David Seckington. 96014195.

University Centre Blackburn College.

Can the empirical success of cognitive behavioural therapy be applied successfully

to people with learning disabilities.

A literature review.

Gates (2007) suggests that people with a learning disability represent a significant

proportion of society and so should be entitled, the same as any other citizen to access the

skilled professionals who are trained and able to meet their specific healthcare and social

needs. From a historical and institutional perspective this has not always been so.

People with learning disabilities are a very diverse group of people. Each person has their

own unique personality and characteristics as well as their own history, values and opinions.

They are a group of people who in law have the same rights as any other citizen although in

the past and frequently today they continue to be excluded and discriminated against

(Hardy, Chaplin & Woodward, 2010).

Due to the improved access to healthcare and survival rates for people with learning

disabilities for both young and old and those with profound disabilities, it is vital that

services such as mental health remain efficient, affective and able to meet the needs of this

client group (Emerson & Hatton, 2008).

This literature review will explore the success and difficulties experienced regarding access

too and the application of cognitive behavioural therapy for people with learning

disabilities. Reviews such as this attempt to maintain awareness regarding this complex

group of people.

1

Introduction.

What is a learning disability?

Within literature the definition of the term learning disability can become confused and

blurred at times with the term learning difficulty. An individual with a learning disability

according to the Department of Health (2001) Valuing People definition, is a person with a

significantly reduced ability to understand new or complex information and to learn new

skills referred to as impaired intelligence. Together with a reduced ability to cope

independently i.e. impaired social functioning which generally started before adult hood

with a lasting effect upon development.

The term of learning disability was implemented to replace the previous and more

derogatory and negative descriptive term of mental handicap. Many people with a learning

disability prefer to use the title of learning difficulty to describe themselves. This term can

be confused with other conditions such as dyslexia although within the health and social

care sector of the United Kingdom this terminology is interchangeable. People with a

learning difficulty such as dyslexia do not have a learning disability as defined by the

Department of Health (2001). The UK is the only country that uses this interchangeable

description between the two groups whilst other countries prefer to use the term

intellectual disability to describe a person with what the UK would define a learning

disability (Gates, 2007).

For the purpose of descriptive clarity this literature review will use the words ‘person ‘or

‘people’ in reference to an individual with learning disabilities and employ the United

Kingdom term and definition of learning disability as defined by the Department of Health

(2001) Valuing People. Emerson, Hatton, Felce and Murphy (2001) advise caution regarding

the labelling of learning disabilities within society. Historically the use of a label placed upon

this particular group of people has served to segregate them from ‘normal’ society and

potentially conjures up negative imagery.

2

Legislative history of learning disability from the 1900’s and early behavioural psychological

approaches towards mental healthcare.

The history of learning disability has been controlled by the ebb and flow of society’s

opinions and attitudes and the governments changing and implementation of law and

legislation.

Gates (2007) suggests that society in the early 1900’s was unable to understand the reasons

why these people looked or behaved the way that they did. Society at the time regarded

these individuals as a threat to their own ideas of what constituted normality, believing that

the degeneration within society was due to these individuals procreating with ‘normal’

people. Through the introduction of the Mental Deficiency Act (1913), individuals could be

removed from society and detained within an institution or asylum if they fitted any of the

four criteria under the act which was idiots, imbecilic, feeble minded and/or morally

defective.

Gates further suggests that the largest influx of people to be detained within asylums or

institutional settings arose from a committee that was originally set up to organise children’s

education but extended its power of control towards the adult sector. With this diagnosis

according to the Mental Deficiency Act (1913) 100,000 people was identified and

recommended for detention. Referred to as The Wood Report (1929), it was responsible for

the removal from society and incarceration of up to 77,000 individuals whom today we

would refer to as learning disability.

Bewley (2008) describes the actions of a chief nurse called George Jepson who was

employed in 1797 by an institution called the Retreat of York. Changes had begun to occur

within established asylums and institutions albeit slowly and with some resistance from

certain members of medical hierarchy. Jepson had become very concerned at the standard

approach of care by staff members towards inpatients and he had expressed doubts that

the reliance on fear which would today be considered physical and psychological abuse to

manage the mentally infirm was completely unnecessary. Jepson assumed that through the

actions and behaviour of the staff towards not only the inmates but also each other, the

inmates would respond and react to positive and friendly stimuli.

3

This intervention and approach by Jepson could be compared to Bandura’s (2006) Social

Learning Theory. The theory of vicarious learning and mirroring of appropriate behaviour

which also would have had a strong impact upon the behaviour of inmates due to their

perception of authority of the staff. The display and mirroring of behaviour has a much

greater impact upon a subject when that subject perceives the display coming from a

person in a place of dominance and elevated hierarchy.

