7 Applying the Self-Determined Learning Model of Instruction to the Psychotherapeutic Context for People with Intellectual/ Developmental Disabilities
Richard A. Chapman; Jessica Schuttler; Karrie A. Shogren; Sydney C. Walls; Hannah Adams; and Aderonke Oyetunji
Chapman, Richard; Schuttler, Jessica; Shogren, Karrie; Walls, Sydney; Adams, Hannah; and Oyetunji, Aderonke O. (2023) “Applying the Self-Determined Learning Model of Instruction to the Psychotherapeutic Context for People with Intellectual/Developmental Disabilities,” Developmental Disabilities Network Journal: Vol. 3: Iss. 2, Article 8.
Plain Language Summary
The Self-Determined Learning Model of Instruction (SDLMI) is a useful way that helps people set their own goals and problem solve. Self-determination includes being able to set and work towards goals. Talk therapy could use the SDLMI to help people grow their self-determination. We look at connections between the SDLMI and a talk therapy called cognitive behavior therapy (CBT). The SDLMI and CBT used together can help young people with disabilities set goals, work towards goals, and reach goals. We talk about future uses in research and practice.
Abstract
The Self-Determined Learning Model of Instruction (SDLMI) is an evidence-based intervention for supporting self-directed goal setting and problem solving. Traditionally, the SDLMI has not been applied in the psychotherapeutic context, however we propose that the SDLMI is an approach that could be integrated into such a context to support self-determination, goal setting, and goal attainment. In this paper, we specifically focus on connections between the SDLMI and cognitive behavior therapy (CBT) and how the approaches can be used jointly, during psychotherapy to support teens and young people with intellectual and developmental disabilities (I/DD) to set, work towards, and reach goals. Implications for future research and practice are discussed.
Introduction
Teens and young people with intellectual and developmental disabilities (I/DD) commonly have mental health needs related to anxiety and depression, which often requires psychotherapeutic interventions. However, teens and young people with I/DD who have co-occurring mental health conditions are often denied access to quality psychotherapy treatment. This results from a lack of providers with training and/or willingness to support people with I/DD as well as misconceptions held by therapists and the broader community about the need for or response of people with I/DD to psychotherapy (Whitehouse et al., 2006). Cognitive behavior therapy (CBT; Beck, 2011) is widely recognized as an evidence-based and effective psychotherapeutic intervention to address symptoms of anxiety and depression, and work has begun to explore adaptations for people with I/DD (Surley & Dagnan, 2018; Witwer et al., 2022). Recent reviews have recommended incorporating a focus on disability rights into psychotherapy practice with clients with I/DD (Surley & Dagnan, 2018).
There has also been an increased call for services and supports that promote self-determination of teens and young people with I/DD. According to Causal Agency Theory, self-determination is defined as “a dispositional characteristic manifested as acting as the causal agent in one’s life. Self-determined people (i.e., causal agents) act in service to freely chosen goals” (Shogren et al., 2015, p. 258). Adolescence is a critical time for the development of characteristics of self-determination. The Self-Determined Learning Model of Instruction (SDLMI; Shogren et al., 2019a) is an evidence-based practice based in causal agency theory. It has been shown to promote the development of abilities and skills associated with self-determination for teens and young people with I/DD across a variety of contexts (e.g., educational, employment, community; Burke et al., 2019; Raley et al., 2018a, 2018b), but it has not yet been explored as an approach within a psychotherapeutic framework.
The purpose of this paper is to connect the SDLMI to the CBT framework as an initial pathway to supporting the development of characteristics of self-determination within a psychotherapeutic context. We begin by introducing the theoretical framework of CBT, given its wide use and recommended adaptations to support people with I/DD. We then introduce the SDLMI, its core components, and how it has been implemented in existing research and practice. Finally, we describe application of the SDLMI framework to the CBT process, with implications for people with I/DD and clinicians.
Overview of Psychotherapy Strategies and Adaptations for Teens and Young People With Intellectual and Developmental Disabilities
“Historically…adults with intellectual and developmental disabilities have had little access to individual therapeutic interventions for psychological problems” (Whitehouse et al., 2006, p. 55), and this extends to teens and young people with I/DD. Past authors (e.g., Bender, 1993) have posited that over reliance on behavior modification and medication as treatments for behaviors reflecting anxiety and depression have led to reduced well-being for people with I/DD, and in fact, are more geared towards the needs of the service provider rather than the person with I/DD. Treatment approaches have expanded, recognizing the need to target mental health symptomatology such as anxiety, depression, psychosis, anger, and abuse and trauma with teens and young adults with I/DD. A recent meta-analysis of CBT approaches to anger treatment with people with I/DD indicates moderate effect sizes. Successful adaptations of anxiety treatments have been documented for young people with autism (Kalvin et al., 2021; McNally et al., 2012). For example, McNally et al. made adaptations to an existing evidence-based anxiety treatment program for children and youth (i.e., Coping Cat), including bolstering parent-training components, lengthening sessions, frequent review of concepts, use of visual supports, incorporation of young people’s specific interests, opportunities for sensory input, and more concrete language based on individual support needs. Children and teens participating in the adapted Coping Cat treatment program had lower ratings of anxiety symptoms relative to their wait-list peers following the 12-week program and at 2-month follow up (McNally et al., 2012). However, the literature on mental health supports for teens and young people with I/DD remains quite sparse relative to what is available for those without I/DD (Nicoll et al., 2012).
