Intellectual Disability, Trauma and Psychotherapy

Tamsin Cottis

• Publisher: Routledge
• Year: 2008
• Print ISBN: 9780415421669
• eBook ISBN: 9781134102518
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

People with intellectual disabilities have emotional and mental health needs just like anyone else. Until recently however there has been little research of effective psychological treatment or direct, accessible psychotherapy provision for this client group.

Intellectual Disability, Trauma and Psychotherapy focuses on the delivery of psychotherapy services for those with intellectual disabilities. Leading professionals in this specialist field are brought together to describe the history, theory and practice of their work in twelve focused chapters that draw on the work of psychotherapists including Bion, Winnicott, Sinason and Alvarez. Topics covered include:

• therapeutic responses to cultural and religious diversity
• support for parents with intellectual disabilities
• developing healthy and secure attachments within the family
• dealing with intense feelings of shame
• helping clients to cope with traumatic sexual experiences.

Drawing on over a decade of pioneering practitioner experience at Respond – a government-funded psychotherapy service for people with learning disabilities based in central London – this book explores the practical issues in providing therapy to this client group, whether individually, in families, in groups, or by the use of telephone counselling. It closes with a chapter exploring the way forward for those who wish to develop services of this kind.

Chapter 1
Psychotherapy and intellectual disability

A historical view

David O’Driscoll

On 2 June 1933, the distinguished psychiatrist and psychoanalyst Leon Pierce Clark (1870–1933), one of the founders of American psychoanalysis, left his comfortable consulting room on East 65th Street, on the Upper East Side of New York. He made the journey across the East River to the ramshackle Randall Island School for Mental Defectives in order to address (for the third year running) a meeting of the American Association for the Feeble-Minded. On this occasion, Clark presented his paper (1933a), ‘The Need for a Better Understanding of the Emotional Life of the Feebleminded’. He used it to introduce the work of Freudian depth psychology, and told the society about his work with these ideas over the preceding decade. He gave the meeting examples from his case studies, showing the practical application of Freud’s theories in an institutional setting. Clark finished the paper confidently: ‘It is our endeavour to recommend these methods so that they may be carried out on a much larger scale in institutions for this class, and to be more patient to the fact that the potentialities for development in the “ament” [an early term for people with an intellectual disability] are not so hopeless as we have heretofore been led to expect’ (Clark, 1933a p. 354).

This was historically important material for two reasons. First, Clark suggested that each mentally defective patient had an active emotional life, which in itself was worth exploring. He also believed that if they received help they could be kept out of the institution. This was a rather shocking statement at a time when most psychiatrists regarded mental defectives as unreachable and lacking in feeling (Trent, 1994). Secondly, Clark’s initiative was the first attempt by a psychoanalyst to create a dialogue with specialists in this area and as such can be seen as a forerunner of today’s multidisciplinary practice (see Chapter 11 for more on this). This paper was very soon followed by a book, The Nature and Treatment of Amentia: Psychoanalysis and Mental Arrest in Relation to the Science of Intelligence (Clark, 1933b) in which Clark was ‘concerned to promote and exchange new ideas in the study and treatment of the ‘feebleminded’ (p. 354) as an alternative to the ideas of that era. In many ways Clark can be seen as a pioneer in expounding ideas and explaining practice that continue to inform psychodynamic and psychoanalytic treatments in the field of intellectual disability today. In this chapter I will outline the development of psychodynamic psychotherapy for people with intellectual disabilities, drawing on new research that describes Clark’s work (O’Driscoll, 2000). A context to this historical view will identify key changes in the medical and government polices that informed care for people with intellectual disabilities. This includes the opening and closure of long-stay hospitals, the influence of the eugenics movement, and the principles of normalization and their culmination in the Government White Paper of 2001, Valuing People (Department of Health, 2001).

Several contemporary commentators have noted the historical reluctance of mental health specialists to provide psychotherapy treatment for people with intellectual disabilities (Bender, 1993; Beail, 1998), often referring first to Sigmund Freud’s (1904) paper, ‘On Psychotherapy’ and to his comment that, ‘Those patients who do not possess a reasonable degree of education and reliable character should be refused’ (p. 254) and the view of Tyson and Sandler (1971) that, ‘mental deficiency is generally regarded as a contra-indication for psychoanalysis’. Beginning with an examination of why Clark’s early work did not take root, I will show how, in spite of the longstanding doubts about the efficacy of psychotherapy work with people with intellectual disabilities, and a tendency to favour cognitive and behavioural interventions, numerous modern practitioners including Sinason (1992) and Beail (1998; Beail et al., 2005) have demonstrated that these patients can be treated successfully by psychodynamic psychotherapy.