Jepson’s approach to the treatment of institutionalised people and the awareness it created

within the staff members and inmates possibly constitutes some of the earliest forms and

attempts at psychological intervention. Bewley (2008) further suggests that the success

shown by Jepson and the Retreat of York paved the way for other institutions and asylums

to adopt this much more psychologically based approach.

Gates (2007) adds that today through public awareness and implementation of both local

and higher government law and legislation, institutions such as these have now closed or

being re-used for other purposes due to the implementation of Valuing People (2001). The

government’s White Paper Caring for People (DOH, 1989) and the NHS Community Care Act

(1990) began to pave the way for inmates to be released back into community based

settings, supported to live within their own homes, able to access the community and health

services with the same rights as any other citizen. Due to the model of care being

institutional, awareness and support by other professionals and services needs to be

directed towards reducing the continuing devaluing psychological effects placed upon these

people. For social inclusion to be truly achieved to enable people with learning disabilities to

successfully access mental health services such as cognitive behavioural therapy, continued

research and monitoring must be carried out nationally as to its effectiveness for this group.

Prevalence of Learning Disability within the United Kingdom.

Emerson and Hatton (2008) argue that it is impossible to accurately determine the numbers

of people with a learning disability within the United Kingdom. If predicted population rates

within England increase from 50.9 million in 2007 to 53.4 million in 2017, it can be assumed

that population numbers of learning disability will also increase. Factors that may also lead

to an increase in learning disability may be attributed to growing numbers of younger males

4

from ethnic communities, increased survival rates among young people with learning

disabilities with complex and challenging behaviour and people living longer due to

increased and improved access to healthcare. Emerson and Hatton estimate that 985,000

people within the United Kingdom have a learning disability, this figure includes 828,000

adults aged 18 years and over. Of these adults the estimated number of people known to

use health services is 177,000.

This increase in population of learning disability appears consistent with previous findings.

Hardy Chaplin and Woodward (2010) suggest that learning disability is one of the most

common forms of disability currently within the United Kingdom with approximately 1.5

million people having a lifelong condition.

What is CBT?

Cognitive behavioural therapy is a form of psychotherapy that teaches the client or the

patient to replace dysfunctional self-speech (Colman, 2006).

Within the booklet entitled Making Sense of Cognitive Behavioural Therapy (CBT) produced

by the National Association for Mental Health (MIND). Hatloy (2012) suggests that this form

of therapeutic intervention is referred to as talking therapy. The focus is placed upon how

the person perceives the direction that their life is progressing. It addresses any thoughts,

beliefs and attitudes that may be influencing the way the person behaves. Sessions are

directed towards exploring negative thought patterns particularly those that impact upon

the person’s daily life. Whilst the client is in session they will explore in a structured but also

flexible and adaptable manner, any problems they are experiencing with both parties

agreeing a plan to challenge and change negative cognitions and behaviours. This may

involve the client engaging in certain tasks and homework.

Cognitive behavioural therapy is evidence based. It is a psychological approach that helps

clients to analyse and ‘reality test’ current trends within their thought process, emotional

reactions and behaviour by assessing current difficulties. Sheldon (2011) further suggests

that by both parties agreeing new approaches towards challenging dysfunctional thought

5

and behaviour whilst employing small steps towards an achievable goal coupled with

monitoring and evaluation, then progress can be made.

Access to CBT through the NHS.

Due to the cost effective nature and evidence based research, cognitive behavioural therapy

is an attractive option and a source of therapeutic intervention for the National Health

Service in these current times of financial cutbacks. Banerjee, Knapp, Scott, Strang,

Thornicroft and Wessely (2012) argues that if any members of the general population who

are unfortunate to be suffering from any mental illness, then currently they are receiving

insufficient treatment. Banerjee et al further suggests that mental illness is now nearly half

of all ill health suffered by people under the age of 65 years. Despite the empirical success

and effectiveness of cognitive behavioural therapy, NHS commissioners have failed to

properly commission the mental health services that the National Institute of Health and

Clinical Excellence (NIHCE) recommends and that in this day and age the access and the

availability to mental health services and cognitive behavioural therapy should be expanded.

This situation is currently the most glaring health inequality in our country.

This health inequality was also reported within the Commission Guide (2008) Implementing

NIHCE Guidance for Cognitive Behavioural Therapy for the Management of common mental

health problems. The report suggests that in many places around the country NHS services

regarding the access to cognitive behavioural therapy are either unavailable or subject to

long waiting lists. Delays are common due to high levels of demand, limited availability of

therapists and confusion regarding referral criteria and treatment pathways. The report

advises that the NHS and primary care trusts should start preparing and planning for

psychological therapies such as cognitive behavioural therapy to become more widely

available in the future. With effective commissioning, costs and inequality will be greatly

reduced and provide a mental health service available for all.

