Positive group psychotherapy modified for adults with intellectual disabilities.

Review

Positive group psychotherapy modified for adults with intellectual disabilities Daniel J Tomasulo New Jersey City University; University of Pennsylvania, USA

Journal of Intellectual Disabilities 2014, Vol. 18(4) 337–350 ª The Author(s) 2014 Reprints and permission: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1744629514552153 jid.sagepub.com

Date accepted: 15 August 2014

Abstract Mental health disorders are considerably more prevalent among people with intellectual disabilities than in the general population, yet research on psychotherapy for people with dual diagnosis is scarce. However, there is mounting evidence to show that adults with a dual diagnosis can find help through group therapy and have more productive and meaningful lives with improved relationships. This article focuses on a review of evidence for interactive behavioral therapy, a widely used model of group psychotherapy for these conditions, and reviews the modifications drawn from the field of positive psychology and positive psychotherapy being incorporated into the model. A sample of a modified positive intervention, the virtual gratitude visit, is explained and suggestions for future research are given. Keywords positive psychotherapy, intellectual disabilities, group therapy, positive interventions, direct interventions

Out of your vulnerabilities will come your strength. —Sigmund Freud

Introduction There have been a number of therapeutic interventions such as cognitive–behavioral therapy (CBT) and psychodynamic therapy shown to be effective with people with dual diagnosis (Beail and Jahoda, 2012; Dagnan and Lindsay, 2012). But there are difficulties that arise in using these Corresponding author: Daniel J Tomasulo, Department of Psychology, New Jersey City University, 130 Maple Ave, Building 9, Suite 9, Red Bank, NJ 07701, USA. Email: [email protected]

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verbal therapy interventions as Beail and Jahoda (2012: 131) explain, ‘‘ . . . people with intellectual disabilities may have difficulties talking about abstract thoughts and feelings.’’ The interactive behavioral therapy (IBT) model of group psychotherapy has evolved over the past 25 years through work with adults who are diagnosed with both intellectual disabilities (IDs) and psychological disorders and who have difficulty verbalizing. IBT is a widely used form of evidence-based psychotherapy, specifically developed for people with dual diagnosis as discussed in detail in Razza and Tomasulo (2005). The IBT model’s theoretical underpinnings, as well as many of its techniques, are drawn from components of many therapeutic interventions, but chiefly from psychodrama, as developed by Moreno (Blatner and Blatner, 1988; Razza and Tomasulo, 2005), the work of Yalom and Leszcz (2005), and more recently from the pioneering work in positive psychology and positive psychotherapy by Peterson and Seligman (2004), Rashid and Ostermann (2009), Seligman, et al. (2006), and Duckworth et al. (2005). There is significant verification that mental health disorders are considerably more prevalent among people with IDs than in the general population (Gobrial and Raghavan, 2012; Horovitz et al., 2011). Yet research on psychotherapy for people with dual diagnosis is scarce, and training for professionals to deliver this treatment is rare. As a result, adults with IDs and mental health issues are not considered good candidates for individual or group therapy. Rather, they are typically exposed to ‘‘social skill’’ training groups that are psychoeducational in nature with limited therapeutic value (Razza and Tomasulo, 2005). But there is mounting evidence to show that adults with dual diagnosis disorders can find help through group therapy and have more productive and meaningful lives with improved relationships (Lundrigan, 2007; Razza and Tomasulo, 2005; Tomasulo and Razza, 2006.) The IBT model was specifically designed for a population that cannot read, has dual diagnosis, and typically has difficulty processing language. The theoretical and intervention adjustments are elaborated upon elsewhere (Daniels, 1998; Razza and Tomasulo, 2005; Tomasulo and Razza, 2006), but it is sufficient to say that the stages of the group process as well as the techniques have been designed to enhance the efficacy for those with these attendant disorders. Highlights of the research on this model are explained below, along with implications of a pilot study on the perceptions about the therapeutic experience in IBT. Finally, drawing on recent advances in positive psychology, the adapted use of character strengths and selected interventions from positive psychotherapy are discussed.

