Introduction
Patients with intellectual disabilities, 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, help 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 patient, based on the linguistic and 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 patient 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 their condition and helping empower patients, by mitigate 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. At alternative option, that 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 3-4 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 maximization 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 facilitator keep track of participants. The best sitting arrangement for group therapy would be in a large circle, where the therapist is sitting among the patients, to limit the therapist being viewed as an authoritative figure or the central focus of therapy (Lesczc and Yalom, 2005). Members of the group should be capable of seeing one another, during the entire session. 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 intellectual disabilities, based on prior experiences, are often told what to do, by an authority figures 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 therapeutics 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 others that are coping and recovering, allowing those in the beginning in 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. Also, it helps the individual understand they accepted and valuable for whom they are.
Empowerment – patients have the ability to help one another by sharing their experiences, 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 non-judgmental, 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 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 their suppressed emotions, which reduce his 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 Intellectual Disability
It may have been thought for years, that patients with Intellectual Disability 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, to illustrate that such individuals can benefit from therapy, if the therapeutic interventions were 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 literature, Interactive Behavior Therapy (IBT), developed by Daniel J. Tomasulo, Ph.D, is the most widely used form for group psychotherapy for individuals with intellectual disability, chronic psychiatric issues, or dual diagnosis (Razza and Tomasulo, 2005). The central focus of IBT, is altering the nature and methods to which therapy in 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 has been coined Psychodrama (Marineau, 1989). Psychodrama is an action oriented therapy and technique, which allows expression of a condition or offer 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 in conducted in a four-stage process, uses 45 minute to 1-hour time slots for therapy sessions. The reduced time demands are beneficial to maximize participation, as patients are more physically/emotional present, limiting levels of exhaustion or inattention (Razza and Tomasulo, 2005).
4 Stages of IBT
Stage 1: Orientation
Goal of facilitator – to create a stable environment for participants, with cognitive impairment to develop skills needed for successful group participation. Focus on creating an environment where each individual is capable of experiencing their feelings and emotions, without interruption, as patients with ID, are unfortunately accustomed to people not listening to them or talking over them. 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 & Sharing
Goal of Facilitator: inviting members to talk about themselves within the group. It is important that each facilitator pay attention to the interaction of members within the group, to help maximize the therapeutic experience. Each member of the group, should take turns disclosing their experiences relating to the topic discussed. Interaction amongst peers is preferred rather than interaction with the facilitator to maximize group adhesion. It can also be beneficial for the experience be interactive, as one member selects another member to continue share his/her experiences (Psychology Today, 2013).
Stage 3: Enactment
Goal of Facilitator: help the implement 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 can be used such as mirroring, role reversal, doubling, etc., selected by the therapist. Therapist can also include allow participants to select which type of enactment they wish to do (Psychology Today, 2013).
Stage 4: Affirmation
Goal of Facilitator: validate and acknowledge the effort of each of the participants, involved in-group. Reflect on important highlights of the session, qualities or characteristics of individuals involved that helped maximize the quality of therapy, 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).
Benefit of IBT approach
The style and techniques used in IBT, are not only beneficial for patients with an intellectual disability, but can be utilized for patients with chronic mental illness, such as schizophrenia, depression, etc., as well 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 their condition (Daniels, 1998). The technique of IBT can be applicable to addressing particular mental health issues, such as anxiety, depression, 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 involvement should focus on educating patients on topics that are important for mental and physical well being, including nutrition, sleep hygiene, psychotropic education, and exercise.
Education on Proper Nutrition –important to discuss with patients the importance of quality nutrition, what types of food/beverage is 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 or not educated about the importance of quality nutrition, which can have benefits on mental and physical health, to limit or hinder likelihood of developing conditions such as diabetes, heart disease, etc.
Education on Sleep Hygiene – important for patients to understand the importance of structuring their life to allow them to maximize the quality and duration that they sleep, as it can be beneficial for mental health. Therapist should discuss topics such as limiting caffeinated beverages before evening, restricting bedroom activities for sleep/sexual activities (limited stimulating activities such as TV, eating, reading), possibility of incorporating relaxation techniques before sleep to reduce internal tension, educating patients on leaving the bedroom, if unable to maintain sleep, etc. Also, important to focus on establishing a consistent regimen in which patients should limit oversleeping, as this can be a counter-productive process.
Education on Sleep Medications– inadequate quality of sleep (nighttime restlessness, inability to fall and/or stay asleep, early morning awakening) can have direct effects on any psychiatric condition, the following day, as the brain is unable to feel rested and calm. Important to address topics related to sleep medications, such as residual sluggishness, grogginess to educate patients on being watchful of over-sedating effects of medications. Also, to educate patients on the ill effects of overmedicating with sleep aids, particularly important for patients who self-administer medications. Also, important to discuss with patients to look out for possible side effects with particular medications, such as parasomnia with Ambien, etc.
Psychotropic Education – based on patients’ cognitive capabilities, discussing with patients the importance of continuity of medication use, the type of psychotropic meds, as well as potential side effects or withdrawal symptoms. Also, harmful effects that patients experience should be discussed with their providers. Pictorial diagrams or illustrations can be helpful for all patients, particularly those with reception cognitive impairment.
Benefits of Exercise – exercise, particularly aerobic exercises, for at least 30 minutes to 1 hour, daily, can be beneficial outlet to dissipate internal tension, which can exist, regards of the etiology of psychiatric illness. Exercise can have physiological effects on the body, as it can reduce level of stress hormones, including cortisol, as well as stimulating the production of endorphins, which are nature mood elevator, as well as pain reliever (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 beneficial for patient to be capable of participating in exercise groups 20-30 minutes, hopefully three times a day, according to staff availability. Also, outdoor activity, due to increased level of sunlight would be beneficial for patients to naturally increase their level of Vitamin D.
Relaxation Skills – it is important for a therapist to help patients address the physical tension that exist, 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 meets the cognitive abilities of each patient. Simpler terminology or directions regarding the exercises, as well as ongoing reiteration, are beneficial to maximize participation within the group. It is important for 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 in-patient 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 emphasis the synergistic effect of group therapy on each patient. Patients with intellectual disabilities, 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 intellectual disability, should be focused on therapy activities that are more action oriented. According to Interactive Behavior Therapy, patients with intellectual disability are able to absorb and understand topics, when the activities are tailored around their cognitive and linguistic abilities. The duration of each IBT activity should be shorter in duration in maximize concentration on each topic (Psychology Today, 2013). 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. Also, 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. Also, it may 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 in-patient 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 in a group therapy, as the purpose of the event in 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.
Source: Inpatient group therapeutic interventions for patients with intellectual disabilities; Journal of Intellectual Disabilities 19(1); November 2014. Author: Vilash Reddy, MD
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.
Gardener W, Hurley A, Pfadt A and Tomasulo D (1996). Counseling and psychotherapy. In: Jacobson J and Mulick J (Eds) Manual of diagnosis and professional practice in mental retardation. Washington, D. C: American Psychological Association.
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://www.psyplexus.com/mhr/group_therapy.html (accessed 12 June 2014)
Montgomery C (2002) Role of dynamic group therapy in psychiatry: Advances in Psychiatric Treatment (2002) Volume 8: 34-41
Psychology Today (2013) Positive Interactive-Behavioral Therapy (P-IBT). Available at: http://www.psychologytoday.com/blog/the-healing-crowd/201308/positive-interactive-behavioral-therapy-p-ibt (accessed 4 July 2014)
Razza NJ and Tomasulo D (2005) Healing trauma: The power of group treatment for people with developmental disabilities. Washington, D.C: American Psychological Association.
Comments