Banerjee et al further argues that restructuring is now greatly needed within the NHS and

mental health services. The net cost to the NHS would be very small whilst the evidence

within this research and study conducted indicated that the cost of psychological therapy is

low with success rates of treatment are high when compared with physical illness.

6

Banerjee et al continues to suggest that when a person with a physical illness and symptoms

receives psychological therapy, the average improvement in the condition and symptoms

displayed by the patient is so great that the resulting costs and savings upon NHS services

would completely outweigh the cost and pay for psychological therapy. Current service

provision for people with mental health concerns is lacking and inadequate.

CBT success and barriers of application for people with learning disabilities.

Pilling and Burbeck (2006) conducted randomised trials regarding the application of CBT

applied to the condition of depression, alone and in conjunction with medication. This

report is one of many that has been published within the area of depression research and

provides a sweeping statement that CBT is an effective treatment.

The study which was conducted involving the general population of non-learning disability

participants concluded by suggesting CBT is effective both when applied either on its own

compared to just administering medication or when used in conjunction with medication. It

will significantly improve the outcome for people with depression. Rates of depression

within those people defined as mild learning disabilities are similar to that of the general

population but the diagnosis and treatment of depression for people with severe learning

disabilities is much more difficult define with a low research and evidence base(Gates, 2007:

Jahoda, Dagnan, Jarvie & Kerr, 2006). Communication and the inability to express their

distress effectively to others leads people with a severe learning disability to increased

levels of frustration, anger and anxiety which becomes displayed in behaviours such as

screaming, irritable moods, aggression, self-injurious behaviour and incontinence.

Professional’s such as doctors and nurses who have had no training within the field of

learning disability support and care are likely to miss-diagnose psychological states such as

depression (Willner, 2007).

Historically services for people with learning disabilities have been delivered separately from

the mainstream population. Treatment such as cognitive behavioural therapy have been

excluded from research trials coupled with systemic underreporting of mental health

problems associated with this group of people. This approach is linked to the beliefs of

7

clinicians who believe that people with learning disabilities do not have the cognitive

capacity to undertake and benefit from cognitive therapy (Leahy, 2003).

Cognitive behavioural therapy is a psychological approach that is based upon scientific

principles and research which has shown to be effective. Grazebrook and Garland (2005)

argues that as regards the approaches and techniques used within cognitive behavioural

therapy, it can be used to help anyone irrespective of ability, race, gender or sexual

preference.

Gates (2007) argues that the approach and techniques employed by cognitive behavioural

therapy may be applicable to society in general and to people with a mild learning disability

but when applied to people with moderate, severe and profound disability then certain

considerations must be considered. The mental capacity of a person and any cognitive and

information processing impairment they may have that impacts upon their level of

understanding must be accounted for.

Psychological and social factors linked to people with a learning disability may also prevent

therapeutic intervention occurring. This person may have experienced past verbal, physical

abuse and social stigma leading to feelings of vulnerability, anxiety and anger. If the person

has a history of institutional care then this is a very de-personalising and de-humanising

experience where everyone within that establishment being treated the same. Staff

numbers were small and organised activities rare so interaction and stimulation was very

minimal. For a person to have lived within and experienced this environment or even born

there, social skills will be affected with reduced self-esteem and increased uncertainty and

self-doubt.

Can CBT be applied to people with learning disabilities?

Cognition and Information Processing.

Oathamshaw and Haddock (2006) suggests that the full approach of cognitive behavioural

therapy focus is upon challenging and changing dysfunctional cognitive operations of an

individual as well as the ability to make links between activating events, cognitions/beliefs

and consequent emotions. This ability of the participant to be capable of appropriately

8

linking activating events and emotional responses may be necessary for an individual with

learning disabilities to successfully participate in cognitive behavioural therapy. Sams,

Collins and Reynolds (2006) agree adding that people with good language skills together

with a high IQ make people more aware and likely to recognise and identify different

emotions among thoughts, feelings and behaviours. Sams et al further suggests that there is

a need for a structured approach to simplify the concepts of cognitive behavioural therapy

linked together with methods of socialization and education to aid therapeutic participation

for people with learning disabilities.

The motivation and determination of the person with learning disabilities is also a

contributing factor for the successful outcome of any therapeutic interaction. The person

must be willing to engage with the therapist who must also in turn recognise if their client is

lacking in confidence, is uncertain of the environment they are in and the tasks that are

involved within cognitive behavioural therapy. This skill of the therapist must be taken into

account, to be able to adapt to the client that is sat before them whilst managing any

hindrance from support staff and family members that may have a negative impact upon a

client’s willingness to participate. If managed appropriately the therapist could enable the

person with learning disabilities to make therapy much more understandable, accessible

and achievable (Taylor, Lindsay & Willner, 2008).

