Cognitivebehavioural therapy

Behavioural principles can be used to target thought as well as behaviour. Mental retardation brings a tendency to perceive the world in polar extremes—people seeing themselves either as acceptable, competent, and successful or else as worthless failures; similarly, others are seen as all good or all bad. Cognitive therapy is usually used with people in the mild or borderline range of retardation, and has a particular importance in the treatment of sex offenders. There are some examples of work with non-verbal people or those with severe mental retardation. Indeed, where problem-solving skills are formally taught, the improvement may be greater in people with moderate than with mild mental retardation, suggesting some form of ceiling effect to their acquisition. Furthermore, performance may have more to do with the type of problem than with formal measures of ability.(3)

Rational emotive therapy, developed in an educational setting, seeks to change the perceptual set and thereby the impact and influence of events on the person. Its background in education resulted in a didactic format, giving the therapist a directive role. The orientation is behavioural, focusing on the development of skills and it lends itself to being taught to groups. A number of open studies of people with moderate and mild mental retardation have shown it to decrease irrationality and anxiety, and to increase internal control and self-esteem.(4)

Anger management was developed with people of average ability, but there are some isolated case studies indicating its effectiveness in mental retardation. (5) There has been little work to identify how frequently, with whom, and what form therapy might take, or whether it should focus on the cognitive response, the arousal, or the behavioural aspects of anger. There are a number of obstacles to anger managment therapy including the following.

1. The inherent nature of anger which means that the problem is an excessive response rather than a deviant one. In this population organic factors are frequent, particularly brain damage, epilepsy, and medication.

2. Its usefulness, especially where there is limited communication and reduced social status.

3. The degree to which habitual use has made anger an entrenched response.

4. Limited communication and personality factors make therapeutic engagement difficult.

5. The emotion of anger can be difficult to distinguish and label. This applies particularly where autism is a component. Here an aggressive response may be the result of excessive anxiety, often amounting to panic.

A programme of anger management may take place at several levels.

1. General clinical care—strategies to reduce anger which include ensuring that the person feels well, that their physical and social environment is suitable, and that there are suitable occupational and recreational programmes.(6)

2. Anger management—information is given to help the person recognize anger, its nature, the signs, and consequences, as well as ideas and information about changing their behaviour. This uses a more didactic group instruction which is general and involves less disclosure and engagement by the individual.

3. Anger treatment—an individually tailored programme which targets change in cognitive perception, autonomic arousal, and behaviour. Individual engagement is essential and transference and countertransference are important and likely to evoke distressing emotions.

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