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Cognitive-Behavioral Therapy for People with Intellectual Disabilities [ID]

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Cognitive-Behavioral Therapy for People with Intellectual Disabilities [ID] Valerie Gaus, Ph.D. gaus_at_optonline.net 631-692-9750 ASSERTIVENESS SKILLS TRAINING Talk ... – PowerPoint PPT presentation

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Title: Cognitive-Behavioral Therapy for People with Intellectual Disabilities [ID]


1
Cognitive-Behavioral Therapy for People with
Intellectual Disabilities ID
  • Valerie Gaus, Ph.D.
  • gaus_at_optonline.net
  • 631-692-9750

2
CURRENT TREND TOWARD USE OF PSYCHOTHERAPY FOR
PEOPLE WITH ID
  • 1990s - present Mental health treatment moved
    toward multi-modal, multi-disciplinary approaches
    to treatment planning
  • Mental health treatment is taking place in
    community growth of outpatient clinics designed
    to serve people with ID psychotherapy is
    included as part of the array of healthcare
    services offered
  • More authors are writing about psychotherapy
    approaches for people with ID (e.g., Butz,
    Bowling Bliss, 2000 Lynch, 2000, 2004 Prout
    Strohmer, 1994)

3
COMMON TRIGGERS FOR REFERRAL TO MENTAL HEALTH
TREATMENT
  • exposure to a traumatic event
  • death of a loved one
  • life stage transition
  • stress (demands exceed coping capacity)
  • work or day program
  • family or residence
  • peers

4
PRESENTING PROBLEMS FOR PSYCHOTHERAPY
  • anxiety
  • depression
  • loneliness
  • social skill deficits
  • problems with employment
  • problems with dating
  • poor judgment
  • poor problem-solving ability

5
RATIONALE FOR USE OF COGNITIVE BEHAVIORAL
THERAPY(see Kroese, B.S., Dagnan, D.,
Loumidis, K. (Eds.), 1997, for a full discussion)
  • Presenting problems in people with ID are often
    maintained by cognitive and social factors.
  • Cognitive-behavioral therapy developed gt30 years
    ago to address cognitive dysfunction in
    non-disabled people with mental health problems.

6
COGNITIVE FUNCTION
INPUT Brain receives input from sense organs
and filters out irrelevant data also
called perception
PROCESSING Brain sorts, organizes,
stores, compares, categorizes, foresees,
plans, formulates using the incoming information

OUTPUT Brain controls and produces output as
a verbal statement or other behavior that is
hopefully an adaptive response to the
original input
7
COGNITIVE DYSFUNCTON
  • Cognitive deficits Information processing
    operations that are missing or working poorly
  • Cognitive distortions Errors in interpretation
    that involve faulty content of thoughts and can
    be associated with changes in mood and behavior

8
COGNITIVE DEFICITS
  • INPUT
  • Problems with sensory perception
  • Inability to filter out irrelevant stimuli
  • Problems attending to relevant stimuli

9
COGNITIVE DEFICITS
  • PROCESSING
  • Incorrect labeling or categorizing stimuli
  • Poor memory capacity or retrieval
  • Slow processing speed
  • Problems following a sequence
  • Problems comparing information
  • Problems with foresight or planning
  • Inability to use internal language or self-talk

10
COGNITIVE DEFICITS
  • OUTPUT
  • Inability or poor use of language
  • Poor motor skills
  • Problems withholding output until processing is
    complete (impulsivity)

11
COGNITIVE DISTORTIONS
  • Distorting the MAGNITUDE of a situation
  • Catastrophizing
  • Overgeneralizing
  • Dichotomous thinking (black and white or all
    or nothing thinking)

12
COGNITIVE DISTORTIONS
  • Making the wrong ATTRIBUTION for a situation
  • Assuming the wrong intent for another persons
    actions
  • Assuming the wrong locus of control in a given
    event

13
COGNITIVE DISTORTIONS
  • Holding unrealistic EXPECTATIONS for a given
    situation
  • Expecting self to be perfect
  • Pessimism expecting things to always go wrong

14
SOCIAL COGNITION
  • The study of how people process and utilize
    information in social situations
  • Social cognition is the study of how people make
    sense of other people and themselves. (Fiske
    Taylor, 1984)

15
SOCIAL COGNITION
  • 1) Analyze information coming from other people
    concerning their thoughts and feelings.
  • 2) Generate expectancies about the overt
    behavior of others.
  • 3) Draw inferences about the requirements of the
    social situation how to behave in response.