The capacity, cognition and information processing of an individual underpins and

determines the suitability and potential effectiveness of cognitive behavioural therapy as an

approach for psychological therapy and intervention for people with a learning disability.

Kroese, Dagnan and Loumidis (2005) further argues that currently there is a wealth of

evidence suggesting people with a learning disability are often unclear and become

confused within a therapeutic setting. It is important for any valued outcome within therapy

that the person is first assessed regarding their cognitive ability and also ability to recognise

causes and consequences of cognition before any therapy takes place. If the therapist is to

use and apply humour within therapy then it is advised there is a relaxed atmosphere to

increase the positive effect of any discussion. The therapist must be confident that the

person has the cognitive ability to understand and comprehend humour and is not laughing

9

with the therapist because they perceive it to be what is socially expected of them at that

specific moment in time. The application of humour within a cognitive behavioural therapy

session must also be accurately assessed by the therapist. There may be a possibility that

humour may be linked by the person themselves to historical verbal abuse. Any negative

aspects of humour that may have experienced could directly impact upon the therapy

session, increasing the anxiety of the person which in turn provides a negative experience

making future therapeutic meetings, involvement in tasks and potential future success will

be more difficult to attain.

The Department of Health (2001) Valuing People refers to the lack of cognition and

information processing as a significantly reduced ability to understand new or complex

information. Oathamshaw and Haddock (2006) argues that people with learning disabilities

do have the ability to undertake cognitive behavioural therapy. Through trials conducted

the ability of several people with learning disabilities was assessed regarding recognition of

emotions, behaviours and linking together events and emotions. Their results indicated that

the majority of the 50 participants who took part were able to recognise and link emotions

and events and differentiate between emotions. Although tasks that involved cognition

were found to be significantly difficult. Results suggest that some difficulty experienced by

the participants was found to be associated with receptive language ability. This study

concluded that people with learning disabilities have some of the skills able to undertake

cognitive behavioural therapy although it was found that the area involving cognitive tasks

and the recognition of being in therapy is particularly challenging. Oathamshaw and

Haddock suggests that clinicians should consider applying cognitive behavioural therapy for

people with learning disabilities due to a small but increasing evidence base that indicates

and supports successful application of this therapy to this population.

Success has been shown regarding training methods to teach people with learning

disabilities to recognise the core concepts of cognitive behavioural therapy.

Bruce, Collins, Langdon, Powlitch and Reynolds (2010) conducted research with the aim to

investigate if people with learning disabilities can learn the skills and concept of cognitive

behavioural therapy, the ability to link, learn and distinguish between thoughts, feelings and

10

behaviours. Results indicated that training techniques taught to a group of thirty four adults

prior to commencing a therapeutic session led to significant improvements in therapy

participation concluding that with prior training of this population , people with learning

disabilities can successfully receive and engage within a therapy session.

Dagnan, Chadwick and Proudlove (2000) argue that whilst conducting research, their results

indicated that the participants, who involved forty people with learning disabilities, had

encountered difficulties within the set activities. Only several people had passed the tasks

regarding their ability to link and identify emotions and situations. Dagnan et al concluded

and agree that with preparatory training, the individuals would benefit greatly and be able

to grasp the concept of cognitive behavioural therapy.

Cosden, Patz and Smith (2009) suggest problems linked to auditory processing and attention

may be a contributing factor in relation to a successful therapeutic outcome for people with

learning disabilities. A study was conducted with 52 adults with learning disabilities and 87

adults who had attention deficit hyperactivity disorder (ADHD). All of the participants were

identified as not having any cognitive or information processing deficits and was conducted

using a computer and web based survey gathering data that dealt with perceptions and

explored the effectiveness of psychotherapy. The study concluded that all the participants

thought the therapeutic process conducted in this manner was helpful although the people

with auditory processing problems were much less likely to reach and attain any goals and

be successful within any therapeutic program. Also 44% of the group who had learning

disabilities within this study also stated that their condition affected the effectiveness of

therapy and this group also stated that they would not seek therapy again. The rationale

behind this research attempted to ascertain the problems associated with information

processing and the affects it has upon the process of psychotherapy for people with learning

disabilities using computer and web based approaches. Research and study that involves

any population must also take into consideration the cognitive ability as well as the complex

nature of that group.

11

Peterson, Maier and Seligman (1993) suggest that when people experience uncontrollable

events and that future events also elude their control, problems may occur regarding

motivation, emotion and learning. Learned helplessness theory has three components.