Guidelines from Hurley et. al. (1998) outlined suggested adaptations to CBT to better match a range of support needs of people with I/DD in psychotherapy. The adaptations offered by Hurley et. al. Aare summarized in the first two columns of Table 1. While we would suggest that Hurley et al.’s recommendations be updated to incorporate more recent research on person-centered and strengths-based approaches, including promoting the development of characteristics of self-determination, this framework to adaptations has guided two different reviews over the past 20 years (Surley & Dagnan, 2018; Whitehouse et al., 2006). For example, Whitehouse reviewed a number of studies that described adaptations to CBT and psychodynamic therapies for adults with I/DD and evaluated the extent to which such studies incorporated the recommendations from Hurley et al. (1998). Their review found the most common adaptation for CBT approaches was to use “flexibility in methods’’ (Whitehouse et al., 2006, p. 61). Incorporating disability and rehabilitation issues and use of more directive methods were the least frequently used methods. A key critique across studies was the lack of clearly described adaptations, leading to limited replicability and the need for further, more rigorous study through randomized controlled trials (Nicoll et al., 2012; Whitehouse et al., 2006). Similar recommendations for future research and practice were provided in a more recent review (Witwer et al., 2022).
| Adaptation | Hurley definition | Related SDLMI educational support |
|---|---|---|
| Simplification | Reduce complexity; chunk interventions; shorter sessions |
|
| Language | Simplify vocabulary, shorten sentences; clearer sentence structure |
|
| Activities | Add drawings, homework assignments, other activities to deepen change and learning |
|
| Developmental Levela | Present information at level that is understandable to the client and age-expected |
|
| Use of directive style | Outline treatment goals, be more direct and explicit about treatment process and progress, provide visual guides |
|
| Flexible methods | Adjust techniques to suit client and rate of progress |
|
| Involve caregivers | Use family or support staff to help with change; assign homework to be rehearsed/discussed with support people |
|
| Transference/ Countertransference | Therapists maintain clear boundaries |
|
| Disability/rehabilitation approaches | Increase client’s understanding of relevant disability rights issues and promote strengths of client |
|
Why Cognitive Behavior Therapy?
In this paper, we focus on CBT as a psychotherapeutic approach as it is widely known, evidence-based, and includes clearly delineated components that can be aligned with the SDLMI as we will discuss subsequently. CBT is a therapeutic approach that can be adapted when supporting people with I/DD and mental health conditions such as anxiety and depression (Kalvin et al., 2021; McNally et al., 2012; Surley & Dagnan, 2018; Witwer et al., 2022).
Overview of Cognitive Behavior Therapy
Principles of Cognitive Behavior Therapy
Generally, CBT principles include a focus on the present and an emphasis on a sound therapeutic alliance and collaborative relationship between the client and clinician to establish goals and focus on resolving psychological needs. CBT aims to accomplish outcomes over a brief period of therapy (5-20 sessions), through structured, educational sessions in an effort to support the client in better understanding and “helping” themselves. This process supports the client to develop new ways of thinking and behaving in service to their goals (Beck, 2011, p. 7).
Structure of a Typical CBT Session
Regardless of the mental health concern, a CBT session is structured with a beginning, middle, and end. At the beginning of the session, the therapist checks on the person’s mood, symptoms, and experiences over the interval period since the last session, creates an agenda with the patient to establish what will be discussed during that session, and reviews results of homework practice since the prior session. In the middle part of the session, the therapist and client work through the agenda, discussing problems the client has brought to the session, and going through a process of gathering information about the problem. This involves analyzing the person’s thoughts, feelings and behaviors related to the problem, and planning a strategy, usually involving problem solving, challenging the person’s unhelpful thinking, and attempting behavior change. The session ends with a review of the strategies discussed, plans for homework practice (e.g., implementing small behavior changes, practicing with thinking strategies), and getting feedback from the client about their experience in the session.
Strategies Used in CBT and Suggested Adaptations
Commonly used CBT strategies include instruction in goal setting and problem solving, behavioral experiments (e.g., behavior activation), and cognitive reframing. Critical to applying these recommendations, particularly given their age, is also focusing on advances in supporting people with I/DD. Such advances include addressing individualized support needs, enhancing self-determination, and considering the context that shapes each person’s life (Shogren, et al., 2014, 2015, 2020). For example, the UK’s National Institute for Health and Care Excellence (NICE) offers guidelines for prevention, assessment, and management of mental health problems in people with learning disabilities (the term used for I/DD in the UK; NICE, 2016). Recommended strategies from NICE are in line with current thinking in the field in regard to incorporating a person’s preferences, level of understanding, strengths and support needs, the right to privacy, and the best format for therapy delivery (e.g., in person or remote; NICE, 2016). A recent review by Witwer et al. (2022) also recommends the development of more robust frameworks that can be flexibly applied to the therapeutic process to enhance experiences and outcomes for people with I/DD seeking psychotherapy.
We offer the Self-Determined Learning Model of Instruction (Shogren et al., 2019a) as a potential model that could be integrated into CBT-oriented psychotherapy to address these contemporary recommendations. The SDLMI comprehensively and systematically provides a framework to support people with I/DD to develop self-regulated goal-setting and problem-solving abilities to enhance self-determination and goal attainment. The SDLMI is designed to be applied in many different teaching or supportive settings; the SDLMI provides a systematic, yet flexible set of components that can be used by a provider in supporting a client to self-direct their goal setting and attainment process, increasing their agency and self-determination. In the next section, we provide a brief introduction to the SDLMI and its theoretical roots in causal agency theory.
Introduction to the Self-Determined Learning Model of Instruction
Causal agency theory is a theory of the development of self-determination, rooted in human agentic theories. It focuses on the development of self-determination as a process that “specifically addresses the causal action sequence leading to the experience of causal agency, and eventually, the development of self-determination” (Shogren & Palmer, 2017, p. 56). People develop self-determination over the life course, and supportive contexts are important to enabling the development of self-determination, including the therapeutic context. The SDLMI was developed as an instructional model that could be used across contexts (e.g., school, home, community) to support the development of causal agency, and thus, characteristics of self-determination. The SDLMI is implemented by trained facilitators who learn to use specific strategies to support people with I/DD to develop and use the characteristics of causal agency, and thus, eventually enhancing self-determination.
