Psychological interventions for people with intellectual disability
and mental health problems
Betsey A. Benson
Purpose of review
This paper focuses on reviews and reports of psychological
interventions for individuals with dual diagnosis (intellectual
disability and mental health problems) from March 2003 to
March 2004.
Recent findings
Two reviews that evaluated the psychological treatment
outcome literature, but spanned different time periods, arrived at
different conclusions regarding the progress of the research
efforts to date. They agreed, however, on many of the limitations
of the research. Case-studies of psychological treatment of
aggression, elective mutism, dog phobia, bereavement,
borderline personality disorder, and sleep problems appeared in
the literature. Intervention techniques represented behavioral,
cognitive behavioral, psychodynamic, and psycho-educational
approaches. One group intervention for women’s health
combined psycho-educational and coping skills training. When
ongoing service delivery in the community was examined,
interventions were found to be non-specific. A report that
detailed characteristics of treatment provided in the community
was an impetus for the promulgation of standards of care in one
region. A measure of sex-offending cognitions was developed
and preliminary validation efforts completed. There continues to
be a need for assessment instruments designed for persons
with intellectual disability. The publication of a psychiatric
diagnostic classification system for persons with intellectual
disability may improve the reliability of diagnoses, which, in turn,
will improve the quality of psychotherapy outcome research.
Summary
Depending on the review period and the evaluation criteria,
authors proclaimed the glass either half empty or half full, that is,
some progress or no progress being made in psychological
interventions with persons with intellectual disability. Case-
studies continue to dominate the literature and offer
considerable variety in terms of the problems treated and the
intervention techniques used. A significant development in
psychiatric diagnosis (Diagnostic Criteria for Psychiatric
Disorder for Use with Adults with Learning Disabilities) will
guide future progress in intellectual disability research.
Continued advances are also needed in assessment.
Keywords
dual diagnosis, intellectual disability, psychotherapy
Curr Opin Psychiatry 17:353–357. # 2004 Lippincott Williams & Wilkins.
Nisonger Center, Ohio State University, Columbus, Ohio, USA
Correspondence to Betsey A. Benson PhD, Nisonger Center, Ohio State University,
1581 Dodd Drive, Columbus, OH 43210, USA
Tel: +1 614 688 3214; fax: +1 614 688 5522; e-mail: benson.3@osu.edu
Current Opinion in Psychiatry 2004, 17:353–357
# 2004 Lippincott Williams & Wilkins
0951-7367
DOI: 10.1097/01.yco.0000139969.14695.dc
Introduction
There is general agreement that persons with intellec-
tual disabilities are prone to mental health problems at a
significant rate [1]. At the same time, they are described
as a largely underserved population in terms of mental
health services. A number of factors are noted as
interfering with individuals with intellectual disability
receiving treatment for mental health problems. One
often-cited barrier to treatment is the perception of
professionals that psychological interventions are inef-
fective because of cognitive deficits and verbal limita-
tions [2]. Publications reporting positive treatment
outcomes would challenge this belief and encourage
more professionals to provide services.
In 1989, Hurley [2] detailed recommendations for
adapting standard psychotherapeutic approaches for
persons with intellectual disabilities to accommodate
their cognitive and developmental levels. Although the
research reports she reviewed were small in number,
generally positive outcomes were obtained. A call for
research was issued to provide further detail on effective
methods and to focus efforts on individuals in commu-
nity residential programs.
In 1994, Nezu and Nezu [3] reviewed psychodynamic,
behavioral and group psychotherapy approaches in out-
patient treatment with people with intellectual disabil-
ity and mental health problems. Again citing the limited
number of reports of basic outcome studies, they
proposed a research agenda with the following recom-
mendations: group designs with random assignment,
homogeneous samples, multimodal assessment, reliable
and valid assessment measures, focus on both the
clinical and the practical significance of outcomes,
assessment of generalization effects, targeting of socially
relevant problems to enhance community integration,
use of interventions tied to a specific model of
psychopathology, and use of a variety of study designs
to allow both comparison of treatments and the break-
ing down of treatment packages into effective compo-
nents.