Contingency refers to any positive or negative outcomes for the person within the situation

they are in. Cognition is the way the person perceives the contingency and evaluates the

future for them. If they have experienced a failure or something negative then this

expectation can stay with them driving the person’s behaviour which may result in future

helplessness, depression, low self-esteem and extreme passivity. If research’s expectations

about the capabilities of people with learning disabilities ultimately affects the way they are

treated then their behaviour may in turn be influenced confirming research's ’expectations

of this population in a self- fulfilling prophecy.

The assessment criteria for people with learning disabilities to detect mental health

problems are not well developed often lacking in reliability and validity (Taylor, Lindsay,

Hastings & Hatton, 2013).

Individuals diagnosed with a learning disability have not been offered cognitive behavioural

therapy to the same degree as the general population who have been diagnosed with the

same conditions. Despite the interventions shown to be effective for the disorder, people

with learning disabilities are known to have enduring life experiences that may expose them

to an increased risk of depression (Taylor, Lindsay & Willner, 2008).

Wilner (2005) suggests there is increasing improvement regarding people with learning

disabilities gaining access to mental health services and cognitive behavioural therapy which

historically was not the case for this population. Wilner further adds that cognitive

behavioural therapy has shown to be successful for mild learning disabilities and some

others diagnosed with more severe conditions but argues that documented reports

regarding the effectiveness of therapy with learning disabilities is extremely limited with a

distinct lack of randomised trials in relation to the effectiveness of the various components

of cognitive behavioural therapy and the level of IQ applied to learning disabilities.

12

Whitehouse, Tudway, Look and Kroese(2006) agree that historically people with learning

disabilities have had little or no access to mental health services and although there is

increasing literature regarding this population, knowledge and research could and should be

greatly improved. In a literature review involving twenty-five studies regarding the effective

application for people with learning disabilities of both psychodynamic and cognitive

behavioural therapy, a total of 94 recommended adaptions were identified within cognitive

behavioural therapy. The most frequently considered and consistent adaption for increasing

the effectiveness of therapeutic intervention being the adoption of a flexible approach by

the therapist and having a person specific plan.

The suitability of cognitive behavioural therapy for short term therapy (SSCT) consists of an

interview and a rating procedure which explores whether a person has the potential to gain

maximum benefits whilst engaging in cognitive behavioural therapy. The process consists of

a one hour semi-structured interview which is focused upon gaining information according

to a nine part selection criteria. The scores provided predict the outcome of short term

cognitive therapy for the individual. This approach regarding the use of a predictive scale

not only accurately assesses the suitability or un-suitability of a person but could also save

time, money and reduce waiting lists (Safran, Segal, Vallis, Shaw, Samstag, 1993).

Oathamshaw and Haddock (2006) argues that the use of an interview and a rated scoring

system to assess the suitability of applying cognitive behavioural therapy may be effective

and applicable to some people but there are many more skills involved in receiving and

engaging in successful cognitive therapy other than verbal. The verbal skills of a person do

not totally predict success although it has been established that verbal skill and ability has

been linked with positive outcomes of CBT.

Cognitive Behavioural Therapy and the application of IQ.

The definition of learning disability and the application of IQ to categorise and help identify

and quantify the mental health needs of people with learning disabilities have begun to be

questioned. Historically a person with an IQ of seventy and below was deemed and labelled

as having a learning disability. Whittaker (2008) argues that IQ is not an accurate measure

of a person’s ability, cognition and information processing skills. The use of applying IQ to

13

the broad spectrum of learning disabilities helps to define, categorise and identify this

population enabling others such as local health authorities, care providers and social

workers an aid to help identify those who may be vulnerable and at potential risk. But a

strong, unwavering belief is placed upon IQ. This method of labelling and categorising has

the great potential for miss and under diagnosing conditions of people with learning

disabilities. Whittaker further argues that the definition of learning disabilities provided by

Valuing People (2001) could also lead to negative and confusing labelling of people. The

definition states that people with a learning disability suffer a deficit in social functioning.

This term must be made much more defined and measured before the person is labelled in

such a way. This categorising and labelling of people with learning disabilities can and does

impact upon their lives and future. It can also impact upon the services that may or may not

be available to them with some people slipping through the net unable to receive the

support they need.

Whitaker (2003) suggests that the rating of IQ 70 in relation to people with mild learning

disability is totally arbitrary and has been chosen simply because it is two standard

deviations below the mean. Any person labelled with such an IQ is immediately assumed as

being unable to cope with the pressures of modern living than those with an IQ of above 71.