History of psychotherapy services for people with ID There are two main points of contact for professional psychologists working with people with IDs, namely intellectual assessment for purposes of classification and treatment via applied behavioral analysis (Sturmey, 2012). There is also a long practice of psychologists working to improve the lives of individuals with ID (Charlot and Beasley, 2013) and a similarly long tradition regarding educational planning (McVilly and Rawlinson, 1998). But something is missing. Other than applied behavior analysis, the mental health needs of people with ID are routinely not researched, overlooked, or worse, ignored. The American Psychological Association’s (APA’s) Division 33, for intellectual and developmental disabilities, rarely explores mental health concerns through psychotherapy (Costello, et al., 2010) although it emphasizes research and training. One possibility for the difficulty in understanding and treating the mental health needs of people with ID is the fact that the symptoms of various psychopathologies manifest differently than they


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do in non-ID individuals (Costello et al., 2010; Tomasulo and Razza, 2006). This makes both diagnosing and treating psychological disorders a difficult—but not impossible—challenge. The atypical manifestation of psychopathology in people with ID makes for a cacophonous clinical presentation that usually results in something called ‘‘diagnostic overshadowing.’’ The term, coined by Reiss, et al., (1982), reflects the tendency of clinicians to use the umbrella of IDs to subsume various psychopathologies. This causes the psychiatric condition to remain unchecked, which naturally results in the condition going untreated (Fletcher et al., 2007; Griffiths et al., 2002; Butz et al., 2000). Indeed, in the APA’s (2012) Guidelines for Assessment of and Intervention With Persons With Disabilities, diagnostic overshadowing is identified as a continuing obstruction in the treatment of people with ID, and, in general, they point toward a dearth of acceptable preparation for psychologists: Unfortunately, while psychologists receive extensive training in treating mental health disorders, they rarely receive adequate education or training in disability issues. (p. 43)

This trend of inadequate services for mental health treatment is not a phenomenon limited to the United States. Dagnan and Lindsay (2012) also describe very similar circumstances and resulting issues in the United Kingdom. One step toward the amelioration of this paucity in training has already been undertaken in the form of a separate Diagnostic Manual for People with Intellectual Disabilities (DM-ID) (Fletcher et al., 2007). This evidence-based manual highlights the shift in diagnostic criteria used for people with IDs. As an example, the usual symptoms of posttraumatic stress disorder (PTSD) in a non-ID population require that the individual has been exposed to a traumatic event where the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury—or a threat to the physical integrity of self or others (Tomasulo and Razza, 2007). But what constitutes the activation of a traumatic reaction in a non-ID population may be vastly different for someone with limited cognitive abilities. According to the DM-ID: In assessing for traumatic exposure in people with ID, take note that events such as developmental milestones, residential placement, and even adult, consensual sexual experiences have led to posttraumatic reactions in some individuals with ID. It appears that the range of potentially traumatizing events is greater for individuals with a lower developmental age . . . . (Tomasulo and Razza, 2007: p. 373)

But even if there were more interest and awareness about psychopathology within people with IDs, research on these issues is scarce and difficult to conduct. People with ID traditionally have been excluded from subject pools in psychotherapy efficacy research (Prout and Nowak-Drabik, 2003) ostensibly because institutional review boards (IRBs) are reluctant to approve investigation of therapeutic approaches for people with ID and comorbid psychological disorders. Of equal importance is understanding the nature of the psychiatric disorders experienced by people with ID. Despite early misunderstandings and the unfounded assumptions of many mental health professionals, people with ID experience the same type of psychiatric illness as their nondisabled counterparts (Charlot, 1998; Nezu et al., 1992). Charlot’s research provides descriptions of symptoms that may vary from those more commonly seen in the nondisabled population—for example, people with ID suffering from depression frequently talk to themselves out loud, rather than ruminate silently. This literature suggests there may be variation in the typical symptom picture of a given disorder, but the experience of the nature of the disorder, for example, depression, anxiety, and even psychoses, is inherently the same.


