Core questions for CBT and people with
learning disabilities.
Professor Dave Dagnan
Consultant Clinical Psychologist/Clinical Director
Cumbria Partnership NHS Foundation Trust
Our Philosophy
What are we trying to
achieve?
1. Access to IAPT or therapy
services for people with
learning disabilities?
2. What is the right level of
reasonable adjustment?
-
Too complex and it will be hard to
maintain
Too minimal and it won’t help
anyone
Presentation Aims
1. Describe our approach
to identification and
screening.
2. Describe our initial
experience of outcome
and training to support
adaptation.
Numbers of People with a Learning Disability
• Cumbria population c 500,000
- 2.5% population IQ below 70 =
12,500
• Only about 20% of adults with
learning disabilities are known to
learning disability services (about
1750 people), therefore about
10,000 people in community with
IQ below 70 not identified as
having learning disability.
- Presumably receiving services
without any adaptation?
What does ‘learning disability’ predict
for adapting IAPT services?
• Little prediction in adaptation
needed by IQ 65-70, 70-75, 75-80.
• Can argue adaptations might be
considered for those with IQ scores
below 85
• 16% (1 in 6) population IQ (in
Cumbria = 77,500)
• At least 1 in 6 of caseloads in the
trust have IQs below 85…. Probably1
in 5 or above.
• National data also suggests about
16% (1 in 6) people are functionally
illiterate and innumerate.
Screening tool
Screening tool
IAPT outcomes in first 2 years
1. Which people with learning disability
used IAPT services?
2. What initial outcomes can we report?
Who used First Step services?
Data from first two years of operation
•
•
27,064 people referred to First Step.
72 identified as people with learning disabilities (all
from Trust database)
•
•
•
0.27% of people referred to First Step were people with
learning disabilities
Compares to 0.47% prevalence of adults with learning
disabilities in Cumbria according to GP data;
At the stage of initial contact with First Step, many
clients did not report their ethnicity or disability. Only
three clients reported themselves to have a learning
disability (we found 72!!).
Example of outcomes
•
Single referral closed cases: IAPT therapy
provided (n=14)
• Average 9.1 scheduled IAPT sessions (range 4-17)
• Attended 70.3% of their scheduled sessions
• IAPT therapy for 8 clients recorded as CBT, for 4 clients
counselling, for 2 clients guided self-help
• Average PHQ9 scores for depression dropped from 17.2
to 11.2
• Average GAD7 scores for anxiety dropped from 14.0 to
10.1
Outcomes summary
•
•
•
•
•
People with learning disabilities do use IAPT services,
although not fully proportionately to the general population
Clients’ learning disabilities generally un-recognised in IAPT
data systems (and services?)
Patterns of referral sources and primary diagnoses similar to
the general population
Around half of people with learning disabilities referred into
IAPT services do not go on to receive an IAPT service
(failure to engage, disengagement, signposting elsewhere)
IAPT services can be highly effective for people with
learning disabilities
Delivering training for IAPT staff
• Outcomes and curriculum
Training Curriculum
• The training is structured in a modular format such that
the training consisted of 4 or 8 modules depending on
the duration of the training.
• 1. Introduction to intellectual disability, epidemiology
and impact of literacy and numeracy difficulties in the
general population.
- 2. Stigma and its impact on therapy relationships
- 3. Introduction to assessment of people with
intellectual disabilities
-
4. Advanced assessment of people with intellectual disabilities
5. Overview of adaptation of therapeutic techniques
6. Specific examples of adaptation; thought diaries
7. Therapy approaches and formulation
8. Overview of local services and discussion of
communication and support systems
Training for simple adjustments
in IAPT
• Accessible communications for all
- Easy read medication guided
self-help
• Allowing extra time, techniques for
reading/delivering MDS questionnaires
• Emphasising less cognitively demanding techniques
• Emphasising smaller set of techniques
• Enabling supporters in therapy
The therapy confidence scale
(Dagnan, et al. The
development of a measure of confidence in delivering therapy to people with
intellectual disabilities. Clinical Psychology and Psychotherapy, in press)
Results
• Significant difference
in confidence between
HI and PWP.
• Significant increase in
confidence for both
groups maintained at 3
months
PWPs
Conclusions
Conclusions: Key arguments for
ensuring accessibility
1. A significant number of
people who are not simply
identified as having a
learning disability will be
helped
2. Helping a small number
will impact on outcome
Conclusions: using screening to
trigger adjustments
1. Using the screen to make sure
those that can’t engage in high
volume assessment are
signposted
2. Identifying people who need
adjusted pathways
3. Staff training and support to
implement adjustments
Our Philosophy
What are we trying to
achieve?
1. Access to IAPT or therapy
services for people with
learning disabilities?
2. What is the right level of
reasonable adjustment?
-
Too complex and it will be hard to
maintain
Too minimal and it won’t help
anyone