Transcript Learning Disabilities & Psychotherapies

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
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“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
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“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
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“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
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“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
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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:
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understand information about the decision
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remember that information
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use that information as part of their decision-making process
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communicate their decision by talking, using sign language
or by any other means
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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
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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‘:
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The disability or handicap itself
Dependency on others
Sexuality
Death
Fears of annihilation
(Banks, 2003 Psychiatry, Vol 2:9)
Adapting psychotherapeutic
approaches
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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
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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
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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 & DBTbased 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.
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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?
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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
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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
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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 & DBTbased 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:
a)
b)
c)
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)
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.