Mental Health and Wellbeing
Practice Guide for Psychologists
Who Support People with Disability
Document approval
This Mental Health and Wellbeing practice guide has been endorsed and
approved by:
___________________________________
David Coyne
Director
Approved:
Document version control
Distribution:
Internal and External Stakeholders
Document name:
Mental Health and Wellbeing Practice Guide
Trim Reference
AT15/102714
Version:
1.0
This document
replaces
N/A
Document status:
Final
File name:
Mental Health and Wellbeing Practice Guide
Authoring unit:
Clinical Innovation and Governance
Date:
January 2016
Next Review Date:
January 2019
Mental Health and Wellbeing for People with Disability (January 2016)
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Table of contents
1
Purpose of practice guide ........................................................................... 5
1.1
1.2
1.3
1.4
1.5
Purpose ................................................................................................ 5
The practice improvement framework ................................................... 5
Core standards program ....................................................................... 6
Copyright .............................................................................................. 7
Disclaimer ............................................................................................. 7
2
Introduction.................................................................................................. 8
3
Risk and resilience in mental health .......................................................... 9
3.1
3.2
4
Risk factors ........................................................................................... 9
Protective factors .................................................................................. 9
Key factors influencing mental health ..................................................... 10
4.1
Quality of life and subjective well-being .............................................. 11
5
Assessment of mental health in intellectual disability............................ 12
6
Models of recovery from mental ill-health ............................................... 12
6.1 Therapeutic input for individuals with intellectual disability and mental
health needs ................................................................................................ 13
6.1.1
6.1.2
6.1.3
6.1.4
6.1.5
6.1.6
6.1.7
6.2
6.3
Person centred treatment planning ..................................................... 29
Improving social and economic circumstances ................................... 32
6.3.1
6.3.2
6.3.4
6.4
Developing individual attributes and behaviour linked to well-being .... 14
Self esteem and confidence ................................................................ 14
Social connectedness .......................................................................... 15
Cognitive therapy techniques .............................................................. 15
Positive view of the self ....................................................................... 16
Valued roles and attributes .................................................................. 17
Relaxation programs............................................................................ 18
Progressive muscle relaxation ............................................................. 18
Managing stress and distress ............................................................... 19
Emotional competence ........................................................................ 19
Mindfulness .......................................................................................... 20
Mindfulness program ........................................................................... 20
Soles of the feet program .................................................................... 21
Problem solving .................................................................................... 22
Problem solving techniques ................................................................. 22
Communication skills ............................................................................ 23
General health and fitness ................................................................... 24
Individual and group treatment for mental disorders ............................ 24
Evidence-based treatment modalities and research designs .............. 25
Cognitive Behaviour Therapy (CBT) .................................................... 25
Eye Movement Desensitisation and Reprocessing (EMDR) ............... 27
Dialectical Behaviour Therapy (DBT) .................................................. 27
Psychodynamic Psychotherapy ........................................................... 28
Behavioural Activation ......................................................................... 28
Adapting traditional treatment therapies .............................................. 29
Social support network: ........................................................................ 32
Positive family interaction ..................................................................... 33
Sense of achievement in academic or vocational pursuits .................. 35
Environmental factors ......................................................................... 35
6.4.1
6.4.2
Access to services ................................................................................ 35
Social integration/inclusion ................................................................... 36
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3
6.4.3
6.5
Physical safety and feeling secure ....................................................... 36
Standardised outcome measures of well-being ................................... 36
Outcome measures for adults: ............................................................ 37
Outcome Measures for children and young persons: .......................... 38
7
References ................................................................................................. 40
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1
Purpose of practice guide
1.1 Purpose
Welcome to the Mental Health and Wellbeing practice guide for psychologists
who support people with disability. This practice guide provides evidence
based, up to date information regarding people with intellectual disability and
co-occurring mental disorders. It also is to promote good communication
channels and collaboration between services.
This practice guide is to provide additional information important for
psychologists to know and use in their everyday person centred work. This
practice guide whilst being part of the psychology specific core standards is
also linked to the Practice Improvement Framework.
1.2 The practice improvement framework
The practice improvement framework (PIF) is available at http://PIF.learnflex.com.au
Psychologists (and others) who do not have login details, will need to register
an account and set up a password to access the information.
The PIF contains the ‘Positive Approaches to Behaviour Support” (PABS)
which supports the content of the Behaviour Support: Policy and Practice
Manual (FACS, 2009) and provides practitioners not only with the knowledge
they need to deliver behaviour support services in the disability context but
also with a process for translating that knowledge into their work practice.
This framework also contains a range of Extension Skills Topics. One of these
topics is titled, ‘Mind matters: supporting the mental health of people with an
intellectual disability’.
Prior to reading this practice guide, it is recommended that FACS
psychologists complete the mind matters extension skills topic. This practice
guide will expand on some of the specific considerations for psychologists, as
well as the practical implementation of behaviour support in the context of a
person with an intellectual disability and co-occurring mental disorder.
This practice guide is designed to complement existing organisations policies
and procedures, rather than replace them. This practice guide supports FACS
practitioners in their clinical work and can be used by them in a number of
different ways:

alongside clinical knowledge, skills and experience to guide clinical
practice

as a basis for self directed learning

as part of FACS core standards learning

for reference and clarification

for part of the induction of new staff

in conjunction with professional supervision
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Although not specifically designed for other practitioners, sections of this
practice guide may be of interest to other practitioners; for example behaviour
support practitioners, occupational therapists or speech pathologists in the
context of the practitioner’s scope of practice, their organisational policies and
procedures, and their professional obligations.
There is an appraisal accompanying this practice guide that is designed to
support psychologists to translate their knowledge regarding mental health
and wellbeing for people with intellectual disability into their everyday practice.
This guide forms part of the supporting resource material for the core
standards program developed by the Clinical Innovation and Governance
Directorate, Ageing Disability and Home Care, Family and Community
Services, NSW, Australia.
Please note that the information contained in this package is designed
specifically for psychologists working with people with disability in Australian
settings.
Your feedback on this Mental Health and Wellbeing Practice Guide is
welcome and should be sent by email to CIGcorestandards@facs.nsw.gov.au
with the words Mental Health and Wellbeing as the subject of the email.
1.3 Core standards program
ADHC has developed an overarching program of core standards. Four
common core standards with practice guides, appraisals and other resources
are available for practitioners1 who provide support to people with disability.
These are located on the ADHC website. Definitions of disability and other
key areas for psychologists are covered in the common core standards.
The common core standards cover the following areas for practitioners who
support people with disability:

Professional Supervision

The Working Alliance

Philosophies, Values and Beliefs

Service Delivery Approaches.
1
The term practitioner as used here includes dieticians, speech pathologists, occupational
therapists, physiotherapists, psychologists, behaviour support practitioners and nurses.
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1.4 Copyright
The content of this practice guide has been developed by drawing from a
range of resources and people. The developers have endeavoured to
acknowledge the sources of the information provided. The practice guide also
has a number of hyperlinks to documents and internet sites.
Please be mindful of copyright laws when accessing and using the information
through hyperlinks. Some content on external websites is provided for your
information only, and may not be reproduced without the author’s written
consent.
1.5 Disclaimer
This resource was developed by the Clinical Innovation and Governance
Directorate of Ageing, Disability and Home Care in the Department of Family
and Community Services, New South Wales, Australia (FACS).
This practice guide has been developed to support practitioners who are
working with people with disability. It has been designed to promote
consistent and efficient good practice. It forms part of the supporting resource
material for the Core Standards Program developed by FACS.
This resource has references to FACS guidelines, procedures and links,
which may not be appropriate for practitioners working in other settings.
Practitioners in other workplaces should be guided by the terms and
conditions of their employment and current workplace.
Access to this document to practitioners working outside of FACS has been
provided in the interests of sharing resources. The Information is made
available on the understanding that FACS and its employees and agents shall
have no liability (including liability by reason of negligence) to the users for
any loss, damage, cost or expense incurred or arising by reason of any
person using or relying on the information and whether caused by reason of
any error, negligent act, omission or misrepresentation in the Information or
otherwise.
Reproduction of this document is subject to copyright and permission. Please
refer to the ADHC website disclaimer for more details
http://www.adhc.nsw.gov.au/copyright.
The guide is not considered to be the sole source of information on this topic
and as such practitioners should read this document in the context of one of
many possible resources to assist them in their work.
Practitioners should always refer to relevant professional practice standards.
The information is not intended to replace the application of clinical judgment
to each individual person with disability. Each recommendation should be
considered within the context of each individual person’s circumstances.
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When using this information, it is strongly recommended practitioners seek
input from appropriate senior practitioners and experts before any adaption or
use.
The information contained in this practice guide is current as at 20 December
2015 and may be subject to change. Whilst the information contained in this
practice guide has been compiled and presented with all due care, FACS
gives no assurance or warranty nor makes any representation as to the
accuracy or completeness or legitimacy of its content.
FACS takes no responsibility for the accuracy, currency, reliability and
correctness of any information included in the information provided by third
parties, nor for the accuracy, currency, reliability and correctness of
references to information sources (including Internet content) outside of
FACS.
2
Introduction
A commonly used definition of mental health is, ‘… a state of well-being in
which the individual realizes his or her own abilities, can cope with the normal
stresses of life, can work productively and fruitfully, and is able to make a
contribution to his or her community.’ (WHO,2001, p.1).
Positive mental health is important not only for individuals but also for
communities, because it promotes higher levels of productivity, education,
employment, earnings, healthy living, engagement, and physical health. In
addition, individuals may be better able to cope with difficult situations they
are faced with and more able to reach their full potential (Friedli, 2009).
It has been suggested that individuals with intellectual disability are more
vulnerable to developing mental health problems and this may be related to
increased social disadvantage (e.g. Einfeld, Ellis, & Emerson, 2011; Gentile &
Jackson, 2008; Deb et al. 2001). Further, they are likely to experience
difficulties in accessing mental health services. This may be partly related to
the perceived confidence and skills of mental health practitioners and
diagnostic issues (McNally & McMurray, 2015).
Until relatively recently, there were very few research articles focusing on
therapeutic approaches for supporting individuals with intellectual disability,
and treatment generally focused on medication (Cooray & Bakala, 2005). This