Historically, implementers of the SDLMI have been teachers in the school context and disability providers in the community context. A large portion of the work on the SDLMI has been implemented with adolescents and young adults, given the importance of this developmental period (Burke et al., 2019; Raley, et al., 2018b). Despite the SDLMI being researched in a variety of contexts, with a variety of facilitators, the SDLMI has not yet been implemented in a psychotherapeutic context with facilitators who are trained clinicians. The SDLMI shifts the role of the facilitator (e.g., clinician, teacher, disability professional) to that of a supporter who works to empower and enable the person with I/DD to make progress toward their self-selected goal, self-directing the learning and goal attainment process (Shogren et al., 2015).
Implementation of the SDLMI by trained facilitators is organized into three phases (Phase 1: Set a Goal, Phase 2: Take Action, Phase 3: Adjust Goal or Plan). Each phase includes four Person Questions that are meant to be answered by the person with I/DD as they work to solve the problem targeted in each phase. In Phase 1, the problem to solve is identifying their goal; in Phase 2, developing their action plans; and in Phase 3, evaluating progress. Through this process, people learn self-regulated problem solving and goal setting skills. By repeatedly applying this process over time to new and different goals, people with I/DD grow in agency and self-determination and work toward new and different goals, expanding their options and opportunities across life domains. The trained facilitator provides support to the person as they move through the phases and supports the person to answer each Person Question by using a series of Facilitator Objectives. Facilitator Objectives provide a “road map” for the facilitator to implement the SDLMI effectively, providing guidance on the outcomes of supporting the person to answer each Person Question. The third core component of the model is Educational Supports, which are strategies used or taught by the facilitator to support the person in answering the Person Questions to meet Facilitator Objectives. Educational supports might involve providing supports for learning self-management strategies or decision-making skills to be applied as working through the SDLMI based on individual support needs. In Table 1, we align SDLMI Educational Supports with recommendations from Hurley et al. (1998) demonstrating how the Educational Supports can align with recommended adaptations. The SDLMI enables people with I/DD to self-direct the goal setting and attainment process, with supports from the facilitator, to identify goals that have personal meaning and value, identifying the supports needed to accomplish their goals, and cultivating beliefs in their ability to make progress towards their goals.
In the next section, we will further describe each Phase of the SDLMI and within each phase, we will define the three core components of the SDLMI : (1) Person Questions, (2) Facilitator Objectives, and (3) Educational Supports. We will also describe how they can be applied within a group setting in schools or communities and then discuss how these components could potentially be applied to a therapeutic setting with teens and young adults with I/DD.
Prior to beginning the SDLMI, the facilitator engages in a series of preliminary conversations. The purpose of these conversations is to introduce the concept of self-determination and the SDLMI. Also, the Preliminary Conversations allow for the gathering of information about the person’s support needs.
Phase 1—Set a Goal: Person Questions, Facilitator Objectives, and Educational Supports
The primary aim during Phase 1 (Set a Goal) is to support the person to solve the problem of “What is my goal?” During Phase 1, the facilitator supports the person in considering the following Person Questions, in a sequential manner: (1) What do I want to learn? (2) What do I know about it now? (3) What must change for me to learn what I don’t know? (4) What can I do to make this happen? In all phases, the Facilitator Objectives link directly to each Person Question. Within this phase, Facilitator Objectives target enabling the person to identify personal strengths and support needs (Question 1), to communicate wants and needs (Question 1), to identify their current status in relation to their goal (Question 2), and to understand the factors (barriers and opportunities) influencing their progress towards such a goal up to this point (Question 2). Facilitator objectives also include enabling the person to identify strategies to approach their goal (e.g., building capacity, modifying environment, or both—Question 3), and prioritizing goal areas (Question 3), as well as clearly articulating a goal (Question 4). The facilitator may offer various types of educational supports to enable the person to meet these objectives. In Phase 1, educational supports could include instruction in choice making, communication strategies, or self-awareness, all in service to gaining increased understanding of what is important for the person and supporting them in growing in their knowledge of themselves and of goals that are important to them (Shogren et al., 2019b). See Table 2 for a detailed list of the Person Questions, Facilitator Objectives, and Educational Supports comprising each SDLMI phase.
| SDLMI phases (problem to solve) and person questions | SDLMI facilitator objectives enable the person to… | SDLMI primary (educational) supports | Related psychotherapy techniques |
|---|---|---|---|
| Phase 1: Set a Goal (What is My Goal?) | |||
| 1. What do I want to learn?
|
1a. identify specific strengths and instructional needs 1b. communicate preferences, interests, beliefs, and values 1c. prioritize needs |
|
|
| 2. What do I know about it now?
|
2a. identify current status in relation to the instructional need 2b. gather information about the opportunities and barriers in their environments |
|
|
| 3. What must change for me to learn what I don’t know?
|
3a. decide if actions will be focused on capacity building, modifying the environment or both 3b. choose a need to address from the prioritized list |
|
|
| 4. What can I do to make this happen? | 4a. state a goal and identify criteria for achieving goal |
|
|
| Phase 2: Take Action (What is my plan?) | |||
| 5. What can I do to learn what I don’t know?
|
5a. self-evaluate current status and self-identified goal status |
|
|
| 6. What could keep me from taking action?
|
6a. Determine plan of action to bridge gap between self-evaluated current status and self-identified goal status |
|
|
| 7. What can I do to remove these barriers?