In the past year, the authors of two review articles came
to differing conclusions regarding the amount of progress
demonstrated in research on psychological interventions
with persons with intellectual disabilities and mental
health problems. A number of case-studies and one
group study were published. Work continues in the
353
354 Intellectual disabilities
assessment arena with a questionnaire based on cogni-
tive therapy and a new depression scale (see Lunsky and
Palucka pp. 359–363). Probably the most significant
advance in recent years is the unveiling of a new
psychiatric diagnostic classification system.
Two reviews
Prout and Nowak-Drabik [4 . .] reviewed psychotherapy
reports during the 30-year period from 1968 to 1998.
Face-to-face interventions by qualified individuals
focusing on feelings, values, attitudes and behaviors
were included in the review, while interventions
primarily conducted by teachers or paraprofessionals
were excluded. According to these criteria, there were
92 eligible studies. Three trained raters provided
consensus ratings of the amount of change and
significance of the outcomes. A meta-analysis was
conducted with only nine of the studies because the
others did not meet the criteria of having a treatment
group and a control group and appropriate data
necessary to compute effect sizes. A mean effect size
of slightly more than 1.0 was reported.
Case-studies and single case-designs were common.
Reports were found to lack detail in describing the
interventions or the client characteristics, to lack
verifiability of the intervention, and to use non-standard
measures. The small number of studies prevented
statements concerning the effects of age, techniques,
or approach on treatment outcome. The authors
concluded that a moderate amount of change and
moderate effectiveness were demonstrated in reports of
psychotherapy with persons who have intellectual
disability.
Beail [5 . .] examined more recent literature (i.e.
published since 1996) and focused on reports of
psychodynamic and cognitive–behavioral psychother-
apy with persons with intellectual disability. Descrip-
tive analysis was used. The cognitive–behavioral
reports tended to deal with self-management skills,
problem-solving and anger management, with a steady
flow of publications dealing with offenders. Fewer
reports were devoted to cognitive therapy, in which
irrational or biased thinking is addressed by the
treatment. The psychodynamic reports cited were
primarily the author’s work with offenders, which
yielded significant improvement. Group designs lacked
sufficient numbers to detect differences, and groups
were not homogeneous. The author concluded that in
the past decade there has been a lack of research
progress.
The modest gains, or the absence of gains, in
psychological interventions for persons with intellectual
disability is probably due to multiple factors. Oliver et al.
[6] discuss the barriers to research-based practice in the
context of a study of assertive community treatment with
persons with intellectual disabilities. Some barriers are
based on the culture of intellectual disability services,
while others pertain to complications presented by the
cognitive level of the research participants. Comparing
the attitude towards research in mental health services
with that in intellectual disability services, the authors
identified obstacles regarding informed consent and
ethical challenges in control-group designs in which
assignment to a no-treatment group is an option. Other
challenges include the longer time needed for changes
to occur. Studies therefore take longer (and cost more). A
smaller number of potential study participants, difficul-
ties regarding time and resources, and vague definitions
of interventions were also cited as obstacles.
Case-studies
The case-study method is useful for reporting the details
of rarely seen disorders, for showcasing treatment
innovations, and for developing hypotheses that can be
tested in more complex designs. The case-study method
can be criticized for the limited generalizability of the
results to other individuals, and, typically, for a lack of
control of extra-treatment variables.
During the period of this review, several case-studies of
psychological interventions for a variety of problems
were published. The studies were conducted in a range
of settings, including in-patient, out-patient, and com-
munity locations.
Singh et al. [7 .] reported on a self-control strategy for
managing aggression in an adult in an in-patient
setting. The study described a particularly challenging
case in which repeated hospitalizations had occurred
over a period of years, with injuries to staff and other
consumers. Agencies refused to provide services to the
individual without proof of significant improvement.