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Although the higher prevalence rate is primarily due to the cognitive limitations and truncated developmental level (Charlot and Beasley, 2013; Fletcher et al., 2007; Razza, et al., 2011), there are many other reasons that contribute to the higher-than-average rates of psychiatric disorders experienced by people with ID. These origins are similar to the dynamics affecting the general population and have been previously established as contributing to depression and other psychiatric disorders for a non-ID population. These factors, as reported in Nezu et al. (1992), include such elements as low levels of social support, poorly developed social skills, a sense of learned helplessness, a low sense of self-efficacy, decreased inhibition in responding to stressful events, and fewer opportunities to learn adaptive coping styles. These circumstances are often best treated by group therapy in the general population because of the modality’s efficiency and effectiveness. It is likely that since these same contributors are present with people with IDs, group therapy will likely be the best treatment for these conditions as well. Development of clinical tools to meet the needs of people with a dual diagnosis is still in its infancy. There would appear to be at least two sides to the research opportunity. First, since people with IDs manifest the symptoms of psychopathology differently, it is reasonable to hypothesize they may respond differently to a particular intervention known to be effective in a non-ID population, necessitating a modification of that intervention. Second, the development and assessment of theoretical models employing these intervention modifications would be a welcome addition to psychotherapy efficacy research. But these opportunities have yet to be fully realized, and the net result is that ID individuals are much less likely to receive psychotherapeutic treatment than the general population. Despite the higher incidence of varied pathologies, there is too little research and too little education for clinicians. This leaves the most susceptible and affected among us with the fewest psychotherapeutic resources for improvement. Below are some findings from work being done to meet these needs and set future directions for research.

Description of IBT IBT has been the subject of a number of studies (Blaine, 1993; Carlin, 1998; Daniels, 1998; Keller, 1995; Lundrigan, 2007; Oliver-Brannon, 2000) and the emphasis of the APA’s first and only book on psychotherapy for people with IDs (Razza and Tomasulo, 2005). The aim of IBT was to use a group format to elicit the same type of therapeutic gain for adults with ID that was available to the general population. For this reason, the model was fashioned around the activation of therapeutic factors originally identified by Yalom (Yalom and Leszcz, 2005), as these elements appeared to be the sine qua non for success in group therapy outcome studies. Therapeutic factors are those features of a group process that have therapeutic value for members and are identified as acceptance/cohesion, universality, altruism, instillation of hope, guidance, vicarious learning/modeling, catharsis, imparting of information, self-disclosure, selfunderstanding, interpersonal learning, corrective recapitulation of the primary family, development of socializing techniques, and existential factors (Razza and Tomasulo, 2005). These factors have been written about extensively elsewhere (Razza and Tomasulo, 2005, 2006), and limitations of space prohibit elaborating on each factor. The reader is directed to these sources for a more indepth discussion. Using action methods from the field of psychodrama, the IBT model emerged as a vehicle to cultivate the activation and recurrence of these factors and strengthen prosocial behavior within the group context (Weiner, 1999). To optimize this cultivation, the IBT model uses a four-stage format