16
Success in a social situation requires a person
to be able to extract meaning from
  • The general physical context of the interaction
  • The nature of the social situation
  • The speech of the other person
  • The body postures of the other person
  • The facial expressions of the other person

17
CBT History
  • 1962 Ellis writes about reason in
    psychotherapy
  • 1963 Beck introduces cognitive hypotheses for
    depression
  • 1971 Meichenbaum and Goodman introduce
    self-instructional
  • strategies
  • DZurilla and Goldfried introduce
    problem solving therapy
  • 1973 Ellis introduces Rational-Emotive Therapy
  • 1976 Beck publishes Cognitive Therapy and the
    Emotional
  • Disorders

18
WHY HAS CBT NOT BEEN APPLIED TO THE
POPULATION MOST AT RISK FOR COGNITIVE PROBLEMS?
19
BASIC ASSUMPTIONS OF COGNITIVE BEHAVIORAL THERAPY
(CBT)
  • Cognitive activity (thoughts) affects behavior
    and emotions.
  • Cognitive activity may be monitored and altered.
  • Desired behavior change may be affected through
    cognitive change.

20
How is CBT similar to traditional behavior
therapy?
  • Both assume problems can be addressed by teaching
    people ways to change behavior
  • Both assess outcome in measureable terms

21
How is CBT different than traditional behavior
therapy?
  • Differ in the view of HOW behavior may change
  • Traditional behavioral approach assumes behavior
    is shaped by the environment - the link between
    behavior and environment is direct
  • CBT takes into account the environment, but
    assumes that behavior change is mediated by
    cognitive change there is a less direct link
    between environment and behavior

22
Environmental Event
Behavioral Response
Behavioral Response
Environmental Event
Cognitive Activity
23
10 Principles of Cognitive Therapy (From
Cognitive Therapy Basics and Beyond, Judith S.
Beck, 1995)
  • 1. Cognitive therapy (CT) is based on an
    ever-evolving formulation of the patient and her
    problems in cognitive terms.
  • 2. CT requires a sound therapeutic alliance.
  • 3. CT emphasizes collaboration and active
    participation.
  • 4. CT is goal oriented and problem focused.
  • 5. CT initially emphasizes the present.
  • 6. CT is educative, aims to teach the patient to
    be her own therapist, and emphasizes relapse
    prevention.
  • 7. CT aims to be time limited.
  • 8. CT sessions are structured.
  • 9. CT teaches patients to identify, evaluate,
    and respond to their dysfunctional thoughts and
    beliefs.
  • 10. CT uses a variety of techniques to change
    thinking, mood, and behavior.

24
ASSESSMENT
  • Explore multiple factors (Gardner Sovner,
    1994). Is the presenting problem being
    maintained by.
  • medical factors?
  • psychiatric factors?
  • environmental factors?
  • social factors?
  • cognitive factors?

25
ASSESSMENT OF COGNITIVE FACTORS
  • What cognitive deficits are maintaining my
    clients problem? Therefore, what skills might I
    teach my client?
  • What cognitive distortions are maintaining my
    clients problem? Therefore, what maladaptive
    thoughts and beliefs can be targeted and replaced
    to alleviate distress?

26
COGNITIVE MODEL (From Cognitive Therapy Basics
and Beyond, Judith S. Beck, 1995)
  • CORE BELIEF
  • INTERMEDIATE BELIEF
  • Situation -gt AUTOMATIC THOUGHT -gt Emotion

27
  • CORE BELIEF
  • I am stupid
  • INTERMEDIATE BELIEF
  • If I dont understand something the first time I
    try, it shows
  • I cant learn
  • Situation -gt AUTOMATIC THOUGHT -gt Emotion
  • New job -gt I will never learn all of
    this -gt Anxiety

28
ASSESSMENT
  • Use of questions to elicit maladaptive beliefs
  • Socratic questioning
  • Downward arrow techniques

29
EXAMPLES OF CBT TECHNIQUES
  1. Problem Solving
  2. Assertiveness Training
  3. Relaxation Skills Training
  4. Cognitive Restructuring

30
PROBLEM SOLVING TECHNIQUES
  • Based on work of DZurilla Goldfried (1971)
  • Teach person to break down a problem that is
    overwhelming and solve through small, manageable
    steps

