Adapting Cognitive Behavioral Therapy for People with Intellectual / Developmental Differences
Cognitive Behavioral Therapy (CBT) has been demonstrated to be an effective treatment for a broad range of psychiatric disorders, particularly those which involve symptoms of emotion or mood dysregulation and anxiety. It may be considered as a first-line treatment to try before using medications to manage symptoms, although a combination of CBT and medication may also be effective. Among major psychiatric diagnoses, CBT has been used to treat generalized anxiety, social anxiety, phobia, and panic disorders; depression; obsessive-compulsive and tic disorders; intermittent explosive disorder and anger-related problems; eating disorders; insomnia; trauma and stress-related disorders; substance use; and chronic pain. Over the years evidence in the literature has grown to support its use with people with intellectual and developmental differences (I/DDs), particularly those with autism and mild intellectual disabilities.
Developed by Aaron Beck in the 1960s, CBT is designed to treat emotional distress, whether it be problematic anxiety, anger, irritability, panic, or sadness, by addressing underlying maladaptive thought or behavior patterns. It is problem focused, with specific symptoms and skill-building targets defined in observable and measurable terms. It may be delivered as individual or group therapy, and manualized treatment protocols exist for both formats. It is time-limited, with interventions ranging from 5 to 20 sessions, although people with I/DD may require a longer course of treatment to master and generalize skills. It emphasizes a collaborative relationship between the therapist and client who work together to identify underlying contributors to mood-related or other problematic symptoms and to practice more adaptive cognitive and behavioral coping strategies.
CBT is based on the idea that thoughts, feelings, and behaviors are interrelated. Treatment targets maladaptive thought patterns and focuses on building adaptive coping skills. The cognitive-behavioral triangle illustrates the underlying theory of CBT, and the primary intervention target is changing thoughts, and potentially feelings, to enable behavioral change.
The cognitive component of treatment focuses on identifying and changing or “restructuring” thought patterns, attitudes, or beliefs that contribute to problematic emotional and behavioral responses. Irrational or distorted thought patterns contribute to distress, which in turn produces maladaptive behavior. CBT focuses on modifying these patterns to change how an individual views and acts on situations. To do this, the therapeutic process uses these strategies:
- thought monitoring and emotion monitoring (with use of direct instruction and Socratic questioning to guide them)
- cognitive restructuring practice to promote more adaptive/flexible thinking
- cognitive relaxation strategies (e.g., guided imagery, imagined exposure)
- identifying antecedents and consequences related to problematic behavior.
Behavioral change involves
- practicing behavioral coping strategies (e.g., deep breathing, progressive muscle relaxation)
- scheduling activities to promote adaptive behaviors for emotion regulation/relaxation/enjoyment
- testing alternative behaviors to help build new responses to stressors, which may include flooded or gradual exposure to fear-inducing stimuli to treat anxiety, or exposure and response prevention methods used to curb compulsive responses to certain situations or obsessive ideation
- using more classic behavior strategies to redirect and replace problematic behavioral responses.
Psychoeducation, guided problem solving, use of reinforcement, parent/caregiver training, and skill practice assignments are methods used to achieve these goals.
Although session formats can be expected to vary according to individual needs and goals, a typical session might follow this pattern.
- psychoeducation on relevant emotion and coping skill topics
- cognitive-behavioral skills practice
- emotion - and thought-monitoring
- cognitive restructuring
- behavioral activities (e.g., exposure exercises, behavioral activation, adaptive behavior practice)
- parent/caregiver training and individual homework.
For people with I/DD, CBT is an important treatment option because they are at significantly higher risk for depression, generalized and specific anxiety, phobias, psychotic disorders, and obsessive-compulsive disorder. Also, psychoactive medications are sometimes used to manage difficult behaviors, so finding effective therapy for these disorders that does not rely on medications helps them avoid complications from side effects and over-medication generally.
When considering psychotherapy for a person with I/DD, he or she must have the ability to understand and process relevant psychological concepts (e.g., thought patterns, emotions, behavior). Because the therapy relies on communication, he or she must also have adequate communication skills to participate in discussion during sessions and therefore to benefit from this type of intervention.