In this article a brief discussion on the nature of psychotherapy is given, followed by a review of the literature concerning psychotherapy and its use with people with intellectual disability. Some issues with regard to best practice when working with people with intellectual disability in the field of psychotherapy are also highlighted.
Bender (1993), in discussing how people with intellectual disability have been neglected historically by psychotherapists, refers to the ‘semantic mayhem’ around psychodynamic psychotherapy, behavioural therapy and cognitive therapy. Turnbull (2000) describes the evolution of psychotherapy as follows. Psychoanalysis, after a period of favour, had its critics who felt that it was rather too introspective and that it relied too heavily on the concepts of instinct and unconscious desires. A move towards a more ‘humanist’ and ‘holistic’ approach became popular and today, psychodynamic therapy is more often referred to than pure psychoanalysis.
Psychodynamic therapy, like other psychological treatments, uses the relationship between the therapist and the client to address issues that contribute to emotional distress (NHS website, 2002). It works in two broad ways. Firstly, in common with all psychological treatments, the client—and whatever difficulty they are experiencing—is accepted as valid by the therapist. Secondly, the therapeutic process itself contributes to the client’s feeling of control and responsibility for finding a solution to the difficulties being encountered and emotions can be expressed freely in a safe environment.
Psychodynamic psychotherapy aims to help people to understand themselves more clearly. The therapist aims to help the client to become more self-aware, uncovering and understanding links between past experiences and current behaviour and relationships. The client is guided towards recognition of emotions and reactions which are rooted in the unconscious rather than the conscious mind. Psychodynamic psychotherapy aims to bring about lasting change in the client’s emotions and patterns of response to others. Psychodynamic psychotherapy undertaken in groups confers possible additional advantages, such as belonging to a group, sharing common experiences and developing trust, which can add to the therapeutic process.
The application of psychodynamic psychotherapy to the difficulties that people with intellectual disabilities encounter has been limited until recent years. Traditionally, it was assumed that the use of a cognitively-based therapy relied on a certain level of cognitive ability. As far back as 1904, Freud suggested that in order to engage in psychoanalysis, patients should possess ‘a reasonable degree of education and a fairly reliable character’.
There was a consensus among many writers in this field, right up to the 1980s, that this kind of intervention was not suitable for clients with an intellectual disability. Some (Tyson & Sandler 1971) went so far as to suggest intellectual disability as a contra-indication for psychotherapy. A glaring error in this assumption is the assumption that people with intellectual disabilities are a homogenous group whose characteristics are similar and generalised across the entire population.
People with intellectual disabilities are referred or, in a few cases self-refer, to psychotherapeutic services for a number of reasons. Psychological distress such as anxiety, depression and traumatic bereavement are examples. Sometimes, people with intellectual disabilities can also be referred in order to explore the reasons why they might display behaviour that challenges.
A review of the research literature published in this area yields results that fall broadly into two categories: reports on case studies and reports on evidence of outcomes in practice. Considering the relative recency of this therapy being used in the field of intellectual disability, it is not surprising that a majority of the research information available is in case studies form, the emphasis being on the process rather than the outcome. Beail and Frankish (cited in Brandon 1989) and Sinason (1992) are some of the major contributors. Nigel Beail, a psychodynamic psychotherapist, has gone on to produce most of the evidence on outcomes of psychodynamic psychotherapeutic interventions.
Symington (1981) published the first account of psychotherapy with a person with intellectual disabilities. (Beail (1998) points out that studies carried out prior to this which claimed to be concerned with people with ‘mental retardation’ were actually dealing with people who were handicapped by emotional difficulties or were of low average intelligence. This view is supported by Sinason (1992).) Symington concluded that he did not know whether the treatment was a success or a failure, because the client decided to stop attending sessions at the end of two years. Symington presents the case study in order to generate debate and to challenge the assumption that psychotherapy is not suitable for people with intellectual disabilities.
Frankish (1989), Beail (1989) and Sinason (1992) published articles in the late 1980s and early 1990s, describing more case work and supporting the use of psychotherapy for people with intellectual disabilities. Debate was generated and more case studies were published, Waitman & Conboy-Hill (1992), for example. These publications tended to focus, as mentioned above, on the process of using psychotherapy with people with intellectual disability, rather than the outcome. This makes it difficult to judge the efficacy of the treatment when used with people with intellectual disability.
Beail (2002) proffers one possible reason for the lack of ‘outcomes studies’ of psychodynamic treatment. Some psychotherapists had expressed the concern that the measurement of outcomes of treatment might interfere with the process of the therapy.
As mentioned above, the literature on the application of psychodynamic psychotherapy for people with intellectual disabilities is scanty. Beail and Warden (1996), Beail (1998, 2001), and Newman and Beail (2002) published papers that deal specifically with outcomes of psychodynamic psychotherapy as used with people with intellectual disabilities.
