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Journal of Applied Research in Intellectual Disabilities 2006, 19, 109–117 On Some Recent Claims for the Efficacy of Cognitive Therapy for People with Intellectual Disabilities Peter Sturmey Queens College and The Graduate Center, CUNY, Flushing, NY, USA Accepted for publication 19 September 2005 Background Many authors have expressed concern regarding the efficacy of psychotherapy, including psychotherapy for people with intellectual disabilities. Materials and Methods Recently, many authors
  On Some Recent Claims for the Efficacy ofCognitive Therapy for People with IntellectualDisabilities Peter Sturmey  Queens College and The Graduate Center, CUNY, Flushing, NY, USA Accepted for publication  19 September 2005 Background  Many authors have expressed concernregarding the efficacy of psychotherapy, including psy-chotherapy for people with intellectual disabilities.  Materials and Methods  Recently, many authors havemade claims for the effectiveness of cognitive therapyfor treating people with intellectual disabilities. Duringthis debate, applied behaviour analysis has been misrep-resented by incorrectly labelling behavioural as cogni-tive techniques, repeated misrepresentations of  behaviourism and attributing the efficacy of treatmentpackages to cognitive components of undemonstratedefficacy when it is more parsimonious to attribute effic-acy to behavioural elements of known efficacy. Conclusions  This article documents and corrects theseerrors. Keywords:  applied behaviour analysis, cognitive therapy,evidence based practice Introduction This concern over the efficacy of psychotherapy has been expressed for over 50 years (Eysenck 1952) andcontinues to this day in the form of questions overwhat psychotherapy works for whom in general mentalhealth and behavioural problem (NICE 2003; Roth &Fonagy 2005). Similar concerns exist over the efficacyof psychotherapies for people with intellectual disabil-ities and autism (Jacobson  et al.  2005), including theefficacy of psychodynamic psychotherapy (Beail 2003;Prout & Norwick-Drabik 2003; Lynch 2004; Sturmey2005a), cognitive therapy (Stenfert-Kroese  et al.  1997;Sturmey 2004; Hassiotis & Hall 2005) and a wide rangeof other psychological and non-psychological treat-ments (Jacobson  et al.  2005). These concerns include thefailure to adopt effective interventions and a tendencyfor treatment fads to occur which may be ineffective oreven harmful to clients (Jacobson  et al.  2005; Sturmey2005b) and the absence of an adequate evidence basefor commonly advocated psychological interventions,such as psychoanalytic and psychodynamic psychother-apy (Sturmey, 2003; Prout & Norwick-Drabik 2003),and cognitive and cognitive behaviour therapy (CBT;Sturmey 2004; Hassiotis & Hall 2005). This absence of evidence for the efficacy of non-behavioural interven-tions contrasts with the extensive and comprehensivedatabase for interventions based on applied behaviouranalysis (ABA). This evidence base includes multiplerandomized controlled trials (Prout & Norwick-Drabik2003), meta-analyses of hundreds of single-subjectexperiments (Scotti  et al.  1991; Didden  et al.  1997; Carr et al.  1999; Shogren  et al.  2004), consensus panels andexpert opinions (New York Department of Health1999a,b,c; Rush & Frances 2000; Committee on Educa-tional Interventions for Children with Autism 2001;General Accounting Office 2005).Recently, several authors have advocated the use of cognitive therapy in people with intellectual disabilities(Stenfert-Kroese  et al.  1997; Stenfert-Kroese 1997; Taylor& Novaco 2005). They present the argument as oneof equity of access (Bender 1993), disdain for peoplewith intellectual disabilities on the part of therapists(Stenfert-Kroese 1997) and dissatisfaction with or appar-ent limitations of ABA (Willner, 2005; Stenfert-Kroese1997; Taylor 2002; Taylor & Novaco 2005). However,these authors do not argue for the superiority of cogni-tive therapy and CBT over ABA, as there is currently noevidence to support such a position (Prout & Norwick-Drabik 2003; Hassiotis & Hall 2005; Sturmey 2005a).  Journal of Applied Research in Intellectual Disabilities  2006,  19 , 109–117   2006 BILD Publications 10.1111/j.1468-3148.2006.00301.x  Indeed, a recent meta-analysis identified only threestudies – which included modified assertiveness trainingand anger management in adults with intellectual dis-abilities – which had some impact after treatment onratings from individuals and carers, but not at 6-monthfollow-up (Hassiotis & Hall 2005).During this discourse, there have been numerous asser-tions and errors made concerning ABA. These includemislabelling ABA as cognitive therapy, misrepresentingABA, and attributing the alleged efficacy of treatmentpackages to cognitive therapy, when it is more parsimoni-ous to attribute it to behavioural elements of the packageof known efficacy. The purpose of this article was todocument and correct these three kinds of