What works for people with mental retardation? Critical commentary on cognitive-behavioral and psychodynamic psychotherapy research.

In What Works for Whom, Roth and Fonagy (1996) provided a critical review of the evidence base for psychotherapy. The key findings are that there is good evidence for the efficacy of psychotherapies, but there was more evidence for cognitive–behavioral than for psychodynamic psychotherapy. References to research with people who have mental retardation, however, were notably absent from the review. The Handbook of Psychotherapy and Behavior Change (Bergin & Garfield, 1994), published 2 years earlier, did not contain any reference to people with mental retardation at all. There is a statement in Roth and Fonagy in relation to people with mental retardation: ‘‘Although there are reports of effective psychodynamic treatment (e.g., Sinason, 1992), systematic outcome research has focused on behavioral training techniques’’ (Target & Fonagy, 1996, p. 312). There was no comment on cognitive–behavioral psychotherapy or any other approaches, which probably reflects the state of the research literature at the time. Psychological treatments provided and researched for people with mental retardation then were either behavior modification or behavioral skills training. These approaches lie outside the scope of reviewers of psychotherapy research, whose main interests are cognitive and psychodynamically based treatments for mental health concerns. Reviewers of psychotherapy with people who have mental retardation published in the mid-1990s only found case studies on the use of psychodynamic psychotherapy, and only two reports of cognitive–behavioral psychotherapy for mental health issues (Hurley, Pfadt, Tomasulo, & Gardner, 1996; Nezu & Nezu, 1994). The reference to Sinason (1992) in Roth and Fonagy (1996) is also surprising because she did not report any data on effectiveness. In a more recent review of the effectiveness of psychotherapy with people who have mental retardation, Prout and Nowak-Drabik (2003), covering the period 1968 to 1998, found 92 reports. Their definition of psychotherapy was fairly broad and included a range of behavioral interventions, including relaxation, desensitization, and various skills training interventions. They concluded that the area is dominated by case studies, with few controlled comparisons or clinical trials. Cognitive–behavioral and psychodynamic interventions only accounted for 28% of the reports reviewed. The largest proportion of the theoretical orientation of the 92 studies could not be determined (37%), and a further third were behavioral interventions. Only 9 studies contained sufficient data for inclusion in a meta-analysis, yielding a mean effect size of 1.01. All but one of these were behavioral interventions. However, in view of the wide acceptance of the effectiveness of behavioral interventions, it is surprising that only 8 were found. The 92 studies were reviewed by an expert panel, which concluded that psychotherapy effects are modest with persons who have mental retardation. The reviewers could only indicate that the effects could be demonstrated across theoretical approaches. This commentary focuses on the effectiveness of the more controversial use of psychodynamic and cognitive–behavioral psychotherapy with people who have mental retardation. The progress, or lack of it, since the publication of What Works for Whom? is considered.