Given that an estimated 60 percent of persons who have intellectual disability also experience severe communication deficits (AIHW, 2008), the literature on counselling this client group consistently refers to the importance of using “creative approaches” (WWILD, 2012, p 60) which allow the client to respond in both verbal and nonverbal ways. Thus, in addition to “talk therapy”, practitioners should consider employing drawing, music, puppetry, drama, and psychodrama. In this post, we review the use of positive interactive-behaviour therapy.

How the therapy works

This newer format for therapy comes highly recommended as a form of group therapy, especially for the over-half (57 percent) of the population with intellectual disability which is also diagnosed as having some form of psychiatric disability (AIHW, 2008). Positive interactive-behaviour therapy combines two approaches:

Positive psychotherapy (PPT), a strengths-based approach that offers a more comprehensive perspective of a client and their life circumstances. Because psychotherapy traditionally focused on symptoms, it was considered to be successful if the symptoms reduced. PPT, conversely, is becoming known as an evidence-based form of therapy that explores both strengths and weaknesses to achieve greater well-being and functioning. Instead of looking at what is “wrong”, it focuses on what is “strong”.

Interactive behaviour therapy (IBT), the most widely used form of group psychotherapy for people with intellectual and chronic psychiatric disabilities. It uses modified techniques from other psychotherapeutic approaches and has been evolving for about 25 years. Its theoretical underpinnings as well as some of its techniques originated with J.L. Moreno’s psychodrama, and it also incorporates the therapeutic factors of Irvin Yalom, as well as Martin Seligman and others (Tomasulo, 2013).

Positive interactive-behaviour therapy combines the two, through modifications of the typical psychodrama session, which has three stages: (1) warm-up; (2) enactment, and (3) sharing. Normally, the first stage would prepare group members for interactive role-playing. The second stage would see the enactment happen, and the third stage would be used for reflection on the role play. The cognitive limitations of people with intellectual disability made this format unworkable, so positive interactive behaviour therapy developed a four-stage model: (1) orientation; (2) warm-up and sharing; (3) encounter; and (4) affirmation (Tomasulo, 2013).

The stages

Looking more closely at the four stages, we can see that the orientation stage helps clients with intellectual and/or psychiatric disability gain the skills needed to participate successfully in a group; in addition to not always observing conversational rules, some people with intellectual disability also have visual and auditory problems.

In the warm-up and sharing stage, group members deepen their level of disclosure and choose a protagonist. In the enactment stage, the emotional engagement of the members is increased; typically it is here that role-playing and deep action methods are employed as primary means through which therapeutic factors are activated. A central stage, this third one employs modifications from psychodrama (drawn from individuals’ concerns) and sociodrama (mirroring collective concerns). This stage used to be used mostly for role (social skills) training, but with the development of IBT, has come to be used to facilitate therapeutic interventions.

The affirmation stage helps people with intellectual disability who, because of difficulty with abstract thinking, are unable to see analogies of group work to their own lives. Here the facilitators reinforce any therapeutic factors they see emerging and encourage members to give affirmation to each other as well. This has the added dimension of increasing group members’ status and value in each other’s eyes. As members become more interested in one another, they are more prone to spontaneously experience the universality that leads to increased support for other members (Tomasulo, 2013).

What the research says

People diagnosed with both intellectual and psychiatric disability were traditionally thought not to be able to profit from insight-oriented group therapy, but now research evidence is accumulating to show that they can benefit. Those with intellectual disability have long experienced “diagnostic overshadowing” (Reiss, Levitan, & Szyszko, 1982), in which any symptomatology (meaning, here: clinically significant symptoms) tended to be attributed wrongly to behavioural components of the cognitive deficit rather than any psychological condition. Over the last several decades, however, the IBT model has been investigated and some promising results are emerging.

In Blaine’s (1993) research testing the efficacy of an IBT group, both participants with intellectual disability and participants without it were treated over 17 sessions. Both groups showed significant positive change from the therapy, but the subjects with intellectual disabilities showed higher frequencies of most therapeutic factors. Similarly, Keller (1993) found the IBT format facilitated the rise in therapeutic factors. The IBT model has also shown to be effective in a study examining subjects with chronic mental illness (Daniels, 1998).

In another study, IBT was compared with behaviour modification techniques. The group exposed to IBT showed greater reduction in target behaviours, increased problem-solving skills, and earlier return to the community (Oliver-Brannon, 2000).

How to best use this therapy with clients who have intellectual disability

Tomasulo notes that the IBT method has been taught to “thousands of human service and mental health personnel via direct trainings and videotaped instruction” (Tomasulo, 2013), and was the focus of the APA’s first book on psychotherapy for people with intellectual disabilities (Razza & Tomasulo, 2005). As the need for psychological services for those with intellectual disability becomes increasingly accepted, there will be more publications like the DM-ID (Diagnostic Manual – Intellectual Disabilities) and the accompanying clinical guide to help clinicians reach an accurate diagnosis (Fletcher, Loschen, Stavrakaki, & First, 2007).

In June of 2013, the first certificate program in IBT was offered at Brock University in Ontario, Canada to help mental health practitioners work with people with intellectual and psychiatric disabilities (Tomasulo, 2013). These steps creating training and information for mental health practitioners will help to increase awareness of these client groups and their mental health needs and should ease the reluctance of such professionals to work with them.

Potential enhancements

Positive interactive behaviour therapy is arguably the already-enhanced therapy, as it combines elements of two therapies and has been customised for clients with intellectual disability.

This post was adapted from the Mental Health Academy course Counselling Clients with Intellectual Disability: A Look at What Works. The specific aim of this course is to examine which approaches and ways of working may be more fruitful with clients who have intellectual disability.


  • AIHW (Australian Institute of Health and Welfare). (2008). Disability in Australia: Intellectual disability. AIHW Bulletin No. 67. Cat No. AUS 110. Canberra: AIHW. Retrieved on 8 December, 2013, from: hyperlink.
  • Daniels, L. (1998). A group cognitive–behavioral and process-oriented approach to treating the social impairment and negative symptoms associated with chronic mental illness. Journal of Psychotherapy Research and Practice, 7, 167–176.
  • Fletcher, R., Loschen, E. Stavrakaki, C., & First, M. (Eds.) (2007). Diagnostic Manual-Intellectual Disability (DM-ID): A Clinical Guide for Diagnosis of Mental Disorders in Persons with Intellectual Disability. Kingston, NY: NADD Press.
  • Razza, N. & Tomasulo, D (2005) Healing Trauma: The Power of Group Treatment for People with Intellectual Disabilities Washington, D.C., American Psychological Association.
  • Reiss, S., Levitan, G., & Szyszko, J. (1982). Emotional disturbance and mental retardation: Diagnostic overshadowing. American Journal of Mental Deficiency, 86, 567-574.
  • Tomasulo, D.J. (2013). The healing crowd: All about group therapy: what it is, why it works, and which group is right for you. Psychology Today. Retrieved on 1 January, 2014, from: hyperlink.
  • WWILD. (2012). How to hear me: A resource kit for counsellors and other professionals working with people with intellectual disabilities. WWILD Sexual Violence Prevention Association Inc: Disability Training Program. Department of Justice and Attorney General Building Capacity for Victims of Crime Services Funding Program. Retrieved on 3 December, 2013, from: hyperlink.