The starting point for this post is that historically people with intellectual disabilities have, for all intents and purposes, not been offered or not received cognitive behavioural interventions that have been shown to be effective for mental health and emotional problems experienced by people who do not have intellectual disabilities. The question is why not but before getting into this let’s have a brief look at the types of intellectual disabilities.
Types of Intellectual Disability
The types (and the effects) of intellectual disability differ greatly among people. Black and Andreasen (2014) report that among those diagnosed with intellectual disability:
- 85% of individuals are in the mild range.
- 10% of individuals are in the moderate range.
- 5% of individuals are in the severe/profound range.
Intellectual Disability and Psychopathology
Adults with Intellectual Disabilities have four times the psychopathology of the general population yet only 10% receive psychotherapy (Einfield et al., 2006). A reasonable question here might be to ask why this is the case? One possible reason is that Intellectual Disability was traditionally viewed as an exclusion criterion for psychotherapy (Hassiotis et al., 2012). Another possible reason is that people with intellectual disabilities may not be considered to have the cognitive capacity to participate in psychotherapy.
Intellectual Disability and Psychotherapy?
Despite the above possible reasons and although this area is under-researched the existing studies show that adults with intellectual disabilities can both participate in and benefit from psychotherapy (Parkes et al., 2007). One form of psychotherapy which has been suggested as suitable for people with intellectual disabilities is Cognitive Behavioural Therapy (Bhaumik et al., 2011) and there are some indications that the use of cognitive-behavioural approaches with people with intellectual disabilities is becoming more widely accepted.
What is CBT?
CBT is an empirical-based, strengths-based and evidence-based talking therapy. After medication CBT is the most effective treatment for reducing the symptoms of almost all mental health problems, but especially anxiety and depression (Mental Health Ireland website, 2019).
How does CBT work?
CBT works with thoughts (the cognitive), behaviours and emotions. The reciprocal relationship between the three is demonstrated in the image below.
The Cognitive . . .
The Cognitive component of CBT identifies negative (maladaptive) automatic thoughts and/or negative core beliefs. It attempts to replace these negative thoughts/beliefs while simultaneously strengthening positive ones. This process is called Cognitive Restructuring.
The Behavioural . . .
Behavioural techniques are used to help clients break unhelpful patterns, face fearful situations, build coping skills, and reduce the impact of painful emotions on self or others. Some of the most commonly used behavioural interventions include systematic desensitization, graded task assignments (breaking tasks down into manageable parts), activity scheduling, and breathing and relaxation training.
The Emotional . . .
The CBT approach views emotions as consequences of what we think and how we act.
Rationale for the Use of CBT with People with Intellectual Disabilities?
Traditionally psychological interventions for people with intellectual disabilities have focused primarily on behavioural supports as opposed to therapeutic interventions. Although behavioural supports are indeed helpful it could be argued that behavioural-only supports do not address the emotional or cognitive components of the presenting behaviour.
Therefore . . .
For CBT interventions to be successful with people who have intellectual disabilities, the cognitive, behavioural and emotional components of the issue require examination and interventions need to be developed that are tailor-made, more accessible and modified appropriately to cater to the presenting cognitive abilities and the sometimes complex communication needs.
Case studies have reported the successful use of modified cognitive behavioural therapy techniques in people with Intellectual Disabilities. CBT appears to be a useful intervention for adults with borderline and mild intellectual disabilities (the majority of people with intellectual disabilities) who are experiencing anger and aggression, chronic pain, fire setting behaviour, hoarding, mood disorders (depression and anxiety), psychosis, or sexually abusive behaviour (Barrera, 2017).
Cogbeh provides both CBT and a Cognitive Behavioural Wellbeing Programme for people with intellectual disabilities. The practitioner is an experienced Cognitive Behavioural Therapist who has also worked for many years in a non-therapeutic role with people with intellectual disabilities (www.cogbeh.com).
Barrera, C. (2017). Cognitive Behavior Therapy with Adults with Intellectual Disabilities: A Systematic Review.
Bhaumik, S., Gangadharan, S., Hiremath, A., & Russell, P. S. S. (2011). Psychological treatments in intellectual disability: The challenges of building a good evidence base. The British Journal of Psychiatry, 198, 428-430.
Black, D. W., & Andreasen, N. C. (2014). Introductory textbook of psychiatry (6th ed.). Washington, DC: American Psychiatric Publishing.
Einfeld, S. L., Piccinin, A.M., Mackinnon, A., Hofer, S. M., Taffe, J., Gray, K.M., Bontempo, D. E., Hoffman, L. R., Parmenter, T., & Tonge, B. J. (2006). Psychopathology in young people with intellectual disability. JAMA, 296(16), 1981-1989.
Hassiotis, A., et al., Manualised Individual Cognitive Behavioural Therapy for mood disorders in people with mild to moderate intellectual disability: Journal of Affective Disorders (2013).
Parkes, G., Mukherjee, R. A. S., Karagianni, E., Attavar, R., Sinason, V., & Hollins, S. (2007). Referrals to an intellectual disability psychotherapy service in an inner city catchment area: A retrospective case notes study. Journal of Applied Research in Intellectual Disabilities, 20, 373-378.