31
PROBLEM SOLVING STEPS
1. Problem identification What is the
concern? 2. Goal selection What do I want? 3.
Generation of alternatives What can I do?
(Brainstorming- no idea is too silly at this
step) 4. Consideration of consequences What
might happen for each alternative I listed
above? 5. Decision-making What is my
decision? 6. Implementation Now do it and write
down how it went. 7. Evaluation Did it work? If
not, try another alternative.
32
ASSERTIVENESS SKILLS TRAINING
  • Teach person to
  • express needs and desires
  • express anger in adaptive ways
  • say No in adaptive ways
  • state opinions and contradictions
  • appropriately confront authority figures

  • Based on Bergman (1985)

33
ASSERTIVENESS SKILLS TRAINING
  • One strategy for identifying needs is to use Talk
    Blocks (Innovative Interactions, 2000)
  • helps individual to identify feelings but also
    identify separately what is he or she needs in
    order to cope with or solve problem
  • Identifying is prerequisite for expressing


  • www.talkblocks.com

34
ASSERTIVENESS SKILLS TRAINING
  • Talk Blocks (Innovative Interactions, 2000)
  • I FEEL frustrated
  • I NEED to be listened to

  • www.talkblocks.com

35
ASSERTIVENESS SKILLS TRAINING
  • To teach expression of wants and needs, focus on
    I statements.
  • One useful tool is the Use Your Is game
    (Western Psychological Services, 2002)


36
ASSERTIVENESS SKILLS TRAINING
  • The Use Your Is game (Western Psychological
    Services, 2002) promotes the following formula
    for an assertive statement
  • I feel ..when ..because..I want ..
  • I feel angry when you change my appointment
    without telling me because I am an adult and I
    want to make my own appointments, please.


37
RELAXATION SKILLS TRAINING
  • Based on Goldfried Trier (1974), Cautela
    Groden (1978)
  • Variety of methods which
  • teach self-control over arousal associated with
    stress and anxiety
  • can be done through progressive muscle exercises
    with breathing control or
  • can be done through guided imagery and breathing
    control

38
COGNITIVE RESTRUCTURING
  • Based on Ellis (1962, 1973) and Beck (1976).
  • Variety of methods which teach
  • how to recognize maladaptive beliefs
  • how to challenge maladaptive beliefs
  • how to replace maladaptive beliefs with more
    adaptive ones

39
ABC Model
40
ABC Model Restructuring B
41
COGNITIVE RESTRUCTURING METHODS FOR PEOPLE WITH
ASD
  • The Thought Chain
  • Social Stories (Carol Gray, 1995)
  • Comic Strip Conversations (Carol Gray, 1994)

42
THE THOUGHT CHAIN Gaus, 2000
43
My roommate asked me to clean up crumbs from
the counter top.
I will be homeless, soon!
44
(No Transcript)
45
SOCIAL STORIES
46
My name is Julie. I see Dr. Gaus in therapy
every week. Today I am going to see her in a
new place
47
I might get to the clinic early. I get nervous
when I have to wait. I also get bored if I have
to wait. I feel better if I eat a snack or
candy
48
Sometimes there is candy in waiting rooms.
Candy that is displayed in a dish on the coffee
table or counter is for people to take. This is
public food.
49
Candy that is not displayed publicly on the
coffee table or counter is private food.
People keep private food in their drawers,
cabinets, pockets or purses.
50
People feel offended when they are asked to give
away their private food. Sometimes when people
feel offended, they hide those feelings.
51
I will bring a book with me. If I have to wait,
I can read my book. I will bring some Lifesavers
in my purse. If I have to wait, I can eat some
of my Lifesavers.
52
COMIC STRIP CONVERSATIONS
53
Spoken words - things we say out loud.
Thoughts - things we say silently to ourselves.
54
Comic Strip Conversations Symbol for Listen
55
Comic Strip Conversations What would you like
him to hear?
56
Comic Strip Conversations What would you like
to hear from him?
57
GUIDELINES FOR USING CBT FOR PEOPLE WITH ID
  • Teach the individual how to recognize, challenge
    and slow down the process of maladaptive thought
    processes.
  • Teach the individual to more accurately read
    the behavior of others and to re-conceptualize
    social situations.
  • Teach concrete skills to increase ability to cope
    with stress.
  • Maintain a balance between the provision of
    structured activities and empathy in the
    sessions.
  • Use visual material to illustrate points, as they
    tend to learn more effectively from symbols and
    pictures, despite their verbal strengths.
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