An understanding of past experience, especially early life experience, and its part in a patient’s current psychological state is considered central to successful psychoanalytic treatment. Even if the patient cannot form a coherent narrative of their life history (see Chapter 2), it is vital that the therapist has some sense of it. However, it is often the case that people with intellectual disabilities, especially older people who may have spent time in long-stay institutions, have little knowledge of their own life stories. The hospital’s patient records concerning their background are often lost forever (O’Driscoll, 2007). It may also be difficult for staff to hold a person’s past in their mind, particularly if it contains many painful experiences of abuse and trauma. But by failing to take account of personal histories, professional carers may be limiting the value of their therapeutic input as well as helping to ensure that people with intellectual disabilities are, in the words of Joanna Ryan (1991), ‘still as hidden from history as they are from the rest of life. What history they do have is not so much theirs as the history of others acting either on their behalf, or against them’ (p. 85).

The first significant work regarding disability was Jean Marc Gaspard Itard’s French study of an abandoned and defective boy, The Wild Boy of Aveyron (1801). In this book, Itard showed that the education of an individual with intellectual disabilities was possible. Itard encouraged one of his pupils, Edouard Séguin (1812–1880), to follow in his path with further experiments in a similar vein. Séguin first published in 1846 an account of his attempts to teach an ‘idiot’ boy, after which he developed a system, in part based on moral treatment, which was an attempt to operate psychologically and was guided by a philosophical belief in the capacity of all persons to be ‘made good’. Put simply, it was thought that if people were given suitable attention and training, they would improve. The tenets of this were to be kind, never abusive and to use physical restraint only in order to prevent harm. Recent enquiries into the abusive institutional treatment of people with intellectual disabilities in Cornwall and in Surrey (Health Care Commission, 2006, 2007), however, show that more than 150 years after Séguin’s work, his apparently simple and uncontroversial approach can be difficult to put into practice. Séguin’s philosophy was grounded in the relationships between workers and inmates. Clark’s (1933a) view was that this reflected the relational basis of principles of psychodynamic psychotherapy – that is, the relationship between patient and therapist is seen as the primary therapeutic tool. Séguin believed that ‘defectives’ had use of their intellectual faculties but lacked the power to apply them because of poor resistance to competing stimuli. Séguin moved to America and was involved in the setting up of the first residential homes in the later part of the nineteenth century.

In England, the experience for many people prior to the ‘asylum era’ is not so well recorded. There was a classification of ‘lunatic’ meaning that the ‘defect’ was acquired and the patient’s life was punctuated by particular times of madness. The term ‘idiot’ indicated that the defect was present from birth and constant (see Wright and Digby, 1996, for more information on this period). There are accounts of ‘idiots’ ending up in the workhouse system where the best they could hope for was benign neglect. (Interestingly, many of the workhouses were then turned into the first asylums for people with intellectual disabilities.)

The first group of asylums was opened in the 1870s and their population grew, especially as a result of the 1913 Mental Deficiency Act, the first piece of legislation to be applied only to this group. This continued to operate until 1959 and was the first attempt to distinguish people with intellectual disabilities from those with mental illness. When these institutions were first opened they were developed with the notion of being a short-term facility with the aim of training people for life in the community. In fact as late as 1929 the Wood Committee, which was established to explore the purpose of hospitals, concluded that the object of the early hospitals was ‘not simply to confine [the patients] for life’ and that the hospitals ‘should not be a stagnant pool, but a flowing lake’. For the majority of patients, though, life in the hospitals was indeed ‘a stagnant pool’. These hospitals were located in isolated positions, outside towns and with poor transport links. Post-war services saw no real change in the dominance of institutions despite a change of management from council care to the National Health Service. The majority of accounts by people who lived in the institutions spoke of mistreatment and cruelty (Cooper and Atkinson, 1997). These institutions seemed also to have pernicious effects on how staff behaved towards the patients, with reports of harsh and abusive treatment (Goffman, 1961). On leaving the institutions the least disabled, i.e. the majority of people living there, often struggled to develop ‘ordinary life skills’ (Felce, 2000). It also seems that these patients found themselves in a ‘Catch-22’ situation, as a visiting superintendent from Denmark remarked, ‘The criterion for discharge (ability to support oneself in the community) indicated that these individuals should probably not have been in the institution in the first place’ (Thomson, 1998, p. 145). It could be argued that while early attempts to provide psychotherapy for people with intellectual disabilities took place in a hospital setting, these settings were, institutionally, profoundly anti-therapeutic.