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that is process oriented. The engagement of the process involves facilitator(s) to guide the members through each of the stages, namely orientation, warm-up and sharing, enactment, and affirmation. Each stage was designed to deepen the engagement of the members in the group process using methods to stimulate the occurrence of therapeutic factors and acknowledging these factors. As part of the training and priming process for facilitators, videotapes of how therapeutic factors emerged within an IBT group were shown and instructions given on how to reinforce them. The orientation stage used a technique dubbed ‘‘cognitive networking’’ to allow members to get ready for the group process by listening and giving feedback on what they heard. The topic of discussion during this initial stage is less important than the process. Members are invited to speak and listen as a way of getting ready to participate. The primary intellectual and psychopathological difficulties as well as secondary disabilities (such as audiological, visual, and attentional deficits) necessitated this preliminary stage to help participants orient to the group. The warm-up and sharing stage was designed to help move members from horizontal selfdisclosure (disclosure about the act of disclosure itself) toward vertical disclosure (in-depth disclosure about the content.) In people with ID, the horizontal self-disclosure might take the form of saying, ‘‘Something happened at the bus stop yesterday.’’ The vertical disclosure might be ‘‘I was called a retard and the person laughed at me and made me feel terrible.’’ The enactment stage uses action methods from the field of psychodrama to role-play emotionally salient scenes from a chosen protagonist, which then become the focus of the group’s work for the day. The three techniques used are the empty chair, doubling, and role reversal. The empty chair is a classic version of the technique originally developed by Moreno where the protagonist engages talking to an empty chair representing another person, a future or past self, or transcendent entity, such as God. With doubling, the protagonist is invited to express feelings evoked by an interpersonal situation while the group members listen. The membership is then asked one by one to stand behind (if this is agreeable to the protagonist) or alongside and represent and establish identity with the protagonist by verbalizing what the protagonist is feeling. The accuracy or alignment of these feeling statements with the protagonist is confirmed or corrected with help from the facilitator(s). In multiple doubling, more than one group participant is asked to identify with the protagonist. This creates various perspectives for both the protagonist and the other group members and provides the protagonist with the feeling of being understood and supported. Such an enactment can foster the therapeutic factors of cohesion, universality, altruism, hope, guidance, vicarious learning, imparting of information, self-disclosure, self-understanding, interpersonal learning, and development of socializing techniques. (Razza and Tomasulo, 2005, 2006) The use of a multiple double lessens the normal egocentric nature of individuals with ID and psychopathology because the protagonist is listening for the accuracy of the double, and the doubles are attempting empathic understanding for the protagonist. The role-reversal technique provides role clarification, reality testing, and most importantly, empathic development as the protagonist is asked to ‘‘step into the other’s shoes.’’ Typically, they would be asked to reverse roles with the empty chair, play that role, and then return to their chair. Once the enactment is completed, and if time permits, others in the group may take their turn as a protagonist. Throughout the first three stages, incidents of therapeutic factors demonstrated that have occurred within the group are acknowledged by the facilitators. Simple acts of moving a chair to allow someone to enter the group (altruism) and spontaneous comments such as ‘‘You’re going to be all right’’ (instillation of hope), or ‘‘I felt like that, too,’’ (universality), are recognized and


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affirmed by the facilitators. In the research section subsequently, there will be more discussion of the evidence for the presence of therapeutic factors (Blaine, 1993; Carlin, 1998; Daniels, 1998; Keller, 1995; Razza and Tomasulo, 2005).The affirmation stage allows for the facilitators to review the therapeutic factors that have emerged throughout the group and relay these instances back to each member. Over time, the members are taught to give feedback to one another during this phase, which also allowed for positive emotional closure of each session.

Summary of research on IBT Blaine (1993) tested the efficacy of an IBT group treating both intellectually disabled and nondisabled participants over 17 sessions. Using a number of measures, she concluded that both types of patients showed significant positive change from the therapy, and interestingly, those subjects with IDs demonstrated higher frequencies of most therapeutic factors (as identified by Razza and Tomasulo, 2005; Tomasulo, 1998; Yalom and Leszcz, 2005). In addition, each patient sets goals for himself/herself and then evaluated himself/herself with regard to how successful he/she felt he/she had been. The final evaluations suggested that patients’ achievements of their interpersonal goals in therapy exceeded their expectations. Keller (1995) also found that IBT encouraged the emergence of many therapeutic factors through high interrater reliability agreement by experts watching videos of IBT groups. Daniels (1998) tested the 16 weekly sessions of the IBT model compared to those on a waiting list with a group of chronically mentally ill adults carrying the diagnoses of schizophrenia or schizoaffective disorder. Multiple clinical rating scales were administered to measure changes in social functioning and negative symptomatology. Three hypotheses were tested, and each was supported by the ensuing data. Specifically, it was found that IBT (1) increases the overall social competence of people with chronic schizophrenia or schizoaffective disorders, (2) improves the negative symptoms that are often associated with poor treatment outcome for people diagnosed with schizophrenia or schizoaffective disorders, and (3) facilitates the emergence of those therapeutic factors found to enhance social competence in people with chronic schizophrenia and schizoaffective disorders.1 What is of particular interest is that in 16 weeks of treatment with the IBT model The Global Assessment of Functioning (GAF) Scale, a 90-item scale used to assess overall psychosocial functioning and symptom level, was significantly improved for the treatment groups. This suggests that the IBT format, in addition to facilitating therapeutic factors, supports the evolution of global social competence. Rather than strengthening specific behavioral components alone, as would be the goal of an applied behavior analysis approach, the IBT model is aimed at more broadranged development of interpersonal socialization. The IBT model was also studied by Carlin (1998), who explored its value in helping individuals with IDs cope with bereavement. A study by Oliver-Brannon (2000) compared IBT with behavior modification techniques in treating subjects with dual diagnosis of ID and psychiatric disorders. The study suffers from small sample size and nonrandom assignment, but data collection revealed that subjects in the IBT group, compared with the behavior modification controls, evidenced greater reduction in target behaviors, increased problem-solving skills, and earlier return to the community, further supporting the emphasis on global social competence. In an intriguing pilot study, Lundrigan (2007) designed a questionnaire based upon Seligman’s Consumer Reports survey of client satisfaction with mental health services (Seligman, 1995). The results are informative about how therapy helps ID participants and how it is perceived. Because