|
7a. Collaborate with client to identify appropriate instructional strategies 7b. Teach client needed student-directed learning strategies 7c. Support client to implement self-directed learning strategies 7d. Provide mutually agreed upon therapist-directed instruction |
|
|
| 8. When will I take action?
|
8a. determine schedule for action plan 8b. implement action plan 8c. self-monitor progress |
|
|
| Phase 3: Adjust Goal or Plan (What have I learned?) | |||
| 9. What actions have I taken?
|
9a. self-evaluate progress towards goal achievement |
|
|
| 10. What barriers have been removed?
|
10a. Collaborate with client to compare progress with desired outcomes |
|
|
| 11. What has changed about what I don’t know?
|
11a. Support client to re-evaluate goal if progress is insufficient 11b. Assist client to decide if goal should remain the same or change 11c. Collaborate with student to identify if action plan is adequate or inadequate given revised or retained goal 11d. Enable client to choose a need to address from the prioritized list |
|
|
| 12. Do I know what I want to know?
|
12a. Enable client to decide if progress is adequate, inadequate or if goal has been achieved |
|
|
Phase 2—Take Action: Person Questions, Facilitator Objectives, and Educational Supports
The problem to solve in Phase 2 is What is my plan? In Phase 2, the person devises their plan for accomplishing the goal they set in Phase 1. During Phase 2 (Take Action), the facilitator supports the person in responding to the following Person Questions: (5) What can I do to learn what I don’t already know? (6) What could keep me from taking action? (7) What can I do to remove these barriers? (8) When will I take action? A listing of Facilitator Objectives and educational supports are presented in Table 2 (Shogren et al., 2019b). As with Phase 1, facilitators have a list of objectives, directly linked to each question, which they use to guide the support they provide to the person with I/DD over the course of Phase 2. Some examples of objectives in Phase 2 are related to identifying current knowledge (Question 5), setting the timing for taking
action (Question 6), identifying and addressing any possible barriers (Question 7), and implementing action for the plan and monitoring progress (Question 8). Facilitators also continue to use a variety of educational supports, based on the person’s needs, as the person takes steps toward their goals. For example, in Phase 2, some examples of educational supports include goal attainment instruction, self-management and self-instruction, communication instruction, and antecedent cue regulation instruction.
Phase 3—Adjust Goal or Plan: Person Questions, Facilitator Objectives and Educational Supports
In Phase 3: Adjust Goal or Plan, the person aims to solve the Problem: What have I learned? During Phase 3, the facilitator supports the person in responding to the following questions: (9) What actions have I taken? (10) What barriers have been removed? (11) What has changed about what I don’t know? (12) Do I know what I want to know? Phase 3 Facilitator Objectives focus on supporting the person to evaluate their goal attainment (Questions 9 and 10) and the impact of their action plan (Questions 11 and 12). A key focus is to determine what they want to continue or do differently in the future as they set and work toward new goals. In Phase 3, the person with I/DD determines if they have met their particular goal. If yes, people are supported to move back to Phase 1 of the SDLMI and determine the next goal they want to work on, using the same process and continuing to build their self-determination skills and abilities. If no, the person considers whether they want to go back to Phase 1 and refine their goal or go back to Phase 2 and refine their action plan, keeping the goal the same. The ultimate focus of the SDLMI is not goal attainment per se, but instead, learning the steps to set and go after a range and sequence of goals, adjusting goals and action plans as needed, and expanding and broadening the goal setting and attainment opportunities available. As with Phase 1 and 2, the facilitator’s objectives link directly to person questions. Facilitators may choose to utilize a variety of Educational Supports.
Implementers learn to apply the SDLMI via a 3-day training that include developing shared definitions of self-determination, offering opportunities to role play SDLMI implementation, and learning how to embed modifications and supports for diverse support needs. In school contexts, the SDLMI has typically been implemented twice a week for 15 or 20 minutes each session and in community contexts during weekly group sessions. Participants typically work through the SDLMI over the course of approximately 16 weeks. A comprehensive Teachers’ Guide to Implementation (Shogren et al., 2019b) in schools outlines supports to assist with the implementation of the SDLMI. Lesson plans and other resources (e.g., PowerPoints, Goal Notebooks) have been developed to align with each Person Question to assist facilitators with implementation and people with I/DD to track their progress and share with family and other supporters.
Integrating the SDLMI Framework Within Psychotherapy
Table 2 provides a framework for aligning the SDLMI framework in the psychotherapeutic context, namely CBT practices. We posit that by intentionally embedding the Person Questions and Facilitator Objectives from each Phase of the SDLMI into CBT sessions, as well as using Educational Supports aligned with a person’s needs within a therapy session, therapists can support their clients to grow in goal setting, action planning, and self-regulated problem-solving abilities. This has the potential to increase client empowerment, and ultimately, enhance the development of characteristics of self-determination. Further, psychotherapy techniques can be integrated with the SDLMI that reduce mental health symptoms. The therapist-client relationship must be situated within the broader disability and cultural context of each client’s life. Recognition of disability as diversity, and as a facet of intersectionality, abandoning pathological models and focusing on acceptance throughout the therapeutic process will be critical (Annamma et al., 2003).