errors. Applied Behaviour Analysis Mislabelled Meta-analysis misinterpreted Several articles have recently and incorrectly claimedthat non-behavioural methods of interventions wereeffective by citing outcome data on behavioural inter-ventions. For example, Prout & Norwick-Drabik (2003)conducted a meta-analysis of psychotherapy outcomeresearch. They identified nine experimental evaluationsof psychotherapy in people with intellectual disabilities,with an average effect size of 1.01 (range 0.06–1.85). Sub-sequently, Lynch (2004) cited this study as supportingpsychotherapy. However, a review of these nine out-come studies indicated that they were evaluations of  behavioural treatments, such as assertiveness training,relaxation training and behavioural methods of weightreduction, and did not include any evaluations of psych-odynamic or psychoanalytic treatment (Sturmey 2005a). Respondent conditioning and extinction Several common respondent conditioning procedureshave been mislabelled as cognitive therapy. Feldman et al.  (2004) conducted a survey of intervention methodsfor challenging behaviours. They developed a classifica-tion system for interventions, including categories suchas behavioural and cognitive behavioural. Under ‘cogni-tive behavioural’ they included relaxation training,which refers to changes in the behaviour of muscles andinvolves no changes in verbal behaviour or privateevents. Relaxation training dates back to Wolpe’s (1958)classic text,  Psychotherapy by Reciprocal Disinhibition ,where it was one of the methods used during counter-conditioning response during systematic desensitizationfor a variety of anxiety and mood disorders.Willner (2004) reported an interesting case study inwhich traumatic nightmares in a man with moderatelearning disabilities was treated by repeated rehearsal of the nightmares, modifying the end of the nightmare andrelaxation training. Willner described the procedure ascognitive therapy, presumably because the interventioninvolved asking the man to change the way he talkedabout the end of the nightmare. Yet, Willner noted thatthe man had poor verbal skills and did not measure anyschemata or attributions probably because of this. Thistype of intervention is almost exactly the same as thatnoted in many earlier papers which reported treatingnightmares by repeated rehearsal and modification/non-modification of the ending of the nightmare (Marks1978; Burgess  et al.  1994). Thus, Willner’s effective treat-ment of the nightmare is most parsimoniously explained by construing the nightmare as a conditioned stimulusand the process considered respondent extinction. Differential reinforcement of verbal behaviour A common error is that interventions that use modifica-tion of verbal behaviour by procedures, such as differen-tial reinforcement of verbal behaviour or respondentextinction must be cognitive interventions, as theyinvolve verbal behaviour. The operant nature of some of human verbal behaviour has been long known. Forexample, Greenspoon (1955) demonstrated that under-graduate students’ emission of plural words was influ-enced by the experimenter saying ‘mm-hmm’.Subsequent studies have revealed that the verbal beha-viour of children with autism (Williams  et al.  2003), psy-chotic speech in both people of average intelligence(Wilder  et al.  2001) and people with intellectual disabilit-ies (Dixon  et al.  2001; Lancaster  et al.  2004), and disrup-tive verbal behaviour in people with intellectualdisabilities (Luiselli  et al.  1981) and autism (Rehfeldt &Chambers 2003) can all be operant behaviour controlled by its consequences.Matson  et al.  (1979) reported a single-subject experi-ment evaluating a behavioural package to changedepressed behaviour in a 31-year-old man with mildintellectual disability. The treatment package includedmultiple components, including praising the man forpositive self-statements. Matson  et al.  construed this cor-rectly as differential reinforcement and did not reportany measurement of attributions or schemata. However,Lindsay  et al.  (2005) discussed that ‘This study goes beyond a purely behavioral interpretation of depression.The authors employed positive self-statements which isa method to address dysfunctional cognitive strategies, 110  Journal of Applied Research in Intellectual Disabilities   2006 BILD Publications,  Journal of Applied Research in Intellectual Disabilities ,  19 , 109–117  such as expecting negative outcomes, blaming oneself for negative outcomes or not crediting oneself for posit-ive outcomes’. Differential reinforcement of verbal beha-viour and cognitive therapy procedures, such aschanging expectancies of negative outcomes can be dis-tinguished from each other. In differential reinforcementof verbal behaviour, interventions take place in the nat-ural environment and after the client emits the targetverbal behaviour a consequence is delivered contin-gently upon the target verbal behaviour and subse-quently, the frequency of the target