guide was developed to assist psychologists supporting people with disability
to collaborate with the surrounding system in developing a comprehensive,
evidence-based approach to supporting an individual with an intellectual
disability and mental health issue.
In addition, this guide aims to encourage psychologists to use preventative
strategies to prevent the emergence of mental ill-health and to increase
quality of life, well-being, and life satisfaction in the individuals they support.
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3
Risk and resilience in mental health
Resilience has been defined as, ‘…a psychological trait that aids a person’s
ability to cope and adapt to changes throughout their life.’ (Conder, MirfinVeitch & Gates,2014,p.573).
The interaction between risk factors and protective factors is the key in
determining an individual’s ability to adapt and cope with a particular stressor
(Mrazek & Haggerty, 1994).
3.1 Risk factors
Risk factors are variables that increase the probability of a person developing
a disorder, including those of a biological or psychosocial nature (Mrazek &
Haggerty, 1994). Risk factors may also vary depending on age and stage of
development. Risk factors may include individual vulnerabilities, which may
arise from genetic predisposition, chronic illness, life adversity, and abuse or
neglect (O'Grady & Metz, 1987).
Factors identified as increasing the risk of mental ill-health for people with an
intellectual disability include social isolation, exposure to violence, feeling less
valued, stigmatisation, unfulfilled dreams of parenthood or intimate
relationships, mothers with an intellectual disability experiencing removal of
children, unemployment, death of one’s parents, dysfunctional family
upbringing, and entering residential care (Taggart et al. 2009a,b, 2010).
Risk factors in children developing psychiatric disorders include physical
health, family dysfunction, and psychiatric illness in a parent (Wallander et al.
2006). In addition, there is an increased risk of mental ill-health in children
who have greater cognitive and language impairments, lower social and
adaptive skills, those with a single parent, and those with a lower
socioeconomic status (Koskentausta, Livanainen & Almqvist, 2007).
Despite the increased risk for people with intellectual disability, it is well
established that not all individuals exposed to risk factors will go on to develop
a mental disorder, and this has highlighted the importance of protective
factors (Gilmore, Campbell, Shochet & Roberts, 2013).
3.2 Protective factors
Protective factors are, ‘…those factors that modify, ameliorate or alter a
person's response to some environmental hazard that predisposes to a
maladaptive outcome.’ (Rutter,1985b, p.600). Protective factors can include
personal characteristics such as temperament or social competence, or they
may be environmental, such as supportive family dynamics or previous history
of positive experiences (Gilmore et al. 2013).
Protective factors that have been identified in the research as buffering the
risks for people with intellectual disability include: strong relationships with
family and friends and opportunities for social interaction; a sense of
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autonomy; feeling happy; keeping busy; maintaining physical fitness; healthy
eating; having structured routines; medication; emotional literacy; community
involvement, early responses to signs of mental ill-health and support through
recovery (Taggart et al. 2009a; Taggart et al. 2010; Conder, Mirfin-Veitch &
Gates, 2014).
Other general protective factors for young people with intellectual disability
include having an attractive appearance, low levels of family stress, a sense
of competence, ability to be understood by others, the ability to adapt one’s
behaviour to the situation, and an accepting community environment
(O’Sullivan, Webber & O’Connor, 2006).
In light of the research relating to the development of resilience in people with
intellectual disability, it may be that part of the role of the psychologist is to
support an individual (either directly or indirectly via the larger system of
support) to develop or access additional protective factors that may provide a
buffer against potential sources of psychological distress. In addition, the
practitioner may work with the system to reduce further exposure to risk
factors.
4
Key factors influencing mental health
The research suggests that people with intellectual disability are at greater
likelihood of developing a range of mental disorders than the general
population (e.g. Deb et al. 2001; Smiley et al. 2007; Conder, Mirfin-Veitch &
Gates, 2014).
Though written in relation to the general population, the World Health
Organization (2012) highlighted three main determinants influencing a
person’s mental health. The WHO (2012) expanded on these three
determinants to include the risk and protective factors associated with each
one. The three determinants of mental health and the associated protective
factors are:

individual attributes and behaviour i.e. self esteem and confidence, skills in
problem solving and managing stress, communication skills and general
health and fitness

social and economic circumstances i.e. social support, family interaction,
physical safety, economic security, and scholastic achievement or success
and satisfaction in the workplace

environmental factors i.e. access to services, social integration, equality,
and physical safety.
These determinants of mental health (and therefore mental ill-health) and
protective factors provide a useful frame to consider in the design and
implementation of psychological intervention for people with an intellectual
disability. Addressing these factors as part of the individual’s overarching
system of support may assist in preventing the emergence of mental
Mental Health and Wellbeing for People with Disability January 2016
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disorders in people with an intellectual disability as well as promoting a
general sense of well-being and life satisfaction (Miller & Chan, 2008).
In addition, targeting these areas in order to promote an improvement may
also assist in recovery for those who have already received a formal mental
health diagnosis, in line with current recovery models (e.g. Andresen, Oades
& Caputi, 2011; Glover, 2012). Recovery models are discussed further below.
4.1 Quality of life and subjective well-being
In mental health and disability research, there has been a shift from deficitcentred models to strength-based models (Xie, 2013). Positive mental health
is the capacity to lead a fulfilling life and not just the absence of illness. The
concept of quality of life is defined as, ‘…individuals’ perceptions of their
position in life in the context of the culture and value systems in which they
live and in relation to their goals, expectations, standards, and concerns.’
(The WHOQOL Group,1995, p.1405).
Subjective well-being (SWB) is a related concept that has been identified as
an important component in the quality of life for people with an intellectual
disability (Cummins, 2005b). Subjective well-being is, ‘…the global experience
of positive reactions to one’s life, [that are]… either cognitive (e.g. life
satisfaction) or affective (the presence of happiness)’ (Diener & Lucas, 2000,
cited by Rey et al. 2013, p.146).
A range of personal and demographic factors have been identified that affect
subjective well-being, such as cultural factors and environment, income,
education, close relationships, etc. In line with this, psychologists and other
practitioners should adopt a strengths-based approach when supporting
individuals with intellectual disability in promoting well-being and positive
mental health.
Whilst previously the focus may have been on addressing external factors
such as employment, physical environment, recreation, etc., the importance of
also addressing thinking style, emotional functioning and interpersonal skills is
highlighted.
Psychologists may consider working directly with individuals with intellectual
disability to promote resilience in a range of intra and interpersonal domains,
such as: recognising, understanding and managing their feelings (Rey et al.
2013), assertiveness skills (McCarthy, 2014), optimistic thinking (Gilmore et
al. 2013), and self-esteem (Mattika, 1996).
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5
Assessment of mental health in
intellectual disability
Psychologists who support individuals with intellectual disability are likely to
play a key role in early detection, assessment, and referral to mental health
services for those who are vulnerable to developing mental disorders.
In addition, psychologists may take the lead in developing the capacity of the
individual’s surrounding support network to also identify and respond to any
signs suggesting a deterioration in mental health. As such, it is important that
psychologists are aware of the symptomatology and diagnostic criteria
associated with various types of mental disorders in intellectual disability,
such as depression, anxiety, and psychosis.
Further, psychologists should also be aware of the kinds of diagnostic issues
that may arise, such as behavioural or diagnostic overshadowing and the
presence of atypical symptomatology. Finally, psychologists should be aware
of the mental health screening tools that have been validated for use with
people with intellectual disability.
The Practice Improvement Framework (PIF) includes detailed information
regarding mental health assessment and referral, standardised screening
tools, as well as a comprehensive list of other relevant resources (such as
diagnostic manuals). As such, this Practice Guide has focused on intervention
rather than assessment.
Psychologists should refer to the PIF ‘Extension Skills Topic’ titled, ‘Mind
matters: supporting the mental health of people with an intellectual disability’
for more information (available at http://PIF.learnflex.com.au) .
6
Models of recovery from mental illhealth
As outlined in the section above, not all individuals with intellectual disability
who are exposed to risk factors will go on to develop a psychiatric disorder. It
is likely that psychologists in disability services will come into contact with
individuals who have received (or are likely to receive) one or more formal
mental health diagnoses. Therefore, it is important that practitioners
understand the general principles underpinning various mental health
recovery models in order to ensure a recovery-orientated approach within the
support they are providing.
Recovery is defined as, ‘…being able to create and live a meaningful and
contributing life in a community of choice with or without the presence of
mental health issues.’ (Australian Health Ministers’ Advisory Council, 2013,
p.2).
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In the National Framework for Recovery-oriented Mental Health Services
(2013), five ‘practice domains’ were proposed with the aim that they are
implemented concurrently. These include:

promoting a culture of hope and optimism

supporting individuals in a person centred manner

supporting individuals to lead their own recovery

promoting a skilled, supported workforce

promoting social inclusion and upholding human rights.
The framework further refers to two models of recovery. Andresen, Oades
and Caputi (2003, 2006 & 2011) hypothesised that personal recovery involves
feeling hopeful and optimistic, retaining or finding a positive self-perception,
feeling purposeful, understanding or making sense of emotional distress or
illness, and feeling in control of life (including any illness).
Similarly, Glover (2012) proposed five processes leading to individual
recovery, including the progression from being a passive recipient of services
to regaining strengths, abilities, and attributes, finding a sense of hope,
reclaiming control and responsibility, learning from the past and finding
meaning in the journey, and finding a sense of connectedness and
participating fully in life.
The two models of recovery mentioned above feature similar principles to
those underpinning behaviour support practices as outlined in the ADHC
Behaviour Support Policy (2012). That is, to support an individual to achieve a
sense of well-being and to assist in the recovery where deterioration in mental
status has occurred.
Psychologists should ensure that services are led by the individual and that
the services promote inclusion, self-determination, choice, hope, safety, and a
sense of purpose and meaning.
6.1 Therapeutic input for individuals with intellectual
disability and mental health needs
As noted earlier, the World Health Organisation (WHO, 2012) reported on the
three key determinants of mental health, which were expanded into risk and
protective factors.
Table 1 below provides a summary of the three determinants and the
protective factors associated with each one. In line with the trend toward
strength-based approaches, this guide focuses on the protective factors and
as such, risk factors were not included. In addressing the mental health needs
of individuals with intellectual disability, psychologists should consider each of
the factors in the table below.
It should be noted that it is not necessarily the role of the psychologist to
directly impact on all of these factors, and not all areas will need to be
targeted for each individual. It is important that psychologists work in
Mental Health and Wellbeing for People with Disability January 2016
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collaboration with key individuals in the person’s support network, which may
include family members, direct support workers, managers, school staff, and
medical and other allied health practitioners.
The following sections provide further information about these factors as well
as guidelines around practical application.
Developing individual
attributes and behaviour
linked to well-being
Self esteem and
confidence
Managing stress/distress
Improving social and
economic
circumstances
Social support
Environmental
factors
Positive family
interaction
Problem solving skills
Sense of achievement
in academic or
vocational pursuits
Social
integration/social
inclusion
Physical safety
and feeling secure
Access to services
Communication skills
Health and fitness
Table 1: The three key determinants of mental health and associated protective factors
(WHO, 2012)
6.1.1 Developing individual attributes, thoughts and behaviour
linked to well-being
This section focuses on building an individual’s resilience by impacting on
their self-perception, perception of the world around them, the use of helpful
behaviour patterns, and development of interpersonal skills.
Psychologists may choose to focus on just one or two of these areas when
supporting an individual to enhance their quality of life or in moving towards
recovery. It is recognised that many of these skills are also addressed through
formal psychological therapies such as Cognitive Behaviour Therapy (CBT),
Dialectical Behaviour Therapy (DBT), Acceptance and Commitment Therapy
(ACT), etc., and more information regarding the current research in those
specific interventions is provided below.
Self esteem and confidence
A review of the research highlighted correlations between self-esteem and a
number of other factors, including social connectedness (Jordan, Kaplan,
Miller, Stiver, & Surrey, 1991), cognitive processes such as social
comparisons and perceptions of stigma (Gibbons, 1985; Paterson, McKenzie,
& Lindsay, 2011), valued roles (Oatley & Boulton, 1985; Linville, 1987), and
relaxation programs (Bouvet & Coulet, 2015). Each of these is explored
further.
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Social connectedness
Social connectedness is strongly associated with self-esteem in individuals
with disability, particularly women (Jordan, Kaplan, Miller, Stiver, & Surrey,
