It is important to remember that CT includes a broad range of interventions, not just thought sheets and rational responses. Thought sheets and rational responses are not likely to be very useful with clients who are of limited intellectual ability or who are illiterate.

However, this doesn't mean CT isn't helpful with these individuals, it means that appropriate adjustments need to be made in the treatment approach. In general, self-instructional training, problem-solving training, modeling, role-play, and behavioral interventions are more useful when the client has significant intellectual limitations. Also, office-based treatment may inadequate unless there is significant coordination with family members, case managers, job coaches, house-parents, and others who play important roles in the client's life.

For example, I am currently working with a young man who experienced a traumatic brain injury as an infant. He was in special education classes through high school and is now able to hold janitorial jobs with some supervision and coaching. CT for anxiety, depression, anger, and OCD has been quite helpful to him. Treatment has required coordination with his psychiatrist and telephone contacts with family members. A good case manager and the client's involvement in social programs for persons with developmental disabilities have been quite helpful. If it is possible to get him into an appropriate group home or supported living situation, that will be really helpful. We're doing CT but we aren't using thought sheets and we are combining office-based treatment with case management, consultation with family members, and a number of supportive services.