behaviour increases(Greenspoon 1955). In cognitive therapy, some non-observable construct, such as negative expectancy of outcomes, is measured indirectly through client verbali-zations. A therapeutic procedure is then used to changethis unobservable construct, and subsequently outsidetherapy behaviour changes. Matson  et al. ’s study isclearly an example of the former, not the latter. It could be argued that even though this procedure was differen-tial reinforcement of verbal behaviour, the true mechan-ism of change was cognitive restructuring. However, nomeasures of expectancy or other constructs used in cog-nitive therapy were taken. Hence, the more parsimoni-ous explanation that behaviour change was due todifferential reinforcement is to be preferred. Self-regulation Several authors have claimed that self-regulation is nota behavioural technique (Taylor  et al.  2004; Taylor &Novaco 2005; Willner 2005) and that behaviouralapproaches must be supplemented or replaced by cogni-tive or cognitive–behavioural methods. For example,Taylor  et al.  (2004) wrote that ‘ …  behavioral approachesto the treatment of aggression  …  tend not to be presen-ted as ‘‘self-actualizing’’ in nature. That is, often they donot actively target self-regulation  … ’ (p. 204) and againTaylor & Novaco (2005) state that ‘ …  behaviouralapproaches, unlike direct treatments, do not explicitlyencourage self-regulation of behaviour  … ’ (p. 50).Skinner (1953) devoted an entire chapter in  Scienceand Human Behaviour  to behavioural analysis of self-control and its implication for treatment. Vernacularlanguage often implies a controlling self who is theagent that causes our over behaviour. Yet, unobserva- ble causes cannot be a part of science. Only independ-ent variables that an experimenter can manipulate andtheir effects that can be observed on behaviour are allthat science has to work with. Thus, self-control mightat first appear to be an insurmountable challenge toABA. However, a behavioural account of self-controlis possible. Skinner’s analysis of self-control posits thatcontrol of one’s own behaviour is no different thancontrol of another person’s behaviour. The independ-ent variables that a person manipulated to influenceanother person’s behaviour are the same as those thatcan be manipulated to control one’s own behaviour.Thus, self-control consists of two classes of behaviour:controlling and controlled responses (p. 231). Forexample, a person might take a healthy snack to workand place it where it is readily available (the control-ling response) in order to change the future probabil-ity of eating junk food (the controlled response). Thevariables that control the controlling responses, likethose controlling other behaviour, are environmentalvariables. If we can identify and manipulate them,then we can teach self-control to people includingpeople with intellectual disability.People learn a variety of self-control strategies, suchas self-restraint by sitting on their hands, folding theirarms or putting their hand over their mouth to reducethe future probability of fidgeting or saying somethingthey should not. We learn to remove stimuli by leavingtemptations such as cash or cigarettes to reduce wastefulspending and snacking at home. We learn to present thestimuli to make other behaviours more probably, suchas putting on glasses and turning on the light to makereading and writing more likely. People may learn topunish our own behaviour, for example, by setting thealarm clock at night to reduce the probability of sleepingthe next morning. Ultimately, the source of self-controlis not the person’s self-will, self-determination or cogni-tions that initiate behaviour, but rather the environmen-tal variables such as the contingencies that control thecontrolling behaviour.This analysis has been extensively used in ABA toteach self-control to people in many situations (Stokes et al.  1987; Guevremont  et al.  1986, 1988; Whitman1990). For example, in correspondence training, corres-pondence between verbal behaviour, such as self-instruction and subsequent behaviour, such as play, istaught. Self-control has been used to teach children toaccurately self-observe and to subsequently accuratelyself-reinforce the absence of their own disruptive behaviour in order to control their own challenging behaviours (Bolstad & Johnson 1972), to teach childrento self-instruct to increase subsequent play (Baer  et al. 1988). This mechanism underlies other research enhan-cing the independence of people with developmentaldisabilities, such as teaching self-regulation of beha-viour through time-management using a palm pilot(Davies  et al.  2002) and activity schedules (Krantz  Journal of Applied Research in Intellectual Disabilities  111   2006 BILD Publications,  Journal of Applied Research in Intellectual Disabilities ,  19 , 109–117  et al.  1993). Hence, a Skinnerian analysis of self-man-agement accounts for the behaviour of self-managingand has been highly productive in