1991). Avenues for social connectedness allow individuals to share common
life experiences, reduce feelings of isolation, and improve self-worth
(Stebnicki & Marini, 2012).
Section 2 provides further information on the importance of social networks.
Cognitive therapy techniques
Rosenberg et al (1989) proposed that self esteem is the evaluation of one’s
own value or self worth, and that this often involves comparing ourselves with
others. Disturbances in emotions and behaviour often arise from evaluations
of the self (e.g. “I am hopeless”), evaluations that others make of the
individual (e.g. “Everyone thinks I am a bad person”), and evaluations made
about other people (e.g. “People aren’t trustworthy’) (Chadwick, et al, 1999).
It has been suggested that young children internalise the responses of their
primary caregivers to their actions and interactions, and behaviour. As the
child grows, this is expanded to include experiences arising from many
different domains in the individual’s life. Marginalised groups, such as those
with disability, are more vulnerable to internalising the negative impacts of
stigmatizing messages they receive from society (Blaustein & Kinniburgh,
2010).
Cognitive therapy involves helping the individual to recognise his or her
exaggerated or biased ways of thinking, and to investigate the validity of their
unhelpful statements. It is the role of the therapist to guide the individual to
consider how their thoughts and feelings (and behaviour) interact (Leahy,
2003).
Cognitive behaviour therapy (CBT) has been successfully adapted for use
with people with intellectual disability with positive outcomes achieved (e.g.
Lindsay, 1999). Suggested adaptations include simplifying the language,
regularly checking understanding, using more visual information, and having a
greater reliance on real-life examples.
Training procedures can be used to assist individuals with intellectual
disability to develop the skill to reliability use Likert scales, using jars of water
filled at different levels and then applying the scale to favourite foods or
activities (Hartley, Esbensen, Shalev, Vincent, Mihaila, & Bussanich, 2015).
Research has demonstrated that many individuals with intellectual disability
have the necessary cognitive skills to effectively engage in CBT (e.g. Dagnan
& Chadwick, 1997; Dagnan, Chadwick & Proudlove, 2000).
It has been suggested that CBT involves three features of cognition –
cognitive capacity such as adequate memory and being able to understand
the concept of more and less; emotion identification skills; and the ability to
understand the antecedents, beliefs and consequences model (Hatton, 2002;
Ellis, 1977).
Mental Health and Wellbeing for People with Disability January 2016
15
Bruce et al (2010) provided training to 34 individuals with intellectual disability
to increase their ability to distinguish between thoughts, feelings and
behaviour using the Thought-Feeling-Behaviour task (TFB; Quakley,
Reynolds, & Coker, 2004). The task involves reading a range of short stories
to the person. After each story, a set of cards is presented and each card has
a sentence from the story.
The individual with intellectual disability must identify correctly whether it is a
thought, feeling or behaviour. In the same study, the researchers used the
Thought to Feeling task (Doherr, Reynolds, Wetherly, & Evans, 2005) to teach
the skill of linking thoughts and feelings, using four Makaton faces (Walker,
1982) and a stick figure with a ‘thought bubble’. The individuals were asked to
imagine themselves as the stick figure while a range of short scenarios were
provided, including the relevant thought. The person with intellectual disability
was required to identify the feeling that matches the thought (Bruce et al.
2010).
Positive view of the self
Blaustein & Kinniburgh (2010) suggested a range of activities that focus on
building a positive view of the self. Although initially developed for traumatised
children, the activities may also be beneficial and easily transferable for
improving the self-esteem in individuals with intellectual disability.
It is important that psychologists and other practitioners always consider each
activity in terms of age-appropriateness and individual skills and abilities prior
to implementation.
Activities for developing self-esteem
Activity
Power
Book
Suggested Procedure
-
-
-
-
The book can be created over a period of time i.e. one
page at a time.
Introduce the book activity to the individual, highlighting
that it is about ‘things that make them feel powerful’ (p.
196).
Start by creating a cover for the book. The cover must
encompass the theme of strength or individual power.
Sections to be covered include strengths, successes,
positive experiences, and internal/external resources.
Successes may include examples where substantial
effort was made, even if the outcome wasn’t as
intended.