We also posit the following CBT strategies align with the SDLMI Phases (see Table 3) and could be integrated in therapeutic situations. Within each of the above stages of psychotherapy, we would encourage clinicians to utilize the Person Questions of the SDLMI at the aligned stages in order to promote the client’s development of the abilities that enable goal-directed actions. From there, a clinician with training on meeting the Facilitator Objectives, could work to support the person to answer each Person Question either during or after therapeutic sessions to facilitate the client’s understanding of their own strengths and areas for growth related to their mental health goals and current characteristics of self-determination. The clinician, in partnership with the client, can also integrate relevant Educational Supports from the SDLMI in service to supporting the client in building skills and abilities associated with self-determination inside and outside of the therapeutic context. See Table 3 for an overview of a proposed session progression of CBT therapy incorporating SDLMI Person Questions, Facilitator Objectives, and Educational Supports. This progression is based on effective delivery practices from education and community contexts of the SDLMI. We would suggest that therapists in a typical 50- to 60-minute session with a client may be able to embed 1-2 of the Person Questions, mindful of each of the Facilitator Objectives, using the Educational Supports to promote learning. However, this may vary based on the client, issues, and goals being targeted in the therapeutic session, consistent with the SDLMI and recommended adaptations to psychotherapy for people with I/DD. The SDLMI Educational Supports also provide excellent examples of how a therapist with less familiarity in working with people with I/DD could systematically consider applicable support options to utilize at each stage in the process, to support the client in advancing towards self-directed goals and ultimately, enhanced characteristics of self-determination.
| Treatment stages | SDLMI phase | SDLMI questions | Psychotherapeutic strategies |
| Intake/Assessment (Session 1) | Preliminary conversations | Preliminary conversations focus on establishing shared expectations and defining key terms (e.g., self-determination, goal, plan, evaluate, barrier) |
|
| Beginning Sessions (2-4) | SDLMI Phase 1: What is my goal? |
|
|
| Middle Sessions (5-7) | SDLMI Phase 2: What is my plan?
|
|
|
| Concluding Sessions (8-10) | SDLMI Phase 3: What have I learned?
|
|
|
It is not a novel psychotherapeutic concept to incorporate a client’s strengths, preferences, and interests, and to support a client in identifying goals. However, the SDLMI advances a focus on self-directed goal setting and attainment as well as the use of an iterative process to goal setting and attainment that can be led by the teenager or young adult with I/DD. This can support the young person to clearly identify their goals during therapeutic sessions, developing concrete strategies to make progress toward goals, take action using a selected strategy or set of strategies, and then evaluate the impact of the strategy on a particular outcome. What is uniquely offered within the SDLMI, is a systematic way for therapists new to working with people with I/DD to apply strategies that ensure that the content of a session driven by the client is focused on their strengths and adapted to the person’s support needs to ensure that information offered within a session is person-led, accessible, and ultimately, impactful.
For example, Session 1 (see Table 3) of a CBT series could be aligned with the SDLMI Preliminary Conversations, in which the therapist seeks to gather information about their client and to begin to identify treatment goals. In this first session, the therapist may engage the client in discussion or review of their current strengths, their communication style, their motivations and interests, and the areas in which they are seeking support. The therapist can utilize a validated measure of the client’s self-determination skills and abilities. A useful tool to measure characteristics of self-determination is the Self-Determination Inventory, developed by Shogren et al. (2018). It is a validated measure of self-determination, namely volitional action, action-control beliefs, and agentic actions that can be used to support the development of self-determination-related treatment goals. The therapist and client can also identify supports needed to engage with the SDLMI, including communication (e.g., visual, technological, or human). It is also key to gauge a person’s interests (e.g., through a preference assessment or observation in a particular context), particularly during the early stages of the SDLMI to inform goal setting. The therapist may begin to provide psychoeducation on the elements of goal setting and problem solving and laying the foundation for a working relationship focused on creating options for choice and decision making. The therapist may choose to use particular Educational Supports that enable the client to engage and internalize the information, enhancing motivation more fully. One example of the use of Educational Supports at this stage could be awareness instruction (discussion or observation of the person’s interests and motivations) and communication instruction (teaching of assertiveness skills). Goal-setting instruction is another Educational Support that may frequently be used in this stage—the therapist may provide explicit instruction about the components of a goal and how to make choices and decisions about setting goals.
Sessions 2-4 of a CBT series could target SDLMI Phase 1 Person Questions related to setting a goal. In those 2-3 sessions, the Person Questions (What do I want to learn? What do I know about it now? What must change for me to learn what I don’t know? What can I do to make this happen?) guide conversation between the therapist and client. The therapist can focus on meeting the Facilitator Objectives through these conversations, supporting the person to answer the Person Questions and using corresponding Educational Supports to enable the client to identify their goals for therapy. For example, a teen or young adult client with I/DD may want to learn more about managing anxiety in different social situations. With the facilitator asking the Person Questions, the teen may identify what they already know about themselves and their anxiety, what still is to be learned, and what behaviors or knowledge may need to change in order for the teen to move forward in their learning on this topic. An example goal could be “I want to manage my anxiety better at school.”
In subsequent sessions (5-7), the therapist may focus on Phase 2 Person Questions that support the client to identify ways to develop an action plan and take steps toward goals, based on client responses to Phase 2 Person Questions (What can I do to learn what I don’t already know? What could keep me from taking action? What can I do to remove these barriers? When will I take action?). As the client identifies areas they want to learn more about to take steps toward their goals, the therapist may introduce the classic CBT strategies of recognition of the thoughts-feelings-actions relationship, and work with the client to develop their abilities related to self-awareness, self-monitoring, and self-management, cuing educational supports of instruction in each of these domains, as fits with the response of the client to each of the Person Questions related to their goal attainment and the SDLMI Facilitator Objectives. For example, instruction in self-scheduling may support a client who wants to schedule enjoyable activities in an effort towards behavioral activation. Visual cues for self-monitoring may be helpful in recognizing thoughts and categorizing them as helpful or unhelpful and the client can integrate these strategies into their action plan developed in Phase 2. Throughout each phase, the focus remains on the client, their responses to each question, and thus their decisions around what is important, what to try, and how to apply each strategy. This ensures that the person guides each step in the process, and the strategies that are used and applied to address a challenge the person is facing, encouraging the internalization of the self-regulatory process of goal setting, problem-solving, and planning.