producing a tech-nology to enhance the self-management skills of peo-ple with intellectual disabilities. Summary The classic methods of ABA, such as skills training,respondent extinction, differential reinforcement of ver- bal behaviour, relaxation training and self-regulationhave been incorrectly labelled as cognitive therapy. ABA Misrepresented Private events and ABA Behaviourism is often incorrectly stereotyped as ignor-ing or denying private events. For example, Stenfert-Kroese (1997) stated that ‘ …  although a pure Skinnerian‘‘black box’’ approach to cognitive processes has beenrejected by most, and people with learning disabilitiesare now credited with thought (be it verbal or non-ver- bal)  … ’ (pp. 5–6).This representation of ABA as denying or ignoringprivate events is a common error that has been repeateddown the years (Chiesa 1994). Skinner (1953; chap. 16,17 and 18) and Skinner (1985) repeatedly addressed theissue of private events. Skinner did not deny privateevents. Rather, he explicitly discussed the contents of the alleged ‘black box’ and provided an analysis of pri-vate events, including making a decision, having ideasand recall. From a radical behavioural perspective suchprivate events are behaviour to be explained, but arenot the causes of behaviour. Skinner (1953; p. 257) wrote‘We need not suppose that events which take placewithin an organism’s kin have special properties  …  Aprivate event may be distinguished by its limited acces-sibility but not, so far as we know, by any special struc-ture or nature  … ’.Stenfert-Kroese’s (1997) characterization of Skinner’swork as a ‘black box approach’ is inaccurate. The realchallenge of Skinnerian analysis of private events it toconstrue them as behaviour to be explained, but not thecauses of behaviour. Herein lies one of the fundamentaldifferences between cognitive psychology, which positsprivate events, such as attributions and schemata, as thecause of observed behaviour, whereas radical behaviour-ism attempts to identify the environmental variablescontrolling all behaviour, including behaviour observ-able to only one person. Client emotional needs Willner (2005) claims that behaviourism cannot addressemotion. Likewise, in Taylor & Novaco’s (2005) reviewof theories of anger, they omit any behavioural accountof anger, while devoting extensive space to psychoan-alysis. They dismiss ABA approaches to anger and butSkinner (1953) devoted a chapter to the conceptualiza-tion of emotions, including anger, rage, loneliness, pho- bias, depression and so on. For example, in the case of anger, emotional behaviours include turning red, sweat-ing palms, facial expression of anger, and observationsof slamming doors, fighting, speaking curtly to othersand approach behaviour to violent scenes. Some of these behaviours, especially those related to autonomic arou-sal, seem to be reflex behaviours, and others, such asslamming doors and violence on other people or objectsseem to be operant behaviours. From a behaviour ana-lytic perspective, emotions are not the causes of beha-viour, but rather a complex of behaviours and statementabout their relationship to the environment. For exam-ple, when we say someone is angry we say that certainstimuli, such as criticism from others or loss of reinforc-ers evoke conditioned responses, and establish violenceand perhaps other consequences to others as powerfulreinforcers. If we know the environmental variables thatcontrol anger, then we can manipulate them to changeanger. We can remove the stimuli that evoke anger, con-duct respondent extinction or present other stimuli thatevoke incompatible behaviour. Likewise, we can con-duct operant extinction (if we are foolhardy or braveenough) or at least reinforce other responses.ABA has been especially effective in dealing with cer-tain kinds of emotional problems through respondentextinction, such as flooding, implosion, graded exposureand systematic desensitization for phobias, abnormalgrieving, stereotypical nightmares, depression, sexualdysfunction, lack of assertiveness and post-traumaticstress disorders (Wolpe 1958). There have been a widerange of treatments of emotional disorders for peoplewith intellectual disabilities using respondent extinctionand counter-conditioning such as phobias (Silvestri1977; Matson 1981a,b; Runyan  et al.  1985; Spencer &Conrad 1989; Love  et al.  1990; Luscre & Center 1996;Conyers  et al.  2004). Relaxation training alone may be aneffective treatment for a variety of disruptive behavioursthat could be characterized as angry (McPhail & Cha-move 1989; Mullins & Christian 2001) and can be effec-tive in prompting adaptive behaviours, such as time ontask (Lindsay  et al.  1994) that might be compatible/incompatible with aggressive behaviour. ABA has also 112  Journal of Applied Research in Intellectual Disabilities   2006 BILD Publications,  Journal of Applied Research in Intellectual Disabilities ,  19 , 109–117
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