Carol Pert

The balance of power in therapeutic interactions with individuals who have intellectual disabilities

OBJECTIVES Establishing a collaborative relationship is a cornerstone of cognitive behavioural therapy (CBT). Increasingly CBT is being offered to people with intellectual disabilities who may have problems with receptive and expressive communication, and a history of disadvantage or discrimination in their relationships with those in positions of power. Consequently, they may have difficulty establishing a collaborative interaction with their therapist. This paper uses a novel method of interactional analysis to examine if collaboration increases as therapy progresses. DESIGN AND METHODS Fifteen participants with borderline to mild intellectual disabilities and significant problems of depression, anxiety and anger were recruited from specialist clinical services to participate in this study. Verbatim transcripts of therapy sessions 4 and 9 were coded using an initiative-response method of analysing power distribution in dialogue, to investigate collaboration at the level of therapeutic interaction. RESULTS The initiative-response scores indicated that power was relatively equally distributed between clients and therapists. On this measure there was no significant increase in collaboration as therapy progressed, as the dialogues were relatively equal from session 4. Analyses of the pattern of interaction showed that whilst the therapists asked most questions, the clients contributed to the flow of the analysis and played an active part in dialogues. CONCLUSIONS The implications of these findings are discussed, along with the possible uses of such interactional analyses in identifying barriers to communication and ways of establishing effective therapeutic dialogue.

A cluster randomised control trial of a multi-component weight management programme for adults with intellectual disabilities and obesity

There have been few published controlled studies of multi-component weight management programmes that include an energy deficit diet (EDD), for adults with intellectual disabilities and obesity. The objective of this study was to conduct a single-blind, cluster randomised controlled trial comparing a multi-component weight management programme to a health education programme. Participants were randomised to either TAKE 5, which included an EDD or Waist Winners Too (WWToo), based on health education principles. Outcomes measured at baseline, 6 months (after a weight loss phase) and 12 months (after a 6-month weight maintenance phase), by a researcher blinded to treatment allocation, included: weight; BMI; waist circumference; physical activity; sedentary behaviour and health-related quality of life. The recruitment strategy was effective with fifty participants successfully recruited. Both programmes were acceptable to adults with intellectual disabilities, evidenced by high retention rates (90 %). Exploratory efficacy analysis revealed that at 12 months there was a trend for more participants in TAKE 5 (50·0 %) to achieve a clinically important weight loss of 5-10 %, in comparison to WWToo (20·8 %) (OR 3·76; 95 % CI 0·92, 15·30; 0·064). This study found that a multi-component weight management programme that included an EDD, is feasible and an acceptable approach to weight loss when tailored to meet the needs of adults with intellectual disabilities and obesity.

Coping with criticism and praise

Through experiencing stigma and discrimination, people with intellectual disability may become more sensitive to criticism from others and be less likely to believe praise. This study compared how people with and without intellectual disability viewed praise and criticism, using a vignette task developed for the study. Participants were asked to imagine someone saying something praiseworthy or critical and were then asked about their emotions, beliefs, and thoughts. People with intellectual disability were more likely to believe and be distressed by criticism. Contrary to predictions, this group were also more likely to believe praise and experience positive affect. The results suggest that the self-perceptions of people with intellectual disabilities is more dynamic and reliant on the views of others.

From Causes of Aggression to Interventions: The Importance of Context

Abstract This chapter reviews several strands from recent research concerning the causes of aggression, including neurological and psychosocial factors. There is some support for the commonly held assumptions linking aggressiveness and social-cognitive problems associated with people’s cognitive deficits. However, this explanation fails to account for the fact that most people with intellectual disabilities are not aggressive. There is a significant danger in simplifying the aggressive behavior of people with intellectual disabilities to a single causative factor. Even if one factor was found to predispose an individual to be aggressive, it is improbable that the other aspects of a person’s life (such as the social and environmental context in which they live) would not also influence the individual’s actions. Moreover, there are different kinds of aggression, including acts that are categorized as reactive and instrumental or planned. An interaction of cognitive, communicative, genetic, and sociocultural factors may influence aggressive behavior. However, aggression is usually a social act and concerns the dynamic relationship between the person and his or her social environment. This means taking seriously how more able people negotiate their social identities in the world and how those with more significant impairments communicate their needs and wishes. Although there is limited evidence for the effectiveness of pharmacological treatments, there are promising findings for the use of behavioral approaches for people with more severe impairments and anger management treatments for those with milder disabilities. In addition to individual interventions, recent attempts have also been made to foster positive change in individuals’ wider lives. It is proposed that promoting a formulation-based approach to interventions might help professionals to take account of the range of intrapsychic and interpersonal factors that can contribute to the person’s difficulties.