Finally, in later sessions, as CBT continues, therapeutic work can continue to be aligned with the SDLMI with a focus on the SDLMI Phase 3 Person Questions (What actions have I taken? What barriers have been removed? What has changed about what I don’t know? Do I know what I want to know?). As the therapist works to address the Facilitator Objectives, they support the client to evaluate their progress on their goals and determine the next steps they want to take toward the current and future goals. SDLMI Phase 3 Facilitator Objectives are aligned well with the CBT strategy of problem solving, and there are also Phase 3 Educational Supports which can be leveraged to support the client’s understanding of and measurement of progress towards goals, and opportunities for adjustment of either the goal or the approaches taken towards the goal. For example, Educational Supports applied within this phase could include self-evaluation instruction, or self-monitoring instruction.
Frequently, within a CBT context, goals that are selected by the client in Phase 1 would relate to addressing low mood, anxiety, or other affective-related symptoms. Thus, it will be important to continue offering psychoeducation related to emotion recognition and management throughout the SDLMI Phases. With the additional application of the SDLMI in CBT, explicit instruction in how and why we set goals, change behavior, and measure impact, facilitates the client to not only learn self-regulation strategies, but to also develop empowerment and motivation more broadly. The SDLMI supports self-direction and agency, which could serve as a buffer against future mental health concerns and enhance self-determination more broadly in the person’s life. The SDLMI provides an evidence-based approach for a therapist working with a teenager or young adult with I/DD to create a more accessible, inclusive, and empowering environment to promote broader characteristics of self-determination for a client.
Vignette – Olivia and Maggie
Olivia is a 14-year-old female with autism and is dealing with issues of depression. Olivia’s parents have decided to seek assistance from their therapist to help Olivia manage her depression. Olivia’s therapist, Maggie, has elected to use the SDLMI to engage Olivia in self-directing the process of exploring ways to manage her symptoms of depression.
Maggie engages in Preliminary Conversations with Olivia and her parents about her strengths, interests, and passions. Olivia enjoys anime, animals, art, and Star Wars. Olivia and her parents separately complete the Self-Determination Inventory (SDI: Self Report and SDI: Parent Report). They also complete behavior rating scales. Olivia’s results on the SDI indicate that her parents and Olivia rate her high in her beliefs that she can accomplish goals, but relatively lower in areas related to identifying a goal and planning to achieve goals across aspects of her life. Maggie, Olivia, and her parents agree to engage with the SDLMI process in the context of CBT-oriented sessions.
Starting at Session 2, Maggie asks Olivia Person Question 1: “What do I want to learn or improve on”? They work to achieve the Facilitator Objectives for Person Question 1 by supporting Olivia to begin to identify her strengths and needs, communication preferences, beliefs and values, and prioritizing needs as she is exploring what she wants to learn or improve on. Maggie suggests focusing these discussions with Olivia on social-emotional health. Maggie uses Educational Supports focused on identifying preferences and values (i.e., a values sort activity). Maggie and Olivia develop a visual reference system (e.g., 5-point scale or color-coding strategy) to prioritize areas she values. Through this process, Olivia shares that an area she wants to learn or improve upon is creative ways to manage her mood when she is feeling down.
After Olivia identifies her response to Person Question 1 (creative ways to manage her mood), Maggie and Olivia then explore Person Question 2: “What do I know about it now?” Here, Maggie supports Olivia to explore what she understands about herself and the connection between her thoughts, feelings, and behaviors, an early component of cognitive behavior therapy. Olivia states, “I don’t know how to manage my mood. When I feel bad, I just watch TV or play Star Wars games on my phone.” Maggie supports Olivia in gathering information about other opportunities she might have to address her mood (e.g., other enjoyable activities, other social connections) and barriers that exist in her surrounding environment related to her goals. Olivia identifies a few supportive adults who are available to talk to her when feeling down, and also recognizes that just staying in her room tends to keep her mood low. She feels better when she goes outside to play with her dog.
At Session 3, they discuss Question 3: “What must change for me to learn what I don’t know” and Question 4: “What can I do to make this happen”? In response to brainstorming on Question 3, Olivia decides she wants to learn more strategies she can do to manage her mood, so she brainstorms the idea of playing more regularly with her dog outside. Maggie also offers to jointly brainstorm other ideas if Olivia is interested. Olivia says yes, so as they brainstorm, Maggie explains more about the concept of “behavior activation” or doing things even when you feel down. In response to Question 4, Olivia decides on her goal: I will use behavioral activation strategies when my mood is low.
In Session 4, they discuss the Person Questions from Phase 2, focused on developing an action plan to make progress toward the goal that Olivia identified at the end of Phase 1: I will use behavioral activation strategies when my mood is low. Person Questions for session 4 include Question 5, “What can I do to learn what I don’t already know?” and Question 6 “What could keep me from taking action?” Maggie supports Olivia to self-evaluate her status in relation to her goal consistent with the Facilitator Objectives, and Olivia develops a plan of action to bridge the gap from her status to where she wants to be. In response to Question 5, Olivia states that she can try to use more behavior activation strategies when she is feeling down. Olivia thinks she will need more strategies to raise her mood. In responding to Question 6, Olivia says “Sometimes I don’t feel like doing this stuff. I might need more ideas.” She records that low feeling of motivation as a potential barrier.
In Session 5, Maggie and Olivia discuss Question 7: “What can I do to remove these barriers”? They brainstorm possibilities for Olivia to try. Olivia brainstorms, “I could set an alarm, or write on my calendar, or try to do it at the same time each day.” Olivia decides she wants to plan to do something fun after school each day, rather than go right to her room like she usually does. Then, Maggie and Olivia talk about Question 8: “When will I take action”? Olivia wants to do her behavior activation (e.g., go outside and play with her dog) after school. Maggie follows up by asking Olivia to choose a specific date and time. Olivia says she can start “next week.” Maggie provides instruction to Olivia in educational supports such as self-scheduling time for pleasurable activities (e.g., setting an alarm to go outside and play with her dog). Olivia decides to set an alarm to remind her to play with her dog and keep track of her activities each day by marking them on the calendar.