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most of the participants could not read, Lundrigan administered the survey via a semi-structured interview to 40 IBT participants, all of whom were dually diagnosed with IQs between 50 and 70. Participants reported feeling helped by their participation in IBT groups, as evidenced by their responses to these questionnaires, and a few selected participants were chosen for in-depth clinical interviews. Of the 40 clients who were surveyed, 34 (85%) felt that they had been helped by participation in IBT. It is of note that this figure corresponds closely to the 87% satisfaction rate found in the Consumer Reports study. The high degree of satisfaction reported in the questionnaire lends further support to the presence of the therapeutic factors in the IBT groups identified by Razza and Tomasulo (2005). The participants entering this study also identified their reasons for treatment. In descending order, the symptoms bringing them for therapy are noted as depression, grief, generalized anxiety, family problems, marital or sex issues, problems at work, desire for weight loss, drug and alcohol issues, and eating disorders. In other words, they appeared for therapy for the same reasons as those in the Consumer Reports study. In the Lundrigan study, the satisfaction level of all the participants ranged from being satisfied to being completely satisfied with their therapist and 97% ranked the competence level of the therapist as fair to excellent. In a similar vein, respondents of the Consumer Reports study were equally pleased irrespective of the fact whether they were seen by a psychiatrist, a psychologist, or a social worker. Of particular importance are the quantitative measures of improvement as a result of taking part in the IBT groups. In total, 90% of the participants felt that therapy improved their ability to get along with others, while 82.5% believed that the therapy helped them become more productive at work. Eighty percent felt it was helpful in coping with everyday stress, and 85% felt IBT helped them enjoy life more. In addition, 92.5% thought that therapy was responsible for personal growth and insight, while 95% noted their confidence and self-esteem had been bettered. With regard to combating the symptoms of depression, the most commonly sought-after reason for treatment, 85% felt IBT helped them alleviate low moods. What is most striking about these numbers is that of the 40 participants none reported that the therapy made them worse, even though this was a clear option given to them during the semi-structured interview. The in-depth interview offered additional insight as to what value the group process has for therapeutic gain. Although only carried out with five participants, the members reported they not only enjoyed receiving help from the group but also relished the opportunity to give it. This matches the work put forth by Adam Grant (2013) which suggests there is great value in increased well-being for the self and others when providing a forum to allow for the opportunity of giving. But it is also emblematic of Yalom’s therapeutic factors, particularly when it is understood in the light of altruism and guidance. According to Yalom (1995: 12): In therapy groups, too, patients receive through giving, not only as part of the reciprocal giving receiving sequence but also from the intrinsic act of giving. Psychiatric patients beginning therapy are demoralized and possess a deep sense of having nothing of value to offer others. They have long considered themselves as burdens, and the experience of finding that they can be of support to others is refreshing and boosts self-esteem.

