Cognitive-Behaviour Therapy for People with Learning Disabilities

Biza Stenfert Kroese, Dave Dagnan, Konstantinos Loumidis, Biza Stenfert Kroese, Dave Dagnan, Konstantinos Loumidis

• Publisher: Routledge
• Year: 2005
• eBook ISBN: 9781134797820
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

Cognitive therapy is a well known and widely used means of helping depressed patients, but is only now beginning to be extended to other client groups. Cognitive Therapy for Learning Disability contains contributions from well known and highly experienced practitioner researchers about the theoretical and practical issues surrounding the application of cognitive therapy to this special client group. Since cognitive therapy is usually understood to consist mainly of talking and introspection, the communication difficulties, challenging behaviours and the whole question of self-regulation make CBT for learning disabled people a challenging and fascinating topic.
Cognitive Therapy for Learning Disability provides a wealth of practical examples for training and will be invaluable to clinical psychologists, psychiatrists and all researchers and practitioners who deal with learning disabled people in their daily lives.

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Cognitive-behaviour therapy for people with learning disabilities

Conceptual and contextual issues

Biza Stenfert Kroese

This chapter will provide a brief overview in order to put the application of cognitive-behaviour therapy* for people with learning disabilities into a historical, clinical and political context. The development of cognitive-behaviour therapy will first be briefly described, after which the application of one-to-one psychotherapy in learning disabilities services will be discussed. I will attempt to provide: (1) some background as to why people with learning disabilities rarely receive therapeutic services which allow them (and their therapists) to explore personal meaning; and (2) some information on how the potential barriers due to clients’ cognitive deficits have been overcome in order to enable cognitive change and ultimately an increase in psychological well-being.

The chapter aims to be a ‘taster’ to this volume as a whole. Most of the issues discussed here will be presented in much greater depth in further chapters.

THE DEVELOPMENT AND PRINCIPLES OF COGNITIVE-BEHAVIOUR THERAPY

In the 1970s the application of behaviour therapy had become the preferred treatment for many psychological disorders, and the rejection of introspection pronounced over half a century ago (Watson and Rayner, 1920) continued to have a powerful influence over researchers and therapists with a behavioural orientation (Hawton et al., 1989). However, some reservations started to be voiced regarding the exclusive use of learning theory as an underlying framework. Particularly, the research by Bandura (e.g. 1977) on observational learning indicated that cognitive mediation takes place during learning. In the clinical field, Kanfer and Karoly (1972) described a model of self-control consisting of self-monitoring, self-evaluation and selfreinforcement, and Meichenbaum (1975) convinced many that the concept of mental operant behaviour (coverants) is not only acceptable, but essential in explaining behaviour change. Other authors introduced the concept of metacognition, that is, ‘knowing about knowing’ and ‘knowing how to know’ (Brown, 1975) and specific problem-solving techniques (e.g. D’Zurilla and Goldfried, 1971).

Since then, cognitive-behavioural principles have been introduced into clinical practice on a large scale. There now exists a substantial body of evidence which indicates that cognitive-behaviour therapies can be effective for a wide range of psychological problems (see Hawton et al., 1989). The underlying assumptions that these cognitive-behavioural approaches have in common can be summarised as follows:

• thoughts, images, perceptions and other cognitive mediating events affect overt behaviour as well as emotion or affect;
• focusing on these mediating cognitions in a systematic, structured manner can be an effective way of changing behaviour, emotion or affect;
• people are active learners, not just passive recipients of environmental influence. To some extent they create their own learning environment. Sometimes their specific learning histories result in cognitive dysfunctions;
• treatment goals centre around creating new adaptive learning opportunities to overcome cognitive dysfunctions and to produce positive changes for the client, which can be generalised and maintained outside the clinical setting;
• the client has an understanding of the intervention strategies and goals, and participates in planning and defining these.

Thus a cognitive-behaviour therapist makes the assumption that the psychological problems with which clients present are at least in part caused by cognitive dysfunction, and that clients’ psychological well-being can be improved by teaching new and more adaptive ways of thinking.