If the figure of Leon Pierce Clark is remembered today, it is for his work with people with epilepsy. His 1932 papers espoused controversial ideas on the ‘epileptic’s personality’ that are now discredited (Dwyer, 2004). Much less known is his pioneering work as the first psychotherapist with people with intellectual disabilities. Clark was born in 1870 and, after gaining his medical degree, spent most of his working life in various institutions around the state of New York, specializing in epilepsy. After going to Europe to study this condition further he developed an interest in psychoanalysis, visiting Sigmund Freud in Vienna and meeting the early analysts, which radically changed his approach. Using these new-found theories in his posting at the Letchworth Village for the Feeble Minded in the UK, he set about developing what he termed a ‘psycholaborate institution for the feeble-minded’ (1933a, p. 19). As this was the period when eugenics thinking was starting to be discredited, he was able to develop his innovative work here. He also started a short-lived psychoanalytic journal, Archives of Psychoanalysis, and translated the first version of Sigmund Freud’s paper on anxiety (1926). He developed his work with intellectually disabled patients and went on to write his book (1933b). Clark’s aims, as set out in the book, were modest: ‘Psychoanalysis as a therapy would not claim to remove the fundamental causes of amentia. It would attempt, rather, to reduce the amount and depth of fixation so that the excessiveness of retardation may be avoided, even though the innate defect is not curable’ (p. 15). He explained that this would be obtained through the radical application of Freudian theory: ‘We believe that mental arrest should be presented in terms of the libido theory of Freud’s, thus giving a broader, more vital conception of the whole process of feeblemindedness and increasing our knowledge of the proper training-treatment for this condition’ (p. 15). Today, although Freud’s influence remains, especially his developing a theory of the mind that includes the unconscious, most therapists in this field would work from a relational perspective. Clark acknowledged the importance of a modified approach to this group of patients, concluding that practitioners should be actively encouraged to extend their therapeutic repertoire. As Jason Upton argues in Chapter 2, it is beholden upon therapists in this field to have a solid theoretical basis to their work but to ensure, primarily, that it is flexible enough to respond to the particular communication needs of their patients who have intellectual disabilities. However, quantitative research of the theoretical trainings and therapeutic practices of therapists in this field has yet to be conducted.

