CBT for Adults with Intellectual Disabilities:
Adaptations and The Evidence Base
IAPT: Evidence and Experience of Supporting
People with Learning Disabilities
Castle Green Hotel, Kendal, Friday, 23rd May 2013
John L Taylor
Professor of Clinical Psychology/
Consultant Clinical Psychologist
Northumbria University/
Northumberland, Tyne & Wear NHS Foundation Trust
Mental Health Problems and People with ID - Vulnerability
People with ID may be more likely to experience MH problems
than the general population for a number of reasons (Deb et al.,
2001; Moss et al., 1998). These include:
• predisposing biological factors
• limited psychological coping resources
• increased exposure to psycho-social stressors e.g.
- deprivation/poverty √√√
- stigmatisation
- social isolation
- traumatising abuse experiences
Mental Health Problems and People with ID - Prevalence
Prevalence studies of MH problems amongst people with ID
report large variations in prevalence rates depending on:
• Study design and methodology (e.g. case note review vs. clinical
evaluation, sampling)
• Location of the sample (e.g. in-patient vs. community vs.
specialist service)
• The type of assessment instrument used to detect MH problems
(e.g. screening assessment vs. full diagnostic assessment)
• The reliability and validity of the assessment instruments used to
detect MH problems
• Whether or not ‘challenging behaviour’ is included as a MH
problem
Mental Health Problems and People with ID Prevalence Rates using Screening Instruments
Prevalence %
Study
N
Total
Affective/
Neurotic
Organic
Disorder
Psychotic
Disorder
1,155
20.1*
14
3.9
10.2
Iverson & Fox (1989)
165
36
(Random sample of service users)
Reiss (1990)
205
39
(Random sample of service users)
Roy et al. (1997)
127
33
(Consecutive sample from SSD
register)
Deb et al. (2001)
90
22.2
Taylor et al. (2004)
(Random sample of service users)
*Note. 4.4% were above threshold for >1 diagnostic category.
Mental Health Problems and People with ID Prevalence Rates involving Clinical Assessments*
Study
N
Prevalence %
1,023
18
Cooper & Bailey (2001)
207
22
Lund (1985)
302
17
Corbett (1979)
402
21
Cooper et al. (2007)
*Note. Rates excluding behaviour problems calculated using data presented
by Copper et al. (2007) in Table 6, p. 33
Lack of Awareness of Mental Health Problems and
Needs of People with ID
Despite the prevalence of these problems, there is a general
lack of awareness of the needs of people with ID and MH
problems (Taylor & Knapp, 2013). Reasons include:
• Concern on the part of service commissioners and
providers to act if these needs were better understood
• A general lack of interest in the needs of people seen as
different
• People with ID are often considered not bright enough
to understand to to benefit from psychological therapies
• The ‘Unoffered Chair’ (Bender, 1993)
 therapists are reluctant to offer individual psychological
therapy to people perceived as unattractive because of
their disability – ‘therapeutic disdain’
Against Psychotherapy With People Who Have
Mental Retardation
Sturmey P. (February, 2005). Against Psychotherapy With People Who
Have Mental Retardation. Mental Retardation, 43, 55-57.
‘Hence, we are unable to make any conclusions as to the
effectiveness, ineffectiveness, or harmful effects of
psychotherapy based on scientific evidence.’ (p. 56)
Evidence-Based Practice in the New NHS
• All NHS treatment (including psychological therapies)
should be evidence-based (Department of Health (1999)
Clinical Governance: Quality in the NHS)
• NICE guidelines for depression, anxiety, panic, OCD,
trauma, psychosis, etc.
• So, what is the evidence for the effectiveness of
psychotherapy for people with ID and MH problems?