IQ is not a predictor of adaptive behaviour or social ability. Many people below IQ 70 have

the social and cognitive ability to learn, adapt and cope within a variety of conditions

despite this categorical label placed upon them. Conversely there are people with learning

disabilities with IQ above 70 who are unable to cope and adjust. Whitaker further suggests

that the continued use of IQ as a way of identifying people with learning disabilities that

may need certain services is a wholly inaccurate predictor of that person and their cognitive

abilities. There should be another definition and title that is applicable to this population

due to this term ‘learning disability’ being so reliant upon IQ. The use of IQ to categorise and

quantify this client group by health authorities and other services is essentially flawed.

Either these people labelled with IQ 70 are coping very well against the definition imposed

upon them or there are many people who have been missed, not been identified by services

and deemed as needing help and support by local health authorities.

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Whitaker (2003) argues that it is far more important to recognise and regard a person’s

developmental milestones whilst in their infancy. Their level of communication, social and

economic position, personal achievements and their level of cognitive ability together whilst

also taking into account a wide variety of other aspects concerning their lives is a much

more valid and accurate assessment of a person rather than be limited and restricted with a

single test involving the use IQ. The use and application of IQ to determine cognitive ability

regarding people with a learning disability is being drastically reduced as this is now

recognised as an imprecise, inaccurate and unreliable science.

From a positive standpoint regarding application of IQ for people with mild to moderate

learning disabilities, the rating and testing may help to monitor and raise concerns about

possible further deterioration of cognitive ability regarding certain metabolic disorders and

in particular Downs syndrome. Also certain cognitive deficits being experienced by the

person such as dyslexia or reading problems, memory or organisational difficulties can be

identified and if they occur can be compensated for within any therapeutic intervention

(Perry, Hammond, Marston, Gaskell & Eva, 2010).

Success and limitations treating depression, anxiety and anger management.

Jahoda, Dagnan, Jarvie and Kerr (2009) points out that it is striking that cognitive

behavioural therapy was developed to treat common mental health disorders such as

depression and anxiety within the general population but for people with learning

disabilities there is a gap. Research regarding this population needs to be addressed due to

the importance of understanding the distress experienced by these people in relation to

their life experiences.

Hassiotis, Serfaty, Azam, Strydom, Martin, Parkes, Blizard and King (2011) agrees suggesting

that due to the nature of people with mild to moderate learning disabilities they are more

likely to suffer from depression and/or anxiety when compared to the general population

due to their negative experiences of society. Cooray and Bakala (2005) agree that people

with learning disabilities are much more vulnerable to psychiatric illness. Due to people with

learning disabilities gradual increasing presence within the community, there will also be an

increase of this group accessing mental health services. Hassiotis et al continues and

15

suggests that today the NHS now recognises and applies cognitive behavioural therapy as

treatment of choice for conditions such as depression and anxiety although this therapeutic

intervention is not readily available for people with learning disabilities due to the need for

modification and tailoring to meet the specific needs of the person whilst taking into

account the persons cognitive problems and complex communication issues.

Haddock and Jones (2006) argues against a need for extensive adaptation. Regarding the

results of a questionnaire passed to eight clinical psychologists engaged in applying

cognitive behavioural therapy for people with learning disabilities suggests that the

consensus of opinion reached is therapeutic results can be gained for people with learning

disabilities if therapy was delivered creatively.

For

people with more severe and profound learning disabilities, the diagnostic criteria for

anxiety are difficult if not impossible to apply. The clinician must rely on observable

behaviour by themselves or other care givers rather than self-reported measures (Cooray &

Bakala, 2005). Hassiotis et al suggests that there is a developing evidence based group of

research that shows cognitive behavioural therapy to be effective and successful in the

treatment of psychosis, obsessive compulsive disorder, anxiety, depression and anger

management for people with learning disabilities. Previous studies have concentrated upon

the behavioural aspect rather than addressing the cognitive. Hassiotis et al conducted a

study with the aim of developing an individualised cognitive behavioural manual for the

treatment of several common mental health disorders that could be applied to the

complexity of mild learning disabilities and could be used as a guide by other professionals.

Through the application of randomised trials the manual was tested to see if it was suitable

for people with mild to moderate learning disabilities which could also improve the

symptoms regarding depression and anxiety. Phase one involved the development of the

cognitive behavioural therapy manual which involved a very wide ranging and varied

consultancy base involving contributions from professionals and specialists working with

learning disabilities. Information was also acquired from various literary sources such as

books, journals and published research trials where cognitive behavioural therapy has seen

positive effects. The manual is intended as a step by step guide that provides advice

16

regarding changing cognition, therapy duration, behavioural techniques and length of

treatment. This research and following trials associated with the cognitive behavioural

therapy manual is a two and a half year project with trials still currently being conducted

and data gathered regarding the effectiveness of the manual and assessments involving the

interviewing of the trial participants to find out how they feel, any positive or negative

changes they may have felt or experienced also to see if any further adaptations can be

made to the manual. Hassiotis et al adds that this trial is the first of its kind to evaluate a

manualised individual cognitive behavioural therapy to treat common psychological

disorders for people with mild learning disability. The results of this trial are likely to have

considerable impact regarding the accessibility of psychological therapy and treatments for

this client group adding to current research evidence base for interventions in people with

learning disabilities which is sparse.

