Psychotherapies

1
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

2
The Developmental Journey of an Individual with
Learning Disabilities

• Early Development
• Family relationships
• Lifelong dependency/vulnerability
• Mental health

3
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 29)

4
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 29
  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 29)

5
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 29)

6
Mental health

• the prevalence of psychiatric disorder in people
  with learning disabilities is higher than in the
  general population (see also Prasher, PSYCHIATRY
  2003 28 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 29)

7
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)

8
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 persons
  demeanour, mood, and willingness to remain in the
  room or to return to it, to go on.

9
Measuring outcomes

• Adapted CORE
• Outcomes chart

10
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 29)

11
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 29)

12
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 29)

13
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.

14
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.

15
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.

16
Specialist Counselling

• A counselling session is most often an individual
  session. The counsellor will be attentive to the
  clients range of emotional expression and will
  tailor the session to meet each individuals
  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
  persons inner and outer worlds. The technique
  utilises experience of creative play,
  imagination, symbolic thinking and metaphor.

17
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.

18
The Individual or the Support?

• Even if the extent of an individuals 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.

19
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
• catch the thoughts he is thinking and consider
  them,
• Identify/label the feelings he is experiencing,
  and
• 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)

20
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.

21
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.