• There have been a number of reviews/commentaries/
critiques
Evidence for Psychotherapy for People with ID - I
Hatton, C. (2002). Psychosocial interventions for adults with ID and mental
health problems: A review. J. of Mental Health
•
Depression
– 2 case studies and 1 case series showed ↓symptoms for modified CBT
•
Anxiety
– A small number of case studies and case series have showed ↓symptoms
for modified CBT and relaxation training
•
Anger
– 2 narrative reviews of psychological treatments
– A number of case studies and case series showed ↓symptoms for modified
CBT
– 3 small trials of CBT have showed significant treatment effects
•
Psychosis
– 2 case studies using behavioural interventions showed ↓ “psychotic speech”
– 1 case study showed ↑ self-management of hallucinations for modified CBT
Evidence for Psychotherapy for People with ID - II
Prout, H.T. & Nowak-Drabik, K.M. (2003). Psychotherapy for persons who
have mental retardation. Am. J. on Mental Retardation
•
Reviewed 92 studies published over a 30-year period
•
Used a clear definition of psychotherapy
•
Many studies lacked methodological rigour
•
In terms of the therapeutic approaches, the studies reviewed included:
–
–
–
–
–
33% behavioural psychotherapy
15% analytic/dynamic
13% cognitive-behavioural
2% humanistic
37% other
•
Meta-analysis of treatment effectiveness – mean effect size of 1.01
•
Results suggest that individual treatment, behaviourally orientated, and
manual-guided provided the best outcomes
Evidence for Psychotherapy for People with ID - III
Beail, N. (2003). What works for people with MR? Critical commentary on
CBT and psychotherapy research. Ment. Retardation
•
Reviewed and compared CBT and psychodynamic psychotherapy
outcome research
•
For CBT numerous case studies and case series were found and a
small number of uncontrolled group studies (mainly in the forensic ID
field)
•
Only a few controlled studies were found :
– 2 concerning CBT for problem-solving yielded mixed outcomes
– 3 concerning CBT for anger problems yielded significant treatment
outcomes
•
4 pre-post open trials of psychodynamic psychotherapy were reviewed
that were successful in reducing behavioural problems
Evidence for Psychotherapy for People with ID - IV
Sturmey, P. (2004). Cognitive therapy for people with ID: A selective review
& critique. Clin. Psychology & Psychotherapy
• Selective review of ‘cognitive therapy’ for anger, depression and
sex offending
• Suggests that in each of these problem areas the evidence for
behavioural interventions is stronger than for cognitive therapy
• Better research using controlled, randomised controlled trials
and single subject experimental designs are required
• Outcome measures require reliability, validity and ‘social
validity’
• However, critique based on a “misunderstanding” of what
defines psychotherapy (Prout & Browning, 2011)
Evidence for Psychotherapy for People with ID - V
Willner , P. (2005). The effectiveness of psycho-therapeutic interventions for
people with LD: A Critical review. J. of Intell. Disability Research
• CBT cognitive skills approaches show promise for a range of
problems including: stereotyped behaviour, social anxiety,
sexually inappropriate behaviour, anger control, and anxiety
• CBT cognitive distortion approaches have quite limited evidence
to support their use for anger, depression, anxiety and sexual
behaviour problems
• Conclusion was that there is a “wealth of evidence” (albeit from
methodologically weak studies) that people with ID benefit from
psycho-therapeutic interventions
Evidence for Psychotherapy for People with ID - VI
Prout, HT & Browning, BK (2011). The effectiveness of psychotherapy for
persons with intellectual disabilities. In RJ Fletcher (ed). Psychotherapy for
individuals with disability (pp 265-287). Kingston, NY: NADD Press.