All studies showed positive outcomes for clients. A criticism of the 1996 study was the lack of information on improvement in the clients’ well being, other than the presence or absence of symptoms. Positive outcomes were measured in respect of reduction in adverse symptoms. This issue was addressed in the 2002 study, which looked at the changes that occurred in the clients understanding of their problem during the process of therapy. The 1998 study was criticised for the short follow-up period; again this issue was addressed in the 2001 study which looked at recidivism rates in clients who were offenders over a four-year period.
Clearly more research in this area, focusing on outcomes of psychodynamic therapy, will add strength to the argument that it is indeed an appropriate therapy for people with intellectual disabilities.
There are a number of issues to be considered when aiming to arrive at a model of best practice in psychotherapy for people with intellectual disability. Many of these were discussed by Dr Nigel Beail (2002) at a lecture held in University College Dublin.
Some issues are to do with service delivery and supports for people undergoing therapy. Some are to do with the therapeutic process itself- Ideally, from a service-delivery point of view, every person with an intellectual disability should have access to appropriately qualified and supervised therapists. People with intellectual disability should know that this type of therapy is available to them and what it aims to treat. Carers and other health professionals should also be aware of this and referrals made as appropriate. Services and carers would also need to undertake to address causal factors where possible. For example, if a person is referred for anger management therapy and one of the causes of their anger is the lack of choice about where they live, the person making the referral would need to be able to address that issue.
Likewise, some people with intellectual disabilities live in somewhat chaotic surroundings. The efficacy of therapy would need to be assessed for the client who has to return to that environment after each session. Carers need to have information about the process in order to support the client outside the sessions. Psychotherapy can be a difficult process personally and clients may need greater understanding and support at this time. Rose et al. (2000) conducted group therapy sessions where carers were present; this is an area that would bear more investigation.
People who do not have intellectual disabilities can generally expect to see their therapists only during their sessions, people with intellectual disabilities, who live in institutions, might come across their therapists in the corridor, on the grounds of the institution or at other meetings. This may cause embarrassment, confusion or doubts about the maintenance of confidentiality. Lastly, clients with intellectual disabilities who are referred for psychotherapy may well be taking medication, psychotropic drugs or sedatives; these may well interfere with the their ability to engage with the therapist.
In discussing the therapeutic process itself, there are a number of issues which may present difficulties for people with an intellectual disability. Consent to engage in the therapeutic process is assumed in the general population by virtue of their attendance. For people with intellectual disabilities, consent must be sought from the person themselves or from their carer. Explanation of the process and aims of treatment must be conveyed in a way the client can grasp. This may present difficulties to some people with intellectual disabilities.
Communication skills are obviously of importance in a therapy that relies on self-reporting, at least in part. The therapist must be prepared to be creative and involved when dealing with clients with intellectual disabilities. Traditionally psychotherapists remained silent during their client’s discourse, in order not to influence it. Beail (2002) reports making use of strategies such as play techniques and picture boards to aid communication in therapy sessions. Stenfert Kroese (1998) discusses the use of open-ended questions to avoid the client being tempted to answer ‘yes’ in an attempt to be ‘right’—and the practice of probing the client’s understanding of an issue with additional questions.
The therapist must become familiar with and fluent in the client’s language. Comprehension and expression of abstract concepts may need to be assisted. People with intellectual disabilities may have differing abilities around maintaining attention and avoiding distractions. The therapist may need to be flexible and accommodating in this regard. An assessment of the client’s ability to concentrate, remember and retain information from session to session will help to shape an appropriate intervention schedule.
Finally, therapists need to be aware that clients with intellectual disabilities may act-out during sessions or after them, and strategies need to be in place to support the client at these times. Beail (2002) reported that in some cases clients felt that the therapists had ended the treatment, rather than the process coming to an end. Termination of the therapy must be handled sensitively with full explanation given to the client in a way that they understand.
Bender (1993) cites Ricks (1990) who stated that ‘eighty percent of the total number of mentally handicapped children and adults in the UK are only mildly handicapped’. Only a proportion of the population with intellectual disabilities is in receipt of services. Most people with intellectual disability do not live in institutions where these services may be on offer—it would seem to follow that the large majority of people with intellectual disability may not have access to appropriately targeted mental health services.
The provision of psychotherapy should be based on the needs of people with intellectual disabilities. Stenfert Kroese (1998) cites Sevin & Matson (1994) who say that people with intellectual disabilities are more likely to experience psychological distress than the general population. As more sophisticated diagnostic tools are developed, there will be accurate information available on the prevalence of mental health issues among people with intellectual disability. In tandem with the provision of appropriate therapy, attention must be paid to the hierarchy of needs of the clients. Perhaps the circumstances in which some people have to live need to be addressed prior to providing for their psychological needs.