The intervention strategy was described as a medita-
tion technique in which the patient focused his
attention on the soles of his feet; this part of the
body was chosen because it was considered to be a
neutral area. Instruction included identifying triggers of
aggression and practising posture, breathing, and
shifting of attention to the feet until calm. Once calm,
the individual could walk away or respond to the
situation without verbal or physical aggression. Follow-
ing instruction in the technique, the patient achieved 6
months without aggression in the in-patient facility,
which allowed him to exit to a community program.
Medications were discontinued. At the 1-year follow-
up, he continued to remain aggression-free and had
increased his social activities in the community. The
intervention approach was described as a ‘mindfulness
technique’.

The treatment of a woman with Down syndrome and
elective mutism that had worsened over a period of years
was the focus of a report by Bell and Espie [8]. The
intervention occurred in individual sessions conducted
three times per week in a community center that she
regularly attended. Any vocalizations were reinforced at
the first stage of the therapy. Communication with one
individual was reinforced and then gradually generalized
to people in other environments over a 2-month period.
Significant improvements were noted in social interac-
tions.
Newman and Adams [9 .] reported on the treatment of an
adolescent boy with moderate intellectual disability and
a severe dog phobia. The boy had previously been
treated successfully for fear of dogs on leads and was
returning for treatment to address a fear of loose dogs.
An individualized fear hierarchy was constructed to
manage the experience of anxiety, using graded
exposure and relaxation training. The boy’s mother,
who admitted to a fear of loose dogs herself, served as a
model during the intervention. After 26 sessions,
treatment was complete and the boy’s anxiety level
around loose dogs had decreased significantly. The
mother was more relaxed around dogs as well.
A combination of psycho-educational and psychody-
namic approaches was utilized in the treatment of
bereavement in a woman with moderate to severe
intellectual disability [10]. Significant behavior problems
were noted following the death of her father. Twelve
individual psychotherapy sessions were offered: these
included education about death and the finality of death,
and expression of ambivalent feelings about her father as
well as feelings of loss and abandonment by her family.
The outcome information included staff reports of
improved behavior immediately after treatment and at
the 1-year follow-up.
Esbensen and Benson [11] described the out-patient
treatment of a young woman with borderline personality
disorder who was receiving psychiatric, psychological
and behavioral services from multiple service-providers.
The integration of the treatment methods was the focus
of the report. Data are presented on the frequency of
target behaviors over 18 months. When integration of
services was achieved, a positive response occurred in
terms of self-harming and other target behaviors,
whereas when interventions were not coordinated, the
response was regression and hospitalization. Difficulties
in coordinating the treatment from multiple sources as
well as the challenges of working with individuals who
require skilled staff were noted.
The use of a multiple-baseline design can eliminate
some challenges to the validity of a case-study by
Psychological interventions Benson 355
demonstrating predicted changes following initiation of
interventions, making it less likely that other factors are
responsible for the change. A single case methodology
with multiple-baseline design across individuals was
used with nine adults with sleep problems [12 .]. For six
of the nine, significant improvements were noted. A
variety of interventions were used depending on the
results of the assessment phase. Scheduling, sleep
hygiene, stimulus control, relaxation, light therapy and
cognitive–behavior therapy were treatment components.
Detailed outcome data were presented illustrating
latency of sleep onset and total sleep time.
Group intervention
A group intervention intended to improve women’s
health was reported by Lunsky et al. [13 .]. An 8-week
curriculum, entitled ‘Women Be Healthy’, was devel-
oped. It includes psycho-education, coping-skills train-
ing, exposure to a medical setting, and assertiveness
training. The recruits were women with mild to
moderate intellectual disability and who had an interest
in their health or who experienced anxiety in medical
care situations. A staff member was encouraged to attend
with the participant. Pre-test, post-test and 10-week
follow-up evaluation of knowledge, beliefs, and coping
was reported. Significant gains were obtained and
maintained at follow-up. The absence of a control group
is a limitation of the study. The strength of the
publication is in the description of the curriculum.