The person is encouraged to be creative and to
consider the possibilities, e.g. to imagine
characteristics that would make them feel powerful and
think of an animal or other subject (person, superhero,
etc.) that embodies that quality.
Structured prompts may assist, such as, “Draw
yourself doing something that you are good at”; “draw
Mental Health and Wellbeing for People with Disability January 2016
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Activity
Suggested Procedure
-
-
Pride Wall
-
-
-
yourself as a superhero”, “list your 5 best qualities”.
Alternatively, consider using pictures from magazines
where the individual struggles with drawing.
The clinician may also be aware of times where the
person demonstrated strengths, successes, etc., and
may highlight these in sessions.
Review the power book regularly, encourage the
individual to share the contents with others (such as
family members).
Designate a wall/area in the house as a ‘pride wall’ and
put up a ‘Pride Wall’ (or ‘Power Wall’) sign.
Discuss with the individual who is permitted to add
contents to the wall.
Keep a set of index cards and/or award cards handy,
near the wall.
The individual (and perhaps family or support staff)
may add cards on the wall outlining positive
achievements, successes, strengths, etc. either in the
written form (or as a drawing where literacy skills are
low).
Consider implementing a routine for adding information
to the wall, e.g. the individual or family/support staff
adds a card each day.
Celebrate the individual’s successes in the moment.
Table 2: Activities for developing self-esteem (Blaustein & Kinniburgh, 2010 p.196-197)
Valued roles and attributes
Social role valorisation (SRV) was defined by Wolfensberger and Thomas as,
‘the application of empirical knowledge to the shaping of the current or
potential social roles of a party (i.e., person, group, or class) – primarily by
means of enhancement of the party’s competencies and image- so that these
are, as much as possible, positively valued in the eyes of the perceivers’
(Osborn, 2006, p.4).
It is suggested that roles and attributes are valued when there is a perception
of achievement or rank, social attractiveness, or group belonging (Allan &
Gilbert, 1995). It has been suggested that individuals with intellectual disability
are less likely to have opportunities to access roles or attributes that they
perceive as valuable. Going one step further, individuals with intellectual
disability can be socialised into negatively valued roles, limiting their lifestyles
in part because of limited awareness or insight into other alternatives (Scott,
1969).
It has been suggested that people with an intellectual disability can
experience devaluing situations that are termed ‘wounds’ (Cocks, 2001).
These include:
Mental Health and Wellbeing for People with Disability January 2016
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
rejecting experiences - such as being placed with other people with
intellectual disability and being segregated from the general population
 accorded low social status - such as being placed in devalued roles
 physical and social discontinuity - the individual is separated from
significant people, possessions and places
 de-individualisation –the individual loses their positive identity through
institutional regimes and management
 loss - including reduced opportunity for choice and self-determination
 reduced opportunity for usual life experiences
(Cocks, 2001).
Psychologist’s can support individuals to obtain valued roles and attributes
preventatively through education of the service system, as well as identifying
possible roles that the individual could be involved in, as well as enhancing
individual competencies.
It is important that the roles and attributes are valued by the individual, and
not just those in the support system. Examples of valued roles might include:
participating in a local sporting team, being a paid employee, engagement in
volunteer work, responsibility for maintenance of the gardens or development
of meal plans.
Relaxation programs – the Jacobson (1938) method
The Jacobson method (1938; cited by Cotton, 1999) is a progressive muscle
relaxation technique aimed at addressing the psychophysiological effects of
stress, and this was the technique selected by Bouvet & Coulet (2015) in their
study as it was considered adaptable for people with intellectual disability.
Psychologists could facilitate a similar program for individuals with intellectual
disability or provide individual sessions covering the same content.
Progressive muscle relaxation
Bouvet & Coulet (2015) implemented a 10 session group relaxation program
with individuals with a mild to moderate intellectual disability and found an
increase in self esteem, reduction in state anxiety and cognitive reappraisal
(re-evaluating situations using a different perspective). The technique used by
the