to maximize participation within the group. It is important for the facilitator to be aware of patients who have decreased receptive skills, as they may require more individual attention to reduce the likelihood of being derailed from the group environment. The patient, to reduce or dampen the physical tension that exists during periods of anxiety, can utilize these newly acquired skills (Anderson and Shivakumar, 2013).

Conclusion Group therapy can be an effective mode of therapy used on an inpatient unit, as it can allow patients to become allies in their journey to understand and overcome their mental health needs. The principles of group therapy, discussed by Dr Yalom, help emphasize the synergistic effect of group therapy on each patient. Patients with IDs, in addition to mental health needs, may need adjustment in the type and delivery of group therapy. Based on the discussed literature, the main focus on group therapy, among patients with ID, should be focused on therapy activities that are more action oriented. According to IBT, patients with ID are able to absorb and understand topics, when the activities are tailored around their cognitive and linguistic abilities. Each IBT activity should be shorter in duration to maximize the

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concentration on each topic (Psychology Today, 2013). The therapist should devote additional time to reiterate concepts to patients. It is less important to cover a number of topics but more important that each topic is well understood by the patients. Also the structure of therapy should focus on interaction among patients, in which they are capable of using role-playing. The therapist seeks the assistance of each member in the group for guidance on developing resolutions to each scenario. This style of therapy is more tangible and meaningful, as patients are capable of participating rather be lectured to. It may also increase their attention span, as various participants are involved. The mode of IBT, in addition to other general topics, should be incorporated into varying therapeutic modalities for patients while on the inpatient unit. Patients experiencing various mental health issues can participate in IBT, which can be tailored to discuss psychological issues that stem from such conditions. However, it is important to be mindful about how the patient would act during group therapy, as the purpose of the event is group participation or collaboration, rather than central focus on one particular patient’s behavior or actions. It is important for staff to screen patients before allowing them to participate; otherwise, the process would be counterintuitive or counterproductive. Funding This research received no specific grant from any funding agency in the public, commercial or not-for profit sectors.

References Anderson E and Shivakumar G (2013) Effects of exercise and physical activity on anxiety. Front Psychiatry 4(27): 1–4. Daniels L (1998) A group cognitive-behavioral and process oriented approach to treating the social impairment and negative symptoms associated with chronic illness. Journal of Psychotherapy Practice and Research 7(2): 167–176. Gardner W, Hurley A, Pfadt A, et al. (1996) Counseling and psychotherapy. In: Jacobson J and Mulick J (eds) Manual of diagnosis and professional practice in mental retardation. Washington: American Psychological Association, pp. 371–380. Lesczc M and Yalom I (2005) The Theory and Practice of Group Psychotherapy. New York: Basic Books. Marineau R (1989) Jacob Levy Moreno 1889–1974: Father of Psychodrama, Sociometry and Group Psychotherapy. New York: Tavistock Routledge. Mental Health Reviews (2005) Group therapy for psychiatric disorders: an introduction. Available at: http:// (accessed 12 June 2014). Montgomery C (2002) Role of dynamic group therapy in psychiatry. Advances in Psychiatric Treatment 8(1): 34–41. Psychology Today (2013) Positive Interactive-Behavioral Therapy (P-IBT). Available at: http://www.psycho (accessed 4 July 2014). Razza NJ and Tomasulo D (2005) Healing Trauma: The Power of Group Treatment for People with Developmental Disabilities. Washington: American Psychological Association.

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Inpatient group therapeutic interventions for patients with intellectual disabilities.

Group therapy can be an effective mode of therapy, used on an inpatient unit, as it can allow patients to become allies in their journey to understand...
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