• Reviewed psychological treatment studies involving people with
ID published between 2006-2011
• Published studies present generally positive results supporting
psychological therapy for people with ID
• Both individual and group interventions are beneficial
• Anger reduction interventions have the most evidence
• Doctoral dissertations completed betw. 1993-2009 provide
further support for the effectiveness of psychological therapies
for people with ID (‘file draw’ phenomenon)
Evidence for Psychotherapy for People with ID - VII
‘Reviews of the Reviews’
• Gustafson et al. (2009). Rsch on Social Work Practice
– Surveyed systematic reviews of psychosocial interventions for
adults with ID
– 55 reviews published between 1969-2005
– Only 2 reviews met the inclusion criterion
– Concluded that CBT reduced anger at the end of treatment
• Prout & Browning (2011). Adv. In Mental Health and Intellectual
Disabilities
– Narrative review of reviews on psychotherapy for people with ID
– Included 7 reviews published between 200-2011
– Research continues to lack a critical mass of studies with robust
designs
– Psychotherapy is ‘moderately beneficial’ for people with ID and a
range of mental health problems
Prevalence of Aggression in People with ID
Prevalence (%)
Study
Location
n
Tyrer et al. (2006)
England
3065
16
-
-
Taylor et al. (2008)
England
782
12
-
-
USA
2491
16
37
-
Harris (1993)
England
1362
11
38
-
Sigafoos et al. (1994)
Australia
2412
10
35
-
Smith et al. (1996)
England
2202
-
40
-
Taylor et al. (2004)
England
129
-
-
47
McMillan et al. (2004)
England
124
-
-
47
Hill & Bruininks (1984)
Community
Institution Forensic
Impact of Aggression in People with ID
•
Aggression is the 1° reason for people with ID to be (re)admitted
to institutional care (Lakin et al., 1983)
•
Aggression is the 1° reason for people with ID to be prescribed
antipsychotic medication (Aman et al., 1987; Robertson et al.,
2000)
•
Physical violence has a significant negative impact on the
rehabilitation of offenders with ID
•
Physical violence has significant costs staff and services (Jenkins
et al., 1997; Kiely & Pankhurst, 1998)
•
Anger is strongly associated with aggression/violence (Novaco &
Taylor, 2004)
Cognitive-Behavioural Treatment of Anger for
People with ID – Summary of Evidence
• Research on anger treatment for people with ID is limited,
but there is some evidence of successful CBT-based
interventions
(see Taylor & Novaco, 2005; Whitaker, 2001 for reviews)
• Post-1985 there have been 35 studies published on the
effectiveness of psychotherapeutic anger interventions for
people with ID
• There are 12 reports on small anger CBT outcome studies
with ID clients that involved comparison groups
(Benson et al., 1986; Hagiliassis et al., 2005; Lindsay et al., 2004;
Rose et al., 2000, 2005, 2008, 2009; Taylor et al., 2002, 2004,
2005; Willner et al., 2002, 2005)
Cognitive-Behavioural Treatment of Anger for
People with ID – Summary of Evidence II
•
Cochrane Review
‘Behavioural and Cognitive-Behavioural Interventions for
Outwardly-Directed Aggressive Behaviour in People with
Learning Disabilities’
•
Just 4 studies included in final analysis
– McPhail & Chamove (1989). RCT, 12 particx, APR vs. no treat.
– Nezu et al. (1991). RCT, 28 particx, problem-solving vs. wait list
– Taylor et al. (2005). Quasi-RCT, 40 particx, individual AT vs.
TAU
– Willner et al. (2002). Quasi-RCT, 16 particx, group AM vs waitlist
•
Conclusions – scant evidence, some evidence of efficacy, could
be preferable to drug treatment, more research trials required,
cost effectiveness studies needed.
Cognitive-Behavioural Treatment of Anger for
People with ID – Summary of Evidence III
• Nicoll, Beail & Saxon (2013). JARID
– Systematic Review and meta-analysis of CBT for anger in
adults with ID
– 12 studies published between 1999-2011 met the inclusion
criteria (10 UK; 2 Australia)
– All studies utilised the Novaco CBT approach
– Studies showed high levels of reporting and internal reliability
– Studies showed lower levels of internal reliability sampling
and external validity
– 9 studies included in the meta-analysis
– Overall large uncontrolled ES = 0.88; 6 group treatment
studies ES = 0.84; 3 individual treatment studies ES = 1.01
– Review reveals an ‘emerging evidence base’ for CB anger
interventions for adults with ID; studies show ‘a good level of
methodological rigour’
Is ‘Therapeutic Disdain’ Still Justified?
Probably not!
1)
The need for psychological therapies is demonstrable given the
prevalence of MH problems in this population
2)
The evidence to support psychological therapies, particularly CBT, is
limited, but is growing and is positive
3)
The levels of professional interest and skills in this area are
increasing, but requires more support
4)
Clients with ID and enduring mental health problems can be
successfully engaged in, and motivated to undertake CBT based on
an individual analysis and formulation of their problems
5)
In particular, clients complex problems and few psychological
resources, can benefit from intensive individual manual guided
cognitive-behavioural treatment.