Community services
The efficacy of ongoing service delivery in the commu-
nity was the focus of two publications. Barron et al. [14]
prospectively examined the re-offending rate of indivi-
duals that were served either by specialist intellectual
disability health and social services or non-specialist
services. A comparison of the offender characteristics in
the two groups found few differences, except that the
offenders in the non-specialist service had higher IQs
than those in the specialist service. There was no
difference in the re-offending rate: for both groups, it
was about 50% after 10 months. Although two-thirds of
the participants were offered psychological therapy, the
authors noted that the therapy appeared to be non-
specific and was not focused on offending behavior.
The type and characteristics of formal and informal
interventions for individuals with intellectual disability
in one Canadian province were examined by Feldman et
al. [15]. Several hundred caregivers of individuals with
behavioral problems were interviewed to identify the
types of interventions being received. The findings for
behavioral, cognitive–behavioral, counseling and crisis-
intervention services are contained in the report. There
were significantly more informal than formal interven-
tions for counseling/psychotherapy and behavioral inter-
356 Intellectual disabilities
ventions. Formal interventions were more likely to be
associated with improvements. The results of the study
influenced the development of standards of care for
services in the region.
Assessment
There are few assessment measures developed specifi-
cally for persons with intellectual disability. This has
hampered research progress because studies are con-
ducted with measures that have not been tested with the
population, with measures adapted for persons with
intellectual disability but which have unknown relia-
bility and validity, or with measures developed by an
author for a single study or purpose. Instrument
development and the somewhat tedious pursuit of
standardization of assessment measures are necessary
steps.
.
Broxholme and Lindsay [16 ] developed a questionnaire
on cognitions related to sex offending. The Question-
naire on Attitudes Consistent with Sex Offending
identifies distorted cognitions that could be targeted in
treatment. The self-report questionnaire was found to
distinguish between offending and non-offending
groups. Test–retest reliability was found to be accep-
table. Further research on this measure is needed.
Psychiatric diagnosis
There may be no greater barrier to the conduct of
replicable treatment outcome studies than that of
unreliable psychiatric diagnosis. Comparative and con-
trol-group designs for interventions must achieve homo-
geneity with regard to the identified problem and must
match or control for other important characteristics. To
answer the question ‘What intervention works best with
whom?’, the diagnosis of the individual must be reliable.
With the publication of the Diagnostic Criteria for
Psychiatric Disorder for Use with Adults with Learning
Disabilities [17], an important step has been taken in the
direction of reliable psychiatric diagnosis. The develop-
ment and field testing of these criteria is reported in a
special issue of the Journal of Intellectual Disability
Research [18 . .]. Continued study and widespread appli-
cation of the classification system are needed before the
full impact of the publication can be felt.
Conclusion
Reviews of research on psychological interventions with
persons with intellectual disability continue to call for
more sophisticated methodology. In the past year, case-
studies characterize the published reports of psycholo-
gical interventions with persons with intellectual dis-
ability. Although these are informative and represent a
range of psychotherapeutic interventions, the criticisms
offered in the past are still valid. Greater detail in
description of the subjects, methods, and outcome is
needed. While some progress is being made in the area
of assessment, more is needed. Improving the reliability
of psychiatric diagnosis through the development of a
classification system for persons with intellectual dis-
ability is one of the few bright spots in an area whose
slow progress has frustrated professionals for many years.
References and recommended reading
Papers of particular interest, published within the annual period of review, have
been highlighted as:
. of special interest
.. of outstanding interest
1 Bouras N, editor. Psychiatric and behavioural disorders in developmental
disabilities and mental retardation. Cambridge: Cambridge University Press;
1999.
2 Hurley AD. Individual psychotherapy with mentally retarded individuals: a
review and call for research. Res Dev Disabil 1989; 10:261–265.
3 Nezu CM, Nezu AM. Outpatient psychotherapy for adults with mental
retardation and concomitant psychopathology: research and clinical impera-
tives. J Consult Clin Psychol 1994; 62:34–42.
4 Prout HT, Nowak-Drabik KM. Psychotherapy with persons who have mental
..
retardation: an evaluation of effectiveness. Am J Mental Retard 2003;
108:82–93.
