It was previously believed that mental retardation itself was the result of emotional abuse and psychological disturbance. The extent to which these factors can reduce adaptive functioning and amplify a cognitive disability is becoming recognized. Symptoms ranging from withdrawal to aggression can respond, on the surface, to behavioural programmes. Psychotherapy can complement these programmes to produce someone who, although no more intellectually able, is more mature emotionally and better able to cope with the tasks of everyday life. Psychotherapy aims to treat the problems of emotional development which are expressed in relationships and in the adjustment to events, particularly loss. Contraindications to this approach are the presence of psychosis, severe personality disorder, or pervasive developmental disorder.
Both the family and the individual have to adjust to disability; this process is akin to a series of grief reactions in which people come to terms with the loss of normality/7) The process of adjustment occurs as a series of crises triggered by events such as the point of initial diagnosis, the failure of initial treatments, educational assessment and specialized placements, puberty, and leaving home. Each stage brings home afresh the degree and significance of the child's disability.
Psychodynamic work occurs on both the individual and the group level, and is characterized by the following.
1. Coping with limited communication of varying degrees and including unexpected, conceptual barriers. For example, the patient may not understand or even notice gestures, facial expressions, and different tones of voice. They may be unable to identify many emotions, label them, or form abstract concepts. Communication has to be at the patient's level, being concrete and using simple words, short sentences, and their colloquial or slang terms. The therapist may circumvent some of these barriers by using different modalities and techniques as alternatives to speech—such as music, art, play, and drama—but again run into very specific well-hidden deficits.
2. A limited and distorted understanding of the roles and relationships of the people around. The patient may be unable to appreciate either that the therapist's knowledge is restricted or that they occupy a different world, and assume they know all about the patient's setting and routines. The therapist must learn something of the patient's background in order to make sense of what is said.
3. Repetition of information, ideas, and conclusions, often as if they have never been mentioned before.
5. An unexpected acceptance of closure. Many have had lives marked by short and changing relationships and a nomadic change of accommodation. Engagement in therapy can be difficult with a consequent ready disengagement.
6. The need to enlist the support of carers who may be reluctant to trust their charge to an unknown therapist.
7. The problem of confidentiality in a field in which dependency and total care have discouraged privacy. Carers frequently expect to be told what happens in therapy. A further complication is the possibility of a disclosure that may range from poor care to frank abuse.
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