Borsay (2012) suggests that regarding anger, a quarter of people with learning disabilities

living within the community currently have difficulty controlling and managing this emotion.

An unfortunate consequence of this inability to control their anger can sometimes result in

the person becoming socially isolated and excluded, suffering loss of day care centres or

residential care as well as having a negative psychological impact upon paid carers and

family members.

Willner, Jahoda, Rose, Kroese, Hood, Townson, Nuttall, Gillespie and Felce (2011) suggests

that anger management through the application of cognitive behavioural therapy for people

with learning disabilities has the most developed base of evidence. Anger within this

population is generally associated with verbal and physical aggression which may lead to a

negative impact upon the quality of care and support the person is receiving whilst if anger

is not properly managed it may lead the person into criminal behaviour. Cognitive

behavioural therapy has become the first line of intervention for anger management for

people with learning disabilities. Willner et al further suggests that anger is the only

psychological condition in which controlled trials have been used properly to evaluate the

effectiveness of this therapeutic intervention for people with learning disabilities. Wilner et

al conducted a review involving seven studies of anger management in settings such as

17

community based day care and one study involving cognitive behavioural therapy within a

forensic setting which involved people with learning disabilities. The review concluded that

published studies are fully consistent in reporting positive outcomes from cognitive

behavioural therapy interventions and are also effective for people with mild to moderate

learning disabilities helping the person to manage their anger. The review also indicated

that treatment gains were maintained after three and six month follows up interviews.

Wilner et al adds that evidence also shows cognitive behavioural therapy to be effective

across a varied range of settings although currently there is little evidence as regards which

key components of CBT are crucially involved within the therapeutic intervention.

Willner (2007) suggests that there is growing and convincing evidence that anger

management therapy that takes place within a group setting for people with learning

disabilities can be a successful approach and provide effective results.

Mishna and Muskat (2001) agree suggesting that group cognitive behavioural therapy

sessions has shown to be effective for certain young people with learning disabilities who

also affend. Despite the very high prevalence of learning disability within young offenders,

research has indicated that this group do not receive interventions that also address their

learning disability. Mishna and Muskat further suggests that to date studies have shown

that cognitive behavioural therapy is less effective involving youths who have not only

suffered academic delays but also have problems at home with dysfunctional families which

ultimately impacts upon the homework tasks involved within the participation of cognitive

behavioural therapy. This group of people has also shown difficulties in completing cognitive

tasks.

Willner (2007) adds that the growth of evidence regarding the effectiveness of cognitive

behavioural therapy as an intervention for people with learning disabilities remains painfully

slow. The conducting of research and trials with such a limited client group are usually small

and often with non-random allocation to groups. The gathering together of information

regarding such a complex group of people currently remains difficult.

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Conclusion.

Common themes throughout the literature review.

Continued research and in-depth study of this highly complex group of people is needed

upon conditions such as depression, anxiety and anger. To date research regarding cognitive

behavioural therapy and its effectiveness is slow whilst only the effective management of

anger having the largest research base. More clinical research and research based practice is

needed before any professional can justify withholding potentially helpful treatments for

people with learning disabilities (Taylor et al, 2008: Wilner et al, 2011: Willner, 2007).

Other health professionals who may also come into contact with people with learning

disabilities must also receive training and awareness of the needs of this client group. Due

to their gradual improving access to health services and to help reduce the devaluing effect

and possible negative experiences they, society and others can have upon them (Emerson &

Hatton, 2008: Gates, 2003: Hassiotis et al, 2011: Willner, 2005).

Success has been shown within research that prior to cognitive behavioural therapy, if

training sessions are employed then there is an increased level of engagement and

participation for people with mild to moderate learning disabilities (Bruce et al, 2010:

Dagnan et al, 2000: Oathamshaw& Haddock, 2006). People with learning disabilities do have

the ability to engage and participate within cognitive behavioural therapy although their

level of motivation and determination to become involved within a therapeutic session and

the tasks involved are a contributory factor (Oathamshaw & Haddock, 2006: Taylor et al,

2008).