COGNITIVE PROCESS AND COGNITIVE CONTENT

Kendall (1985) made the important distinction between two types of cognitive dysfunction—cognitive deficits and cognitive distortions. The former refer largely to problems in the cognitive processing whereas the latter are concerned with cognitive content.

The earlier cognitive-behaviour therapies were based on a deficit model and emphasised cognition as a process: that is, they addressed the deficits in the manner in which (1) people collect information about and interpret the world, and (2) they resolve problems. The aim of self-instructional training (Meichenbaum, 1975), for example, is to rote-learn and internalise a set of explicit self-instructions which are to replace or override maladaptive thoughts.

A number of more recent cognitive-behavioural approaches are more focused on identifying the actual content of thoughts and assumptions. Beck’s (1976) cognitive therapy and Ellis’ (1973) rational-emotive therapy are the two most influential of these approaches. Both assume that the content of distorted cognitions must be made explicit by the client and questioned by the therapist before ‘guided discovery’ (Young and Beck, 1982) can take place. That is, awareness and evaluation of the cognitive content are necessary in order to ‘learn to view thoughts and beliefs as hypotheses whose validity is open to the test’ (Beck et al., 1979). Dagnan and Chadwick (in this volume) have adopted the distinction introduced by Ellis (1977) to discuss the origins and aspects of these elegant cognitive therapies and contrast them with more simple approaches. Also in this volume, Williams and Jones describe cognitive-behaviour therapies in terms of those which require metacognition and those which merely involve rote-learning of self instructions. Roberts and Dick (1982) previously made a related but nevertheless independent distinction. They identified that self-control can be either achieved through contingency management or through cognitive change. Similarly, Whitman (1990a and 1990b) talks of passive and active self-control methods and postulates that active self-control methods are more likely to produce lasting and generalised changes in behaviour.

Whether we describe certain cognitive-behavioural therapies as elegant, active, involving understanding or requiring cognitive change, they appear to have two aspects in common—a search for personal meaning and an assumption of self-determination. The question posed here is: Why do people with learning disabilities so rarely receive therapy (be it cognitive-behavioural or not) which contains both these ingredients?

PERSONAL MEANING

The meaning of people’s overt behaviour is discussed at length by Lovett (1985) in his book Cognitive Counselling and Persons with Special Needs, which is a critique of traditional behavioural approaches to people with learning disabilities. He observes that carers and professionals who work with people with learning disabilities sometimes describe the behaviours of their clients in a seemingly objective but meaningless way (e.g. attention-seeking) rather than specifying the possible motivation or emotion driving that behaviour (e.g. wanting to make more friends or feeling bored or lonely), thus ignoring the meaning of the behaviour and labelling a person’s wish for human contact in a negative way.

Some data reported by Harper and Wadsworth (1993) illustrate this point. A group of adults with learning disabilities who had recently experienced a significant loss were asked how they expressed grief and dealt with their loss. A group of carers and professionals were also asked their views of how people with learning disabilities cope and respond during grief. The participants with learning disabilities reported mainly emotions such as loneliness, anxiety, sadness, depression, dislike of the new residential place, worry about not being able to locate the grave or inadequate income. Only a small percentage of responses concerned behaviour (decrease in activities and behaviour problems). The carers and professionals, on the other hand, reported largely on behaviours or somatic symptoms such as crying, sleep problems, hostility towards others, passivity and poor hygiene, and very few responses concerned emotions. Thus, the personal experience and meaning of grief reactions were largely ignored by carers, although clearly reported by the participants with learning disabilities.

SELF-DETERMINATION

Lovett (1985, See page) also stressed the importance of self-determination, especially through creating a collaborative relationship rather than an authoritarian one between the therapist and the client:

I think that the relationship between the person helping and the person helped is often a critical variable. I think it is more than just ‘playing with words’ to say that when we ‘treat’ a person, we are putting ourselves in a relationship that is very different (and for me, less desirable) than when we work with a person on a challenging situation.

