Psychotherapies & Learning Disabilities

Developmental journey Experience of the family

Life-long dependency on others Located within a complex system

Managing consent issues & measuring outcomes

Possible psychotherapeutic approaches & adaptations

The Developmental Journey of an Individual

with Learning Disabilities

Early Development

Family relationships

Lifelong dependency/vulnerability

Mental health

Early Development

“The quality and reciprocity of communication and physical contact with primary care-giver can be impaired, resulting in:

Fragile emotional attachments Impairment of symbol formation Delayed development of self and object

constancy”(Banks, 2003 Psychiatry, Vol 2:9)

Family relationships

“the birth of a disabled child can be experienced by parents as a loss of the anticipated 'healthy' child (see also Lindsey, PSYCHIATRY 2003; 2:9: 48). This bereavement can be a lifelong issue that becomes reinforced at various life stages and by the individual's inability to fulfil the 'normal' expectations of our culture and society. Siblings may also be affected, experiencing difficult and conflicting emotions such as loss, resentment or guilt.” (Banks, 2003 Psychiatry, Vol 2:9)

Lifelong dependency/vulnerability

“People with learning disabilities, either out of necessity or because of the limited expectations of others, tend to be highly dependent on other people for care and protection; they are also less able to deal with choices, problems and challenges. This makes them vulnerable, and it is well known that people with learning disabilities are more likely to be sexually abused.” (Banks, 2003 Psychiatry, Vol 2:9)

Mental health

“the prevalence of psychiatric disorder in people with learning disabilities is higher than in the general population (see also Prasher, PSYCHIATRY 2003; 2:8: 11); estimates range between 10% and 39%. In addition to defined disorders, there may be traits and symptoms (such as identity disturbance, problems with symbolization and concepts of reality) that are similar to poorly integrated or borderline personality disorders.” (Banks, 2003 Psychiatry, Vol 2:9)

The Development of Defences

The handicapped smile (Sinason 2010) – comes from loss and abuse and is a defensive way of dealing with trauma.

“Sometimes the smile is to keep depressed parents happy, sometimes it is to prove that no intelligence is alive.” (p.124)

Managing consent

CONSENT Capacity to consent is determined by individuals being able to: understand information about the decision remember that information use that information as part of their decision-making

process communicate their decision by talking, using sign

language or by any other means

It is often difficult to establish whether or not the person is making an informed choice about therapy, and we may only have a person’s demeanour, mood, and willingness to remain in the room or to return to it, to go on.

Measuring outcomes

Adapted CORE Outcomes chart

Psychotherapeutic approaches in learning disabilities

Adapting traditional psychoanalytic methods has enabled considerable progress to be made, and a variety of related approaches are being developed. Sinason (1992) has written extensively in this area, with vivid illustrations of case material. She emphasized the significance of secondary handicap as a defence against the trauma of disability. Together with Hollins, she described issues that commonly arise with this patient group, which are too painful to address in everyday life, and thus assume the nature of taboo subjects or 'secrets‘:

The disability or handicap itself Dependency on others Sexuality Death Fears of annihilation

(Banks, 2003 Psychiatry, Vol 2:9)

Adapting psychotherapeutic approaches The therapeutic relationship: the fundamental importance and

efficacy of the therapeutic relationship is common to all psychological therapies. It is characterized by attentiveness, empathy, consistency, warmth and non-intrusive concern. People with learning disabilities whose early relationship experiences have been of rejection or lack of intimacy, and who expect to be devalued or disliked, may find it difficult to form a trusting treatment alliance. If the therapist takes the concept of 'analytic neutrality' too literally, they may be perceived as cold, rejecting or lacking in concern.

A greater degree of warmth and friendliness, combined with a more flexible approach to the timing of sessions and the use of physical touch, can help to establish a more positive and trusting relationship, although this may be at the expense of the patient's ability to express and process negative emotions in therapy.