Clark’s book was supported by key members of the psychoanalytic community, and included a foreword by the President of the British Society of Psycho-Analysis, Dr Ernest Jones: ‘One can only admire Dr Pierce Clark’s assiduity in the immense labours he has devoted to this field, usually considered so unpromising. It must be a source of gratification to him to observe that these hopes are beginning to meet with a degree of success’ (Clark, 1993b, p. xi). Clark, in his acknowledgements, thanks a number of people, including the famous Hungarian psychoanalyst Sandor Ferenczi, who had visited Clark at his sanatorium. Today it is difficult to evaluate his work properly as he does not give much information on his ‘therapeutic methods’. The analytic sessions reported seem to focus on the urging of ventilation of feelings and tolerating the effects produced – the ‘cathartic method’ – rather than interpreting the specific anxiety of the moment. Clark used the Freudian concept of ‘narcissism’ to explain states of mind in which emotional investment in anybody or anything outside the self appeared to have been withdrawn. Freud’s early formulation was of an early developmental stage that followed autoerotism but was before anaclitic object choice. This became know as primary narcissism and is theoretically followed by secondary narcissism, a state of non-object relatedness, being fixated in a form of aloofness and an illusion of self-sufficiency. For Clark (1933b, p. 318) the key clinical point was for the ‘client’ to enter into a relationship with the support staff, to gain identification with them. Clark wrote about how the child takes in (introjects) the good objects (staff) and how this strengthens their ego. As more and more good objects are introjected, the child feels better about himself and discovers that others respond to his love. Clark felt that these experiences contribute to a stable personality. In this way, ‘the narcissistic shell must be broken through in order to expose the real weaknesses, the fears and dependent needs which lie behind’. Clark believed the therapist should replace the narcissistic requirements of the patient’s dependency on their mother: ‘We hold that the primary narcissism is too rigidly attached to the ego in the severer forms of amentia (idiocy): and that only in the milder grades of feeblemindedness, where there is some degree of secondary narcissism can we hope to advance the ament toward a more adult ego and a greater object-cathexis.’ (1933b, p. 50). This view would today be challenged by those practitioners (including several in this book), who find that improvement can be seen in the emotional well-being of even the most severely disabled people. Clark also believed that the therapist’s task was to make the ‘ament superego’ less domineering (1933b, p. 51). It seems that here, Clark has identified one of the challenges that continue to face therapists in this field, who may struggle to understand what drives a patient’s impulsive and challenging behaviour. It may often not be clear what behaviour is connected to the organic handicap or to subsequent trauma. The work of Sinason (1992) explores this in depth. She has shown that therapy which aims to alleviate emotional pain in the aftermath of trauma can provide relief from distress and so lead to a reduction in disturbed behaviour. Through his work in hospitals, Clark was able to develop Séguin’s belief that people with intellectual disabilities have emotional lives. This was undoubtedly a very radical view for the time and for some time afterwards. In 1983 the historian of intellectual disability, Scheerenberger, wrote, ‘The emotional and mental health life of intellectually limited persons had little interest and little impact, with few medical schools offering any training about this, a circumstance that had been not rectified by 1983’ (1983, p. 90). Clark thought that his early Freudian view could be modified and changed to help this group of patients, believing that an understanding of the inner conflicts would help not only them but, crucially, their support staff, ‘Handling of these behaviour problems can be advanced by a better understanding of the impulses and the emotional needs which are behind them’ (1933b, p. 45). This is still a key point today, which is why therapy organizations working with people who have intellectual disabilities often offer support and training to support staff, in conjunction with the provision of psychotherapy to clients (see Chapter 11).

Clark’s other main contribution was his view that the feebleminded, as a group, are more fixated at a stage of primary narcissism than the average individual, and that this stops development. This is an interesting idea and resonates in work today, where a therapist may find that the patient with intellectual disabilities often has difficulty in conceptualizing the notion of ‘the other’ and in, almost literally, being able to put themselves in another’s shoes. This can make the development of ordinary and rewarding relationships more than usually difficult, and may also impair the capacity for empathy in those who have gone on to offend against others (see Chapter 6 for a further exploration of offending behaviour). Clark also hypothesized that the excessive sleeping and foetal postures of handicapped patients represented a return to the foetal stage to avoid the damage of handicap to come.

Clark died in 1933. The economic depression of this time limited the potential to develop his work, as the state institutions started to look elsewhere for ideas. It seems that a very pessimistic outlook took hold of professionals working in the institutions (Trent, 1994) at that time.

In England in the post-war period, the advent of the N...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Notes on contributors
• Foreword by Anne Alvarez
• Acknowledgements
• Introduction
• 1 Psychotherapy and intellectual disability: A historical view
• 2 When words are not enough: Creative therapeutic approaches
• 3 Words as a second language: The psychotherapeutic challenge of severe intellectual disability
• 4 Speaking through the skin: The significance of shame
• 5 Love hurts: The emotional impact of intellectual disability and sexual abuse on a family
• 6 ‘Can they see in the door?’ Issues in the assessment and treatment of sex offenders who have intellectual disabilities
• 7 Going on down the line: Working with parents who have intellectual disabilities
• 8 Differences, differences, differences: Working with ethnic, cultural and religious diversity
• 9 Therapy for life and death: A focus on the Respond Elders Project
• 10 In one ear: The practice and process of telephone counselling
• 11 Outside in: The effects of trauma on organizations
• 12 Life support or intensive care? Endings and outcomes in psychotherapy for people with intellectual disabilities
• Glossary