Working with a person on a challenging situation means that the client is centrally involved in determining therapy goals and the methods by which these will be achieved. The literature that describes the application of cognitivebehaviour therapy for people with learning disabilities indicates that this collaborative relationship does not often exist. An overview by Harchik, Sherman and Sheldon (1992) of fifty-nine studies using self-management techniques showed that nine of these studies addressed the reduction of challenging behaviour and fifty aimed to increase social skills or performance (accuracy and speed) in academic or work settings. The authors conclude that self-management procedures are effective for people with learning disabilities but note that ‘methods to expand the range of self-management procedures to include those that more fully involve the person in the design of the procedures would be of interest to researchers and practitioners’ (p. 222).

Such an initiative would also perhaps be of some interest to the client. Cognitive-behavioural treatments applied to people with learning disabilities have been almost exclusively concerned with social control and therapy goals are largely determined by the therapist or instructor. Success has been measured in terms of productivity and/or the eradication of challenging behaviours. The psychological well-being of the client is rarely mentioned as an outcome measure.

WHY THIS THERAPEUTIC DISDAIN?

The lack of reported studies where a collaborative relationship has existed between the client with learning disability and the therapist is not unique to cognitive-behaviour therapy. Bender (1993) talks about ‘therapeutic disdain towards people with a learning difficulty’. There is a higher incidence of psychological disturbance in people with learning disabilities (e.g. Reiss, Levitan and McNally, 1982; Lund, 1985) and consequently a greater need for psychotherapeutic services. However, Bender’s description of the attitudes of mental health professionals towards clients with learning disabilities strongly suggests a common ethos of pessimism and rejection. Freud (1904) stated that psychoanalysis is not suitable for ‘those patients who do not possess a reasonable degree of education and a fairly reliable character’ (1953, p. 263). Since then, with very few exceptions, psychoanalysts and other psychotherapists have strictly adhered to the principle that learning disabilities are contra-indicative of successful outcome (Tyson and Sandler, 1971). It is interesting to note that the exceptions, (i.e. those therapists who did provide therapy for people with learning disabilities) shared the notion (described by Gunzburg in 1974 and more recently expounded by Sinason, 1992) that learning disabilities are often the result of social and psychological distress in early life. Sinason has described the phenomenon of ‘becoming stupid’ as a mechanism to protect the self from ‘unbearable memory of trauma’. Therefore, a possible outcome of effective psychoanalysis or psychotherapy is an increase in intellectual functioning (e.g. O’Connor and Yonge, 1955).

Since Sinason’s publications and an edited book by Waitman and Conboy-Hill (1992) entitled Psychotherapy and Mental Handicap, more psychotherapists have been inspired to consider the possibility of entering into a therapeutic relationship with people who may have limited verbal skills and be seemingly unresponsive to their environment (see Beail (1995) for a review of this area).

A parallel development has taken place in the cognitive-behavioural field. Other than psychotropic medication, the therapy of choice for people with learning disabilities was behavioural, usually aimed at controlling or changing the individual’s behaviour through external contingency management. With the increasing influence of normalisation principles (Wolfsenberger, 1972), the sole use of contingency management programmes (particularly avoidance contingencies) has become less accept...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Illustrations
• Contributors
• Preface
• Acknowledgements
• 1 Cognitive-behaviour therapy for people with learning disabilities
• 2 Theoretical and practical issues in cognitive-behavioural approaches for people with learning disabilities
• 3 Anger assessment for people with mild learning disabilities in secure settings
• 4 Understanding and assessing depression in people with learning disabilities
• 5 Teaching cognitive self-regulation of independence and emotion control skills
• 6 Social problem-solving groups for adults with learning disabilities
• 7 Cognitive-behaviour therapy for people with learning disabilities
• 8 Cognitive-behaviour therapy for anxiety in people with learning disabilities
• 9 Applying cognitive-behavioural approaches to the carers of people with learning disabilities who display challenging behaviour
• 10 Sustaining a cognitive psychology for people with learning disabilities