(Banks, 2003 Psychiatry, Vol 2:9)

Adapting psychotherapeutic approaches

Communication: it can take time to establish an effective communication style in therapy. Non-verbal communication and the use of adjunctive methods such as drawings, doll figures and picture books are emphasized; art, music, play and drama therapies are particularly prominent. If difficulties in communication are experienced, it is important that silence can be both tolerated and used therapeutically.

(Banks, 2003 Psychiatry, Vol 2:9)

Possible psychotherapeutic approaches

Potentially, any approach that is used with the general population could be adapted for use with a person with a learning disability:

Arts Therapies Counselling CBT CAT Eye-Movement Desensitisation and Reprocessing Systemic work Psycho-educational approaches – CBT & DBT-

based work.

The Arts Therapies The arts therapies represent an area of psychotherapy that

encourages emotional expression and psychological healing through involvement in a creative process. They offer approaches that can be used with individuals who have little verbal expression and/or more profound intellectual disabilities.

There are four separate professions within the arts therapies: Art Psychotherapy Dance/Movement Therapy Dramatherapy Music Therapy

Each approach has a unique quality associated with the particular art form, but each share the same outcome goal; to help the individual overcome their emotional difficulties.

The arts therapies can be experienced individually, or as a member of a group.

Who uses the Arts Therapies? The arts therapies are suitable for people of all ages, genders,

ethnicities, and disability. It is not necessary to have any previous experience or particular talent in any of the art forms.

One of the advantages of an arts therapies approach is the containing aspect of the arts medium when experienced in a safe and supportive therapeutic relationship. This provides the client with the possibility of working through painful or distressing material in a more bearable and symbolic way.

Within the safety of the session the client is encouraged to experience the therapeutic relationship and the creative process as a means of personal exploration, identifying and connecting with emotions, making sense of past events and the expression of things that are hard to name or say in other ways.

Specialist Counselling A counselling session is most often an individual session. The

counsellor will be attentive to the client’s range of emotional expression and will tailor the session to meet each individual’s needs. This might include the use of sandtray therapy techniques, drawings, diagrams, figures and found objects.

Sandtray therapy is a non-verbal way of encouraging the expression and construction of images which have special meaning for the individual. The process involves using trays of sand into which small figures and objects are placed, thereby creating a representation of a person’s inner and outer worlds. The technique utilises experience of creative play, imagination, symbolic thinking and metaphor.

Psychological Therapies & Learning Disabilities

As was said earlier, potentially, any approach that is used with the general population could be adapted for use with a person with a learning disability:

Cognitive Behaviour Therapy Cognitive Analytic Therapy Eye-Movement Desensitisation and Reprocessing Systemic work Psycho-educational approaches – CBT & DBT-

based work.

The Individual or the Support?

Even if the extent of an individual’s learning disabilities is such that a verbally-based individual therapy cannot helpfully be offered, a psychological therapy can inform support and advice given to carers.

Cognitive Behaviour Therapy as an example: Some learning disabled individuals can be

appropriately referred to Plymouth Options (i.e. the IAPT Service).

If someone can:a) ‘catch’ the thoughts he is thinking and consider

them, b) Identify/label the feelings he is experiencing, and c) Discuss the connection between thoughts and

feelings, Then that individual is likely to be able to engage in

individual, slightly adapted CBT. (Dagnan and Chadwick, Chapter 7, Cognitive-Behaviour Therapy with People with Learning Disabilities (1997), Stenfert Kroese, B. (Ed)

Cognitive Behaviour Therapy

If the individual struggles with one of the three tasks, then a referral to the specialist LD service might allow the individual to be helped to develop some relevant skills and then to engage in a more heavily adapted form of CBT.

Cognitive Behaviour Therapy

If it becomes apparent that the individual cannot engage in CBT herself, then the carers can be engaged by the therapist to assist in the management of anxieties or low mood by offering: guided relaxation, interruption of/distraction from troubling thoughts; the labelling of feelings; and the offering of insightful observations that help the individual make sense of her experiences.