Transcript Insert Presentation title here

A real connection
Andrew Jahoda
Making a connection with you
•
Why therapy?
•
Communication barriers.
•
What’s important about therapy for people with
intellectual disabilities? Insights from i) a group based
anger study run by ‘lay therapists’, and ii) a study
examining clients’ perspectives of CBT.
•
Tensions between listening and helping – finding the
right balance.
Why therapy?
•
Mental ill-health – point prevalence 41%
(PBs - 22%; psychosis - 4% (SIR=10); mania - 1% (SIR=42);
dementia >65yrs - 20%; Depression more enduring; psychosis 14%
remission in 2 yrs)
•
Life experience – a story to tell (my PhD concerned
stigma and people with learning disabilities)
News.
Disabled complain of widespread bullying.
People with learning difficulties face widespread harassment.
Nearly nine out of 10 people with learning difficulties have been bullied and many face
harassment on a regular basis, says a mencap report.
•
Stephen Hoskin’s horrific murder.
Psychological therapies: Cognitive
Behavioural Therapy (CBT)
• The most commonly used psychological therapy for
emotional problems in the UK is Cognitive Behavioural
Therapy.
• Like all other psychological therapies of this nature it is
essentially a talking therapy.
CBT
• Looks at the meaning we attach to our experiences.
• Focus on the links between the way we think, feel and
behave.
• A collaborative approach ‘working together’ on
problems. Homework tasks – practise new ways of
thinking.
CBT: The Good and the Challenging
•Good: gives people a voice; works with their
experience and views of their world.
•Challenge: demands a certain level of communicative
ability to understand what the therapist is saying and
express one’s thoughts and feelings.
Managing cognitive / communication
difficulties (Paul Wilner).
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Overcoming communicative challenges –
the client.
• Overall ability – mild to moderate intellectual disability.
• Particular abilities - Ensuring that people have
particular abilities to take part in therapy – e.g. making
the link between thoughts and emotions (Dagnan and
Chadwick, 1997).
• Socialising into the model - Beginning therapy by
teaching particular skills.
Overcoming communicative barriers – the
therapist. Including…
• Simple and clear language
• Use memory and comprehension checks
• Repetition and structure
• Use recent memories and time anchors
• Use different media - visual and not just
verbal
• Make the communication about key topics
more immediate and less abstract e.g.
through the use of role play
CBT – simply a matter of making it
accessible?
• Ensuring people are able to take part in therapy and
adapting the process are important considerations.
• The temptation to simplify the approach is often
taken rather too literally.
• This might mean adopting a more educational or
skills based approach – and being more didactic –
but does this necessarily promote better
understanding (Dagnan and Chadwick, 1997)?
Moving towards a shared understanding
of therapy.
AND
•
This makes an assumption of what people want from
therapy and how they understand the process.
•
Proper communication is about achieving a shared
understanding but how is that to be achieved if we don’t
know what each other want?
•
‘Non specific factors’ key to therapeutic success in
general adult mental health work.
What works: an example from practice
with lay therapists where the aim was to
build on existing relationships.
The ‘I’m In Control’ Group:
An evaluation of a manualised anger
management intervention for people with
mild to moderate learning disabilities.
Paul Wilner, John Rose, Andrew Jahoda, David Felce, Biza StenfertKroese, Kerry Hood, Pamela MacMahon
Introduction
• Anger is a problem for many people with learning disabilities.
It is estimated that between 11 and 27% of the LD population
will be experiencing problematic anger at any one time (Rose
et al 2008).
• Problematic anger is often associated with verbal and/or
physical aggression. These problems are common among
people labelled as having challenging behaviour (Benson &
Brooks, 2008).
• Consequences of problematic anger include:
- exclusion from day services
- breakdown of residential placements
- involvement with the criminal justice system
- negative impact on the psychological and physical wellbeing of the
service-user and others
Introduction (cont)
• Cognitive behaviour therapy (CBT) for problematic
anger has been proven to be an effective form of
intervention.
• However, previous studies have been relatively small,
or have lacked an appropriate comparison group, which
limits the conclusions that can be drawn from the
research.
• This study was the first large-scale and
comprehensively-evaluated randomised controlled trial
(RCT) of any psychological therapy in this population.
Study Objectives
Main objective:
To evaluate the effectiveness of the ‘I’m In Control’
group in reducing levels of reported anger, compared
to normal care.
The group-based intervention was intended for
people with mild to moderate learning disabilities and
was delivered in a service setting, by support staff.
Plus:
Exploring and evaluating the experiences of staff and
service-users who participated in the groups.
Research Method
30 day services were recruited, each ran one group
All participants completed assessment questionnaires. Then groups were
randomly assigned to either begin the intervention, or to wait
Intervention Groups
Control Groups
Half the groups started immediately.