From a historical and cognitive perspective it is important to be aware of how the use of

labels upon a person or group of people can mislead and potentially be abusive. This can

give a preconceived idea regarding the actual ability of a person or client group which may

impact upon their potential to engage within therapy such as the application of IQ and the

possibility that it may conjure up negative imagery of that person or group. The application

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of IQ to quantify people with learning disabilities is not an accurate predictor of the

cognitive ability of a person (Emerson et al, 2001: Whitaker, 2003).

Due to the complexity of this client group there is a need for any therapeutic intervention to

be adapted to meet the needs of the person by simplifying the concepts of cognitive

behavioural therapy and having a defined and structured approach whilst research has

shown group therapy to be successful for people with learning disabilities (Gates, 2003:

Hassiotis et al, 2011: Mishna & Muskat, 2001: Sam et al, 2006: Willner, 2007).

There are currently strong indications that health services and practitioners are offering

cognitive behavioural therapy to people with learning disabilities in line with the general

population and that contrary to historical belief the vast majority of this client group are

able to participate and benefit from cognitive behavioural interventions (Taylor, Lindsay &

Willner, 2008: Whitehouse, Tudway, Look & Kroese, 2006: Willner, 2004).

Alternative approaches and future research.

Difficulties can arise regarding the participation within cognitive behavioural therapy tasks

for people with learning disabilities when not only there is a deficit of capacity and cognitive

impairment present but also elevated levels of anger and anxiety. Foster and Banes (2009)

adopted a narrative psychological intervention for a man who in the study was named Paul.

This gentleman had mild learning disabilities and had previously attempted to engage in

cognitive behavioural therapy to help manage high levels of anger and anxiety but had

failed. By the use of speaking and conversation this person was placed central to his own

world and as Foster and Banes describes, enabled Paul to be an expert in his own life. The

use of dialogue was intended to assist him to access his own strengths, resources and

enable him to view himself as being separate from the problem. As the intervention

continued Paul expressed feelings of being more in control of his own life and emotions

whilst also experiencing a greater sense of wellbeing and calmness. Foster and Banes

concludes that with modifications to standard techniques, a narrative therapeutic approach

offers a viable alternative to cognitive therapy for people with learning disabilities who have

previously encountered difficulties engaging in therapy sessions and tasks.

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The effectiveness of cognitive behavioural therapy applied through different mediums is

currently being researched, one such method is cognitive behavioural therapy by telephone.

Jones (2012) suggests that this method is of therapeutic application is as effective as and

more accessible than face to face therapy for the majority of clients whilst also saving the

NHS money and time. Study data was gathered from 39,000 patients through the Improving

Access to Psychological Therapies Services (IAPT) in collaboration with Midlands and East

NHS, National Institute for Health Research Collaboration for Leadership in Applied Health

Research and Care in conjunction with University of Cambridge researchers. A comparison

with both face to face and phone therapy results showed that phone therapy was as

effective as face to face with overall costs per session being 36.2% lower although there was

an identifiable group of people within the study whose psychological conditions displayed

more severe illness, results indicated that phone therapy would not be suitable for this

client group. These results have been so encouraging that Midlands and East NHS have

instigated a training programme to start and standardise service delivery of cognitive

therapy by telephone ensuring therapists are competent at phone contacts.

For many years self-help books have been a popular resource for people seeking help,

advice and guidance with a wide and varied range of problems. Haeffel (2010) suggests that

current research regarding self-help books can do more harm than good. Popular books

such as the ‘Dummies’ series and in particular those based upon principles of cognitive

behavioural therapy have shown that people who engage in regular ruminative thinking

have a high propensity to develop depression. Research results indicated that the research

group who read and followed the self-help book based upon cognitive behavioural therapy

displayed more depressive symptoms than the other groups. Haeffel suggests that the

current results suggest that self-help books currently sold in high numbers in many stores

may not work for people with ruminative thinking; these people may need a modified form

of cognitive skills training.

The effectiveness of cognitive behavioural therapy needs to be not only adaptable for

people with learning disabilities but also flexible in its delivery. Brown and Marshall (2006)

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suggest that people with a learning disability are a growing section of the community with a

growing evidence base regarding their mental health needs and the services they require.

The success of applying cognitive behavioural therapy to this client group is also growing

showing improved mental health support within certain key areas whilst the best persons to

deliver this therapeutic intervention would be registered and trained learning disability

nurses. Research and training for qualified nurses would be needed to be able to implement

cognitive behavioural therapy through this group of clinicians. They are well placed within

their role and within the community to apply this therapeutic approach. Brown and Marshal

adds that there is a need for leadership and direction regarding this extended role within

learning disability nursing and action is required to support education and practice

development that will contribute to addressing the mental health and emotional needs of

people with learning disabilities whilst also contributing to the preparation of registered

learning disability nurses to practice cognitive behavioural therapy and the on-going

research within this area of clinical practice.

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