At Session 6, Maggie uses the Person Questions for Phase 3 to support Olivia in evaluating her implementation of the plan she developed at session 5. She and Olivia discuss Person Question 9: “What actions have I taken?” to enable Olivia to self-assess her progress towards her goal. Olivia reports that she used the alarm and played outside with her dog for about 5 or 6 days out of the last week since starting to use the alarm reminder and the calendar. Then Maggie and Olivia discuss Question 10: “What barriers have been removed?” to compare Olivia’s progress with her desired outcomes. Maggie uses Educational Supports such as a self-assessment tool that Olivia rates her mood before and after playing outside with her dog. Olivia mentions “it is getting easier to go outside and spend time with my dog, even when I feel down. Practicing did help.”
Maggie and Olivia discuss how these small steps have informed her thinking in response to Questions 11: “What has changed about what I don’t know?” Olivia shares “Now I understand a little better how my mood relates to how I act. I feel like I can do more about it when I feel down.” Maggie and Olivia then discuss Question 12: “Do I know what I want to know?” Olivia says “I know that playing with my dog can help, but what if my mood is down and playing with my dog doesn’t help as much? I want some other ideas.” Olivia decides she wants to adjust the goal she set in Phase 1, and adds to her goal to say, “I want to learn behavior activation strategies and other strategies that could help my mood” and revise her action plan from Phase 2.
At Session 7, Maggie and Olivia go back to Phase 2 Questions 5: “What can I do to learn what I don’t know?” Olivia and Maggie brainstorm again about other options to help alleviate some of the low moods when they happen. Olivia decides she wants to learn more things she can do when the moods come up and wants to be able to use them where she is (home, school, in the community). They discuss Question 6: “What could keep me from taking action?” Olivia says, “I can’t play with my dog at school. When I’m at school I want to do things for my mood that aren’t too obvious to other people.” With Question 7: “What can I do to remove these barriers” Maggie and Olivia brainstorm again, and Olivia decides she wants to learn more about strategies like deep breathing. Maggie shares information she has about these strategies, and they practice them together in the session, and then discuss Question 8: “When can I take action?” Olivia targets specific situations where she will practice such strategies. “I could try deep breathing when I’m in class.”
In Session 8, Olivia and Maggie move into the 3rd Phase again to evaluate what she has learned so far. Maggie and Olivia discuss Question 9: “What actions have I taken?” and then “What barriers have been removed?” They celebrate that many barriers have been removed. Olivia reports “I know more options of what I can do if I feel low. I like using the rating system because it tells me where I’m at right then with my mood.” Maggie and Olivia discuss “What has changed about what I don’t know?” in terms of how Olivia knows how to regulate her mood. They consider Question 12: “Do I know what I want to know?” Olivia says “I do feel better about managing my mood. I still need to figure out how to get my parents to better help me when I need it.” Maggie and Olivia celebrate her progress towards her goal, and Maggie encourages Olivia that she can now apply the things she’s learned from going through the SDLMI Person Questions to other situations. Maggie and Olivia then cycle back to Phase 1 with questions geared towards understanding Olivia’s goal related to self-advocacy.
Implications for Research and Practice
There is a significant need in the mental health field for more clinicians equipped to effectively support people with I/DD and co-occurring mental/behavioral health conditions. In education and other human services fields, the concept of developing self-determination through a structured intervention like the SDLMI has been shown to be effective at promoting overall quality of life and enhanced self-determination for people with I/DD. In this paper, we provided ideas for how the SDLMI could be infused into CBT with the intent of opening access to better mental health supports for people with I/DD, empowering clinicians to support persons more effectively with I/DD, and enhancing empowerment and better addressing mental health supports for people with I/DD.
Psychotherapy that includes interventions to promote self-determination could have a variety of impacts on clients both with and without I/DD. The framework that has been proposed in this article is, as yet, untested. However, there is the potential for an intervention synthesizing the strengths of both the SDLMI and CBT to have profound impact on clients. Enhancing characteristics of self-determination for a person could lead to enhanced mental health, which could lead to an increase in overall emotional wellness, and overall improved quality of life.
Additional research is needed to enable people with complex communication needs to access self-determination supports within the psychotherapeutic context. The SDLMI provides a structured approach for working with persons who may have these complex communication needs. Additional resources, such as use of pictures, graphic organizers, visual rating tools, and other communication supports can be found in the SDLMI Complex Communication Needs Supplement (Shogren et al., 2019b). As research continues regarding the application of the SDLMI to the psychotherapeutic context, input from persons who have complex communication needs will be crucial. Additionally, we recognize that not all individuals with I/DD have the same support needs, and those needs vary based upon multiple aspects of a person’s identity and experiences, (i.e., race, culture, gender, sexuality, and other intersecting identities; Annama et al., 2013). We will continue to develop this model that could be adapted to the individual characteristics of each person.
Supporting clinicians’ understanding of self-determination and providing a structured way for them to use the SDLMI Person Questions, Facilitator Objectives, and Educational Supports to promote the development of characteristics of self-determination within the therapeutic context could also empower clinicians to feel more confident and competent in working with people with I/DD in their practice, impacting access to such services for teens and young adults with I/DD.
References
Annamma, S. A., Connor, D., & Ferri, B. (2013). DIS/Ability Critical Race Studies (DisCrit): Theorizing at the intersections of race and Dis/Ability. Race Ethnicity and Education, 16(1), 1–31. https://doi.org/10.1080/13613324.2012.730511
Beck, J. S. (2011). Cognitive behavior therapy: Basics and beyond (2nd ed.). Guilford Press.