12 sessions, usually one per week.
Half the groups were assigned to wait.
Participants received support as usual.
16 weeks after randomization, all participants completed follow-up assessments
6 months later, all participants completed follow-up assessments again
Control Groups
Received the group intervention and
subsequently completed a final set of
follow-up assessments
Participants
•
Day services were recruited from 3
research sites: Scotland, England,
Wales.
•
Service-users were identified from
within interested day services, by day
service staff in consultation with
psychologists.
30 day centres
179 participants
179 key-workers
127 home carers
•
Approximately 20% of participants
dropped out by the conclusion of the
study.
Measures
• We measured:
- Reported levels of anger (Provocation Inventory)
- Anger coping skills (PACS)
- Frequency and severity of aggressive behaviour
(MOAS)
- Psychological well-being (anxiety, depression and
self-esteem; Glasgow Anxiety and Depression Scales)
The ‘I’m In Control’ Group Intervention
• The ‘I’m In Control’ group
- manualized CBT for anger delivered over 12 sessions
- 2 – 4 lay therapists per group
- 4 – 9 service-users per group
- lay therapists participated in training and supervision
• Sessions encouraged service-users to:
- Be aware of situations that triggered angry feelings
- Identify physiological & behavioural components of
anger (e,g, knowing how your body feels)
- Develop skills to control and manage anger, including
relaxation strategies, behavioural strategies such as
‘walk away’ and ‘ask for help’, and cognitive strategies
such as ‘rethinking the situation’
• Activities, discussion, role-play, Hassle Logs.
Outcomes of the Study
• Levels of anger
• Group participants did not report being less angry than those who had not
been in a group.
• However, key workers did report that the group produced a significant
reduction in people’s anger. This reduction was sustained six months after
the group had finished.
• Use of anger coping skills
•
Service-users who took part in the group reported greatly improved use of
coping skills. This was still the case 6 months after the group was finished.
•
Key workers reported even larger improvements how people who took part
in the groups used coping strategies. Again this was sustained 6 months
after the group had finished.
• Home carers also reported improvements in the use of anger-coping skills.
What worked?
• Clients didn’t report feeling less angry, although
their key-workers thought their anger had reduced
– ABOUT BEING ABLE TO TALK MORE OPENLY
ABOUT FEELINGS NOT LESS.
• However, the intervention appeared effective in
increasing use of anger coping skills, and
improvements were maintained 6 months after the
intervention had finished.
• Is the ability to talk more openly about one’s
feelings a sign of good therapeutic relationships?
Qualitative Study
• 11 service-users and 9 lay-therapists participated in
interviews exploring their experiences of participating
in the group.
• Service-users’ interviews explored:
1. Individuals’ experiences of participation in the group
2. Aspects that they did or did not find enjoyable
3. The impact of the group on their everyday lives
• Key themes:
1. What we did in the ‘I’m In Control’ group.
2. What it was like to take part.
3. What difference the group made to my life.
4. Presenting a positive self.
Qualitative Study - Clients’ experiences
What it was like to take part?
•The value of the shared experience
‘I worked out that if you’re swopping stories it helps each other
out.’
•The importance of relationships with the lay therapists
‘It’s managed to put the staff in, like, to trust them a bit more with
me.’
Qualitative Study – Lay therapists
• The ingredients of success - taking on the
‘therapist’ role
“These six people always come and talk to me, no
matter where I am, how many times I talk to them, how
many times I see them … which to me is a great
satisfaction. I get pleasure out of knowing that I’ve
helped them, even if it’s only a little bit.”
“It’s as if we have all been through something together
and we all seem to have a bond that was formed, not
that you treat anyone different but it just feels different
with that group (…) we’re more open and honest with
each other.”
Qualitative summary
• Relationships were key to both the service users and lay
therapists.
• The lay therapists were not clinically trained and versed in
therapeutic language perhaps makes their observations more
persuasive.
• Service-users valued the opportunities to talk and be listened
to and to demonstrate their new skills. More than talking also about learning new ways to cope with their feelings and
develop a different sense of self.
‘Not in a bad mood in the house now. (…) Eh…up in the
morning. Not mad. Not mad. Not else. Stop the crying. (…)
Mum not write in the book (…) Mum not want to tell (keyworker).’
Are these findings unique to an anger
management group?
• Examining process issues in individual CBT for
individuals with mild intellectual disability referred
to clinical psychology with anxiety, depression or
significant anger problems
• (Andrew Jahoda, Carol Pert, Biza Stenfert-Kroese,
Dave Dagnan, Peter Trower, Bronwen Burford,
Mhairi Selkirk).
Participants who took part in a video
review of their CBT sessions
• 18 clients took part (9 women and 9 men).