This is the more optimistic of the two review articles published in the period studied
here. Both expert consensus panel and meta-analytic approaches were used to
rate the outcome research over a 30-year period.
5 Beail N. What works for people with mental retardation? Critical commentary
.. on cognitive–behavioral and psychodynamic psychotherapy research. Mental
Retard 2003; 41:468–472.
This is one of the two review publications published in the period studied here. It
summarizes recent reports on the efficacy of cognitive–behavioral and psychody-
namic interventions.
6 Oliver PC, Piachaud J, Done J, et al. Difficulties in conducting a randomized
controlled trial of health service interventions in intellectual disability:
implications for evidence based practice. J Intellect Disabil Res 2002;
46:340–345.
7 Singh NN, Wahler RG, Adkins AD, Myers RE. Soles of the feet: a
.
mindfulness-based self-control intervention for aggression by an individual
with mild mental retardation and mental illness. Res Dev Disabil 2003;
24:158–169.
The apparent simplicity of this intervention for a serious behavioral problem in an
in-patient setting is the most compelling aspect of this case-study.
8 Bell DM, Espie CA. Overcoming mutism in adults with learning disabilities: a
case study. Br J Learn Disabil 2003; 31:46–53.
9 Newman C, Adams K. Dog gone good: managing dog phobia in a teenage
. boy with a learning disability. Br J Learn Disabil 2004; 32:35–38.
This report included a detailed graded exposure hierarchy and included a family
member in the treatment process.
10 Summers SJ. Psychological intervention for people with learning disabilities
who have experienced bereavement: a case study illustration. Br J Learn
Disabil 2003; 31:37–41.
11 Esbensen AJ, Benson BA. Integrating behavioral, psychological and
pharmacological treatment: a case study of an individual with borderline
personality disorder and mental retardation. Ment Health Aspects Dev Disabil
2003; 6:107–113.
12 Gunning MJ, Espie CA. Psychological treatment of reported sleep disorder in
. adults with intellectual disability using a multiple baseline design. J Intellect
Disabil Res 2003; 47:191–202.
Individualized interventions and multiple-baseline design distinguish this report on
sleep disorders. Detailed outcome data are presented.
13 Lunsky Y, Straiko A, Armstrong S. Women Be Healthy: evaluation of a
. women’s health curriculum for women with intellectual disabilities. J Appl Res
Intellect Disabil 2003; 16:247–253.
This paper describes a group psycho-educational program with cognitive–
behavioral interventions for women addressing health concerns and participation
in health care. The curriculum is well designed.
14 Barron P, Hassiotis A, Banes J. Offenders with intellectual disability: a
prospective comparative study. J Intellect Disabil Res 2004; 48:69–76.

15 Feldman MA, Atkinson L, Foti-Gervais L, Condillac R. Formal versus informal
interventions for challenging behaviour in persons with intellectual disabilities.
J Intellect Disabil Res 2004; 48:60–68.
16 Broxholme SL, Lindsay WR. Development and preliminary evaluation of a
. questionnaire on cognitions related to sex offending for use with individuals
who have mild intellectual disabilities. J Intellect Disabil Res 2003; 47:472–
482.
This paper describes one of the few measures of cognitions for persons with
intellectual disabilities.
Psychological interventions Benson 357
17 Royal College of Psychiatrists. DC-LD: Diagnostic Criteria for Psychiatric
Disorders for use with Adults with Learning Disabilities/Mental Retardation.
London: Gaskell; 2001.
18 Cooper S-A, Melville CA, Einfeld SL. Psychiatric diagnosis, intellectual
.. disabilities and Diagnostic Criteria for Psychiatric Disorders for Use with
Adults with Learning Disabilities/Mental Retardation (DC-LD). J Intellect
Disabil Res 2003; 47:3–15.
This paper describes the development of a psychiatric classification system for
persons with intellectual disabilities. If widely adopted, the system will energize
psychological intervention research.