Bender M. (1993). The unoffered chair: The history of therapeutic disdain towards people with a learning difficulty. Clinical Psychology Forum, 54, 7–12.
Burke, K. M., Shogren, K. A., Antosh, A. A., LaPlante, T., & Masterson, L. H. (2019). Implementing the SDLMI with students with significant support needs during transition planning. Career Development and Transition for Exceptional Individuals, 43(2), 115–121. https://doi.org/10.1177/216514341988 7858
Hurley, A. D., Tomasulo, D. J., & Pfadt, A. G. (1998). Individual and group psychotherapy approaches for persons with mental retardation and developmental disabilities. Journal of Developmental and Physical Disabilities, 10, 365–386.
Kalvin, C. B., Jordan, R. P., Rowley, S. N., Weis, A., Wood, K. S., Wood, J. J., Ibrahim, K., & Sukhodolsky, D. G., (2021). Conducting CBT for anxiety in children with autism spectrum disorder during COVID-19 Pandemic. Journal of Autism and Developmental Disorders, 51, 4239–4247. https://doi.org/ 10.1007/s10803-020-04845-1
McNally Keehn, R. H., Lincoln, A. J., Brown, M. Z., & Chavira, D. A. (2012). The coping cat program for children with anxiety and autism spectrum disorder: A pilot randomized controlled trial. Journal of Autism and Developmental Disorders, 43(1), 57–67. https://doi.org/10.1007/s10803-012-1541-9
National Institute for Health and Care Excellence (NICE). (2016) Overview: Mental health problems in people with learning disabilities: Prevention, assessment and management: Guidance. https://www.nice.org.uk/guidance/ng54
Nicoll, M., Beail, N., & Saxon, D. (2012). Cognitive behavioural treatment for anger in adults with intellectual disabilities: A systematic review and meta-analysis. Journal of Applied Research in Intellectual Disabilities, 26, 47–62. DOI: 10.1111/jar.12013
Raley, S. K., Shogren, K. A., & McDonald, A. (2018a). How to implement the Self-Determined Learning Model of Instruction in inclusive general education classrooms. TEACHING Exceptional Children, 51(1), 62–71. https://doi.org/10.1177/0040059918790236
Raley, S. K., Shogren, K. A., & McDonald, A. (2018b). Whole-class implementation of the Self-Determined Learning Model of Instruction in inclusive high school mathematics classes. Inclusion, 6(3), 164–174. https://doi.org/10.1352/2326-6988-6.3.164
Shogren, K. A., & Palmer, S. B. (2017). Causal agency theory. In M. L. Wehmeyer (Ed.), Development of self-determination through the life-course (pp. 55–67). Springer.
Shogren, K. A., Burke, K. M., Anderson, M. H., Antosh, A. A., Wehmeyer, M. L., LaPlante, T., & Shaw, L. A. (2018). Evaluating the differential impact of interventions to promote self-determination and goal attainment for transition-age youth with intellectual disability. Research and Practice for Persons with Severe Disabilities, 43(3), 165–180. https://doi.org/10.1177/1540796918779775
Shogren, K. A., Hicks, T. A., Raley, S. K., Pace, J. R., Rifenbark, G. G., & Lane, K. L. (2020). Student and teacher perceptions of goal attainment during intervention with the self-determined learning model of instruction. The Journal of Special Education, 55(2), 101–112. https://doi.org/10.1177/ 0022466920950264
Shogren, K. A., Luckasson, R., & Schalock, R. L. (2014). The definition of “context” and its application in the field of intellectual disability. Journal of Policy and Practice in Intellectual Disabilities, 11(2), 109–116. https://doi.org/10.1111/jppi.12077
Shogren, K. A., Raley, S. K., Burke, K. M., & Wehmeyer, M. L. (2019a).The Self-Determined Learning Model of Instruction teacher’s guide. Lawrence, KS: Kansas University Center on Developmental Disabilities
Shogren, K. A., Raley, S. K., Burke, K. M., & Wehmeyer, M. L. (2019b). SDLMI teacher’s guide supplement: Supporting students with complex communication needs. Lawrence, KS: Kansas University Center on Developmental Disabilities
Shogren, K. A., Abery, B., Antosh, A., Broussard, R., Coppens, B., Finn, C., Goodman, A., Harris, C., Knapp, J., Martinis, J., Neeman, A., Nelis, T., & Wehmeyer, M. L. (2015). Recommendations of the self-determination and self-advocacy strand from the National Goals 2015 conference. https://doi.org/10.1352/2326-6988-3.4.205
Surley, L., & Dagnan, D. (2018). A review of the frequency and nature of adaptations to cognitive behavioural therapy for adults with Intellectual Disabilities. Journal of Applied Research in Intellectual Disabilities, 32(2), 219-237. doi: 10.1111/jar.12534
Whitehouse, R. M., Tudway, J. A., Look, R., & Kroese, B. S. (2006). Adapting individual psychotherapy for adults with intellectual disabilities: A comparative review of the cognitive-behavioural and psychodynamic literature. Journal of Applied Research in Intellectual Disabilities, 19(1), 55–65. https://doi.org/10.1111/j.1468-3148.2005.00281.x
Witwer, A. N., Walton, K., Held, M. K., Rosencrans, M., Cobranchi, C., Fletcher, R., Crane, J. M., Chapman, R., & Havercamp, S. (2022). A scoping review of psychological interventions, accommodations, and assessments for adults with intellectual disability. Professional Psychology: Research and Practice, 53(6), 615-625. https://doi.org/10.1037/pro0000474