Cognitive Behaviour Therapy for People with Intellectual Disabilities

This book examines the influence others have on the lives of people with intellectual disabilities and how this impacts on their psychological well-being. Based on the authors’ clinical experiences of using cognitive behavioural therapy with people who have intellectual disabilities, it takes a social interactionist stance and positions their arguments in a theoretical and clinical context. The authors draw on their own experiences and several case studies to introduce novel approaches on how to adapt CBT assessment and treatment methods for one-to-one therapy and group interventions. They detail the challenges of adapting CBT to the needs of their clients and suggest innovative and practical solutions. This book will be of great interest to scholars of psychology and mental health as well as to therapists and clinicians in the field.

Chapter Three - From Causes of Aggression to Interventions: The Importance of Context

Abstract This chapter reviews several strands from recent research concerning the causes of aggression, including neurological and psychosocial factors. There is some support for the commonly held assumptions linking aggressiveness and social-cognitive problems associated with people’s cognitive deficits. However, this explanation fails to account for the fact that most people with intellectual disabilities are not aggressive. There is a significant danger in simplifying the aggressive behavior of people with intellectual disabilities to a single causative factor. Even if one factor was found to predispose an individual to be aggressive, it is improbable that the other aspects of a person’s life (such as the social and environmental context in which they live) would not also influence the individual’s actions. Moreover, there are different kinds of aggression, including acts that are categorized as reactive and instrumental or planned. An interaction of cognitive, communicative, genetic, and sociocultural factors may influence aggressive behavior. However, aggression is usually a social act and concerns the dynamic relationship between the person and his or her social environment. This means taking seriously how more able people negotiate their social identities in the world and how those with more significant impairments communicate their needs and wishes. Although there is limited evidence for the effectiveness of pharmacological treatments, there are promising findings for the use of behavioral approaches for people with more severe impairments and anger management treatments for those with milder disabilities. In addition to individual interventions, recent attempts have also been made to foster positive change in individuals’ wider lives. It is proposed that promoting a formulation-based approach to interventions might help professionals to take account of the range of intrapsychic and interpersonal factors that can contribute to the person’s difficulties.

Working with Others

When working with people with ID, there are a number of other people who we may need to be in contact with, not just to gather background information but also to recruit them as allies who can play an influential and long-term role in implementing and maintaining psychological and environmental change. We need to carefully consider when it is and when it is not suitable to involve other people so that we respect the client’s right to confidentiality. We may need to spend time with caregivers and staff to make sure that they understand and agree with the CBT model and the formulation. As therapists we must also liaise with our health and social services colleagues and ensure that the various interventions received by clients are well coordinated and are not detrimental to each other. Family carers and support workers as well as health and social services professionals can complement the CBT approach and improve the chances of significant and enduring improvements in psychological well-being.

The First Stage of Therapy

This chapter concerns the first phase of therapy when the client should develop a sense of the structure and purpose of sessions, if not an understanding of the CBT model itself. Communication is the core of a talking therapy like CBT and techniques and approaches that therapists can use to help foster a therapeutic dialogue and overcome communicative barriers are discussed. These include role play and the use of visual materials. Moreover, talking with the client about salient emotive events may be the most immediate and least abstract way of helping clients to make sense of the CBT model. By the end of this first phase the therapist should present the client with a formulation, helping to explain their difficulties. The formulation should take account of the wider context of the client’s life and the very real challenges they may face. CBT should not be used as a panacea for social disadvantage faced by people with intellectual disabilities.

Making a Real Difference

There is a need to broaden people with intellectual disabilities’ access to psychological services. One proposed way of achieving this is for mainstream services to deliver CBT to people with intellectual disabilities. However, it is argued that there remains a need for specialist support, and thought should be given to a more systematic approach to the training and supervision of therapists delivering CBT. Another way of reaching more people is through lower intensity CBT interventions delivered by lay therapists. However, the lay therapists would require careful supervision. Over and above who delivers the therapy, suitable manuals and materials also need to be developed or shared and made freely available to therapists. Electronic media could provide an effective way to distribute materials. There might also be an opportunity to build an online community of more dispersed CBT therapists and to use this as a means of offering peer support both nationally and internationally.

Mindfulness and Third Wave Therapies

The principles and attitudinal qualities underpinning third wave therapies have potential benefits for clients with intellectual disabilities; nevertheless, more research is required to explore their applicability for this client group. Most of the adaptations used to make CBT more accessible for people with intellectual disabilities will also be relevant for third wave therapies, such as keeping exercises short, providing more repetition and using visual aids and storyboards to overcome communication difficulties. Further adaptations are necessary to clarify some of the abstract concepts underpinning mindfulness and other third wave therapies and to help clients apply the key principles. The use of vignettes and storyboards can be used to assist this process. Adapted compassion-focused techniques hold some promise to further enhance clients’ coping mechanism, such as when problems are associated with a sense of separation or alienation. However, research is needed to explore the clinical effectiveness of an adapted approach.