The IBT model uses a format that prepares the facilitators to notice traits that emerge naturally within a group. These traits are known to have positive therapeutic value with other populations and the work of the IBT group facilitation is to acknowledge and facilitate their activation for the purpose of improving the global social competence of the membership. The specific techniques,


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such as the empty chair, doubling, and role reversal, are used to engage members in an encounter where they can both give and receive. The accumulated result of these efforts results in greater well-being for the members as indicated in the studies reviewed. In recent years, research in the field of positive psychology and positive psychotherapy has been used to enhance these efforts through the establishment of work on character strengths and positive interventions. The impact of these advances will be reviewed for their potential for future directions for research and practice.

Adapting positive psychotherapy and interventions Martin Seligman’s (1992) work on optimism helped establish a theoretical and empirical base for his positive psychology platform as president of the APA in 1998 (Seligman and Csikszentmihalyi, 2000). Demonstrating that individuals with a pessimistic style could learn to be optimistic, he made the transition from understanding the mechanics of helplessness (Seligman, 1975) to teaching people how to be optimistic (Peterson, 2000). He suggested that psychology include a model of building strengths—promoting mental health—rather than only treating mental illness. The publication of Character Strengths and Virtues: A Handbook and Classification (Peterson and Seligman, 2004) was designed to offer a compendium of what is right and virtuous in human beings and was created in direct contrast to balance out the Diagnostic and Statistical Manual’s (2000) list of what is wrong. In the same timeline as Seligman’s learned helplessness work, another researcher (Fordyce, 1977) had pioneered a series of happiness interventions (such as increasing socialization, becoming more active, and deepening one’s relationships). He found students trained in a variety of 14 different happiness interventions demonstrated fewer symptoms of depression and were, in general, happier than a control group. Deci and Ryan (1985), along with a few others (Csikszentmihalyi, 1990 [1976]; Diener et al., 1985), moved the theoretical into the empirical, substantively ushering positive psychology to its current position. Evidence-based interventions demonstrating effective changes toward increased well-being and flourishing are now the standard (Seligman et al., 2005). Indeed, the fact that we have this current focus in positive psychology is a direct outgrowth of more than a decade of empirically validated treatments and research studies. Positive and transcendent experiences are now investigated with rigorous scientific methods and robust results. Seligman’s work on optimism also served as a foundation for positive interventions, residing at the core of the Penn Resiliency Program; for the prevention of depression (Seligman et al., 2009); finding its way into education (Reivich et al., 2005); the military (Reivich et al., 2011); and most relevant to the current interest in this article—into positive psychotherapy (Rashid and Seligman, 2013; Seligman et al., 2006). The research focusing on the use of positive interventions within positive group therapy is most relevant to the current topic.

Positive group psychotherapy Traditional psychotherapy focuses on helping clients through symptom reduction, meaning that when the indicators for therapy fade away the therapy is considered successful (Seligman, 1995, 2011). Positive psychotherapy (PPT) developed by Rashid and his colleagues (Rashid and Ostermann, 2009; Rashid and Seligman, 2013; Seligman et al., 2006) is a strength-based approach that is directly aimed at offering a more comprehensive perspective of a client and his or her life circumstances. It is becoming known as an evidence-based standpoint that explores both strengths