• Participants referred to clinical psychologists with a
range of emotional problems: anger, anxiety and
depression.
Video review study - a qualitative
approach.
Video review method.
Part of a larger process study, Jahoda et al., (2009).
• Carried out in Scotland and England.
• 6 experienced therapists (Clinical Psychologists).
• Formulation driven approach. Fidelity checks carried out by
CBT expert.
Aims
• To examine clients’ own experiences of CBT sessions.
• Pilot the video review method with this client group.
Method and Analysis
• Video Review Method devised by Bronwen Burford (2003).
1. Clients viewed tapes of their therapy sessions and told the
researcher when they thought something important was
happening.
2. After watching the whole video, the researcher then showed
the person the sections of tape they had highlighted, and
asked the person to comment on what was happening.
3. There are no ‘right or wrong’ responses, and nor is the
person is not restricted in what they say
Analysis
Data was analysed using Thematic Analysis
Why bother? Because….
Two strands to the findings.
1. Supportive aspects of
therapy
•Valuing a positive
therapeutic relationship.
•Feeling supported and
understood.
•Valuing the chance to talk
about feelings.
2. Changes linked with a
CBT approach.
•Working together on
problems. CBT approach
leads to better
understanding of problems
and better coping skills.
•Positive impact on self
identity and self efficacy.
FINDINGS. What clients say about CBT (1)
A positive
therapeutic
alliance.
Trust
Empathy
“I’ve never ever told anybody
else, I wanted to talk about that.
I feel really, really glad with (T).
It felt really good, I trust (T).
“ I enjoy the sessions with (T),
they’re good. And I felt that (T)
understands how I feel. More
or less that I’ve got feelings.”
What clients say about CBT (2).
Talking about
problems is
helpful.
Enjoy talking
Having someone to
talk to.
“T’s good to talk to and that’s
helpful. I come here to get a
bit of help.”.
“…..It’s kind of helped me cope
with life. Because before (T),
before I came here I’d actually
nobody to talk to really.”
What clients say about CBT (3).
Learning
about
myself.
Views of
self.
“Never heard myself say that before.
Never done in my life. I’ve always
hurt people and caused grief. I’m
seeing a different me”
“When I was watching myself I was
thinking is there anything wrong
with me or not? People say there
is and I say there’s not. But when
you see that I don’t know what to
think.”
What clients say about CBT (4).
“I actually felt like an adult
Learning
about
myself (2).
in there a fully mature
adult”.
“Like (T) said (to me) you
did all the hard work, I’ve
Self worth.
A greater sense
of competence.
listened to you and
you’ve explained things
to me, thing is you did it
yourself, all the hard
work.”
What clients say about CBT (5).
“(T) went through all my
Learning
about my
problems and
coping better.
Breaking problems
down.
Understanding
emotions
anger….breaking it down into
smaller separate, you know
what I mean. Trying to find
out in depth what causes it.
Basically (T’s) helping me, I
really am finding it’s
helping?”
“The way (T’s) talking and that,
helps you understand how
you feel. That’s good.”
Once again relationships and expertise are
the main points highlighted
• Key ingredient is a positive therapeutic relationship.
Due to a lack of supportive relationships?
• Feeling supported and understood. A chance to talk
about feelings.
• A collaborative CBT approach may help clients to
build confidence in their abilities. See themselves
differently. Better understand their problems. An
expert relationship.
BUT: Change can be seen as fragile.
• Change might not last. A common view expressed
by service users we interviewed was that therapy
had been helpful but that the benefit would not last.
I just don’t want to stop seeing (therapist)
because it’ll take some time to get to see her
again.
What have we learned about therapeutic
work and achieving a real connection?
Where to now?
And finally – back to story telling
• In common with other people receiving
psychological help for mental health problems they
found the chance to talk beneficial (Pesale and
Hilsenroth, 2009).
• What I perhaps didn’t appreciate – the importance of
being listened to, particularly for people who often
aren’t listened to properly or taken seriously.
Making a real connection.
How to listen properly:
•Awareness of context, for example people with
intellectual disabilities rarely refer themselves for help.
•Achieving a shared understanding and a shared focus
is not only about what you talk about but how you talk
with someone at an emotional level.
•Shared activity is also a way of building trust and a
common bond – it shouldn’t be an intellectual activity.
•Therapeutic expertise does not work if it creates an
emotional distance.
Confiding relationship to a real sense of
change – continuing tension.
• Not like talking to a friend.
• Enjoyed a sense of making real changes and a
growing sense of control in their lives.
• But also a sense that such change is difficult to
maintain, perhaps because many factors in their
daily lives remain outwith their control.
• Perhaps build in a component of therapy to promote
a sense of self-efficacy.
•
The therapist to work alongside significant others
(family and workers), to support change and
recognise achievements in everyday life.