Disability psychotherapy is an evidence-based treatment approach concerned with providing psychotherapeutic supports for people with disabilities. While psychotherapy has not traditionally been considered a treatment option for people with intellectual disabilities, this approach advocates that individuals have a rich and mature emotional life despite any cognitive impairment (Sinason 1992). The analytic approach seeks to explore the individual’s inner world in order to make meaning of past and present experiences and, so, it promotes insight, integration and the management of unbearable thought and emotional states.
Treatment occurs through the use of regularly scheduled psychotherapy sessions., which usually occur at least once weekly. Regular sessions offer the conditions needed for a secure base (Bowlby 1988) to be developed which supports the creation of the therapeutic alliance. It is within this alliance that the therapist and patient can begin to think and experience together the workings of the patient’s inner world. This is done by recognising and interpreting the individual’s thoughts, feelings, dreams, nightmares, fantasies, fears, behaviours and any non-verbal communications. It is not a prerequisite of the therapy for the person to have verbal communication, because the therapist is skilled at using many different interventions through which to communicate and understand the individual.
Generally people enter into psychotherapy treatment when they are in a state of crisis. This is no different for people with intellectual disabilities. Treatment is often initiated to help manage self-injurous behaviour, grief, loss and mourning, experiences of abuse or sexual violence, or the risk of or engagment in sexualized or seriously harmful behaviours. The use of psychotherapy recogniaes that behaviours are a symptom of psychological distress. A reduction in symptoms is ideal, but it is not the focus of the therapy. The focus of therapy is to support unmanagable thoughts and feelings to become tolerable, thus facilitating personal growth and self-understanding. When this happens, there can often be a reduction or ceasation of risky or harmful behaviours.
Disability psychotherapy acknowledges the pain and impact of having a disability. Disability carries the knowledge that one is profoundly different from others. Sinason (1992) introduces many insightful concepts which help deepen our understanding of the psychological impact of disability. The ‘handicapped smile’ suggests that one has to smile and be compliant, but underneath the façade is tremendous pain, loss and grief. We see this with our patients who disclose the most horrendous experiences with a smile. While this phenomenon is not limited to people with disabilities and regularly occurs in mainstream psychotherapy practice, it highlights the pain of disability in a profound way with this patient group. A highly evolved defense mechanism is developed which protects the person from unwanted thoughts, feelings and experiences. The ‘secondary handicap’ allows us to recognise that a disability can be exaggerated and used as a defence, and for respite against the pain of the disability. This can be seen, for example, where the individual behaves in a way showing the organic disability to be much greater than it may actually be.
Disability challenges us to enter into a world that can be filled with despair. Hollins (2000) has noted that disability, mortality and sexuality all feature for people with disabilities. The disability itself brings lifelong struggle within society and, in some cases, the family. Having to depend on another for intimate care needs can be difficult, stripping one of autonomy and independence. Sex and procreation may be viewed as damaging for the person and the family system. The thoughts of sexuality and engaging in sexual relationships may be taboo. It often appears that people with intellectual disabilities are seen as asexual beings without sexual needs, drives and desires. Sex may be viewed as bad or wrong; that there was something wrong with the act or that one/both of the parents may have contributed to the disability. Shame and guilt may be entrenched in the family’s psyche. The longed-for able-bodied child may need to be mourned within the family system.
There are some families and service providers who struggle to support the adult with an intellectual disability to be autonomous, as the cognitive impairment can anchor the person to discreet developmental stages. This vulnerability to the world outside the home or service provider can be threatening. Alternatively, the person may find it difficult to step into being an adult, which requires facing greater challenges and being responsible for one’s own thoughts and actions. There can be underlying thoughts of destruction and death wishes or fantasies towards the person with the disability, which is mirrored in our society where disability is shunned.
Psychotherapeutic treatment provides a space for these feelings and experiences to be examined. Sinason notes that ‘whenever a handicapped patient says “I don’t know”, it means that they do know but don’t know if we can bear it’ (Sinason 1994: 15). This insight is incredibly helpful in supporting the therapist to think about what they may find too difficult to let in. The therapist’s own supervision and personal psychotherapy can provide the spaces to think about what can seem most unthinkable.
While Irish clinicans have been working psychotherapeutically with people with disabilities for many years, this work has frequently occupied an isolated space within the profession. The creation of the Institute of Psychotherapy and Disability, UK, in 2001 serves to support its Irish members. It was set up to develop, accredit and regulate psychotherapists who work in this field. The field of disability psychotherapy advocates for equal access for all citizens to psychotherapeutic treatment. It recognises that emotional intelligence cannot be labelled as disabled.