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and weaknesses to achieve greater well-being and functioning, that is, moving from looking at what is wrong to what is strong. The research on using PPT is gaining more attention in the clinical sector. One study in positive psychotherapy conducted in a group therapy format will highlight some implications for IBT (Seligman et al., 2006). Forty mild to moderately depressed students were divided into a treatment and a nontreatment group. The treatment condition consisted of two groups of 8–11 participants seen for 6 weeks for 2-h sessions. The session was half a discussion of the exercise assigned from the previous week and an introduction to the new exercise. The participants carried out homework assignments and reported back each week on their progress. The first week participants were asked to take the inventory of strengths (VIA-IS) survey (the one developed from Peterson and Seligman, 2004) and use their top five strengths more often in their day-to-day lives. Week two involved writing down three good things that had happened during the day and why you think they occurred. The third week participants were asked to write a brief essay on what they want to be remembered for the most that is, a biography or an obituary, if you will, of having lived a satisfying life. The next session involved composing a letter of gratitude to someone they may never have thanked adequately and reading that letter to them in person or by phone. During the fifth session, the members were asked to respond very positively and enthusiastically each day to good news received by someone else. The final session involved savoring daily events in their lives that they normally did not take time to enjoy and journaling how this experience differed from their normally rushed occurrence. Time was also spent during this last session on tailoring the exercises for their use following the end of the study.2 The group PPT participants did better than the no-treatment group on assessments of depression and satisfaction with life. But there is a powerful finding beyond this positive change. The gains made by the PPT groups were maintained with no other intervention by the researchers throughout a 1-year follow-up, while the baseline levels of depression for the nontreatment group remained unchanged. This is very unusual in the study of depression and highlights how the use of these exercises involved self-maintaining features that served the participants beyond the intervention. In a recent pilot study (Meyer et al., 2012), a modification of these interventions is applied with people with schizophrenia with promising results. But a closer look at the research shows that while the effects of these positive interventions are powerful, they required the participants to be able to read and write. As has already been established, the most susceptible among us, people with IDs, are those who can do neither. The questions then become, is it possible to extrapolate from these interventions ways in which people with simultaneous existing intellectual and psychiatric disabilities could profit from modified interventions? If so, what modifications may be necessary? The first four of the five successful interventions identified in the use of positive interventions for group therapy involve participants reading or writing. A modification for people with IDs would combine the best practices from PPT by incorporating adapted interventions (not requiring literacy) into the existing IBT model. Central to the development of a strength-based intervention is the identification of character strengths (Peterson and Seligman, 2004), but as of yet no provision exists for the survey to be given to those who do not read. This will be an avenue for future development, but strengths can be noticed and cultivated by facilitators perceiving these character strengths in the participants. Just as facilitators were trained to spot therapeutic factors as they emerged, we have begun training IBT facilitators to know their own strengths and then coached them to spot strengths in group members. In doing so, it was found that character strengths and therapeutic factors are remarkably similar. In fact, upon a closer inspection, some of the terms used


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were identical or very closely overlapped. As an example, the character strength of hope as identified by Peterson and Seligman’s (2004) is Yalom’s (1995) instillation of hope. Spirituality as a strength may be translated into the therapeutic factors of universality, existential factors, and altruism. Social intelligence might be viewed as the therapeutic factor of development of socializing techniques, and the character strength of perspective or wisdom could be seen as Yalom’s imparting of information or self-understanding. But there were also some character strengths that were clearly unique and yet very relevant for our dually diagnosed participants. Persistence, vitality, and bravery are all character strengths that are not neatly covered by the therapeutic factors but could clearly be used to describe many of the individuals in IBT groups. Future research should articulate how therapeutic factors and character strengths can be used jointly for therapeutic gain. But perhaps the most important intervention in identifying strengths takes place before each IBT group begins. Flu¨ckiger (2008) and his colleagues have developed a procedure, resource priming, where the facilitators of psychotherapy take 10 min before their session to focus on the strengths of their individual client. The result is that the priming leads to resource activation whereby participants focus on the positive perspective of their behavior, which in turn leads to better progress in therapy as measured by greater reduction in symptoms and higher levels of wellbeing. Such resource priming is now part of what IBT facilitators focus on along with therapeutic factors. We now include a pre-group contemplation of each member’s strengths. In augmenting IBT to use the findings of PPT, four stages have been enhanced. During orientation and warm-up and sharing stages, the facilitators identify the occurrence of therapeutic factors and character strengths. This continues as a foundation for support and encouragement while accessing vertical self-disclosure from the participants. This brings the group to the central stage of enactment. It is in this stage that there is a shift from reading and writing interventions toward role-playing interventions and an example is given subsequently. Finally, the affirmation stage allows for a review of each participant’s display of therapeutic factors and character strengths throughout the group by facilitators and members alike.

Adaption through enactment: The virtual gratitude visit (VGV) Expressing gratitude as a positive intervention has been central to the positive psychology movement. The gratitude visit, where participants wrote and delivered a letter of gratitude to a person they felt they had not properly thanked, was one of the first positive interventions studied (Seligman et al., 2005). In this initial report, when compared to other interventions, those who performed the gratitude visit were found to be the least depressed and the happiest of all the participants. Gratitude has also been found to enhance self-esteem (McCullough et al., 2002), life satisfaction (Kashdan et al., 2006), prosocial behavior (Wood et al., 2008), and better interpersonal relationships (Algoe et al., 2008; Tsang, 2007). It was also found to directly influence the capacity to broaden and build positive emotions (Fredrickson, 2004, 2009) and was noted by Lyubomirsky et al. (2005) as one of the main interventions that can lead to sustainable happiness. But there also have been some surprising results with regard to gratitude. Boehm and Lyubomirsky (2009) studied participants who savored positive events by keeping a gratitude journal of five things they were grateful for either once a week or three times a week and then compared with a control group that did not keep a journal. Pre- and postmeasures on well-being revealed that gratitude journaling worked better once in a week than three times a week or the control group. In fact, it was the only condition in which improvement in well-being was noted. The authors theorize that the success of a positive intervention depends on not only what the intervention is but also how it is delivered.


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As mentioned above, the gratitude visit is a core intervention in PPT and can be easily modified for those unable to read and write by making the gratitude visit virtual through a roleplaying exercise within the group. There is benefit from using role playing as a core intervention in a group of people with dual diagnosis because it enhances the engagement of the members while activating more of the senses (Hurley et al., 1996; Tomasulo and Razza, 2006) and is often used as a component to enhance the viability of approaches like CBT (Beail and Jahoda, 2012; Dagnan and Lindsay, 2012) Within the IBT format, the VGV has been used effectively because it moves away from the need to write a letter or use a journal and is only done during the typical once-a-week IBT group. It uses the empty chair as a vehicle for delivery of gratitude, which broadens the application to those people who may no longer be accessible to the protagonist because they have moved away, passed on, or have simply not had gratitude expressed to them by the protagonist. It also allows for expressing gratitude toward someone unknown, such as a stranger who was kind. For this technique, two chairs would be arranged, namely one for the protagonist and the other, empty chair, for the unavailable/other person. The protagonist arranges the chairs in a way that symbolically depicts the relationship, that is, are the chairs close? Far apart? Side by side? One behind the other? The chairs’ arrangement sets the emotional tone for the encounter.3 The protagonist then sits in his or her chair and expresses his or her gratitude for the person symbolized by the empty chair. Following this, the protagonist would reverse roles and become the auxiliary. By becoming the auxiliary, the person would respond as if the gratitude had just been expressed to him or her. This auxiliary role is then relinquished, and the protagonist would return to the original chair and respond to the auxiliary’s empty chair. This ends the enactment. Such use of psychodramatic techniques within the IBT format has the advantage of being used without the need for reading and writing. But the technique has the potential to be used for a nonID population as well. More than 775 million adults in the world are illiterate (List of countries by literacy rate, 2014) and experiential techniques such as the VGV can extend the power of a proven positive intervention to this group.

Conclusion Although people with dual diagnosis are an underserved population, there is evidence to show that a viable form of group treatment can be effective. Additionally, research on positive psychotherapy suggests that strength-based positive interventions can be effective in a therapeutic setting with those having the ability to read and write. Future research should look toward validating a character strength survey for those unable to read, testing the effectiveness of facilitators engaging in resource priming and spotting strengths in group members, and developing positive intervention alternative that do not require literacy for group members. There are many challenges and research opportunities to move toward more effective use of group therapy for people with IDs. The foundations of research on IBT combined with the promising developments in positive psychotherapy provide a rich and fruitful model for researchers and clinicians to pursue. Notes 1. A version of the material in this section appears in a blog written by the author. Available at: http://www. psychologytoday.com/blog/the-healing-crowd/201308/positive-interactive-behavioral-therapy-p-ibt


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2. A version of the material in this section appears in a blog written by the author: Available at: http://www. psychologytoday.com/blog/the-healing-crowd/201301/positive-group-psychotherapy 3. A version of this section appears in a blog by the author. Available at: http://www.psychologytoday.com/ blog/the-healing-crowd/201112/the-virtual-gratitude-visit-vgv-psychodrama-in-action

Acknowledgement Thank you to Professor Joel Morgovsky for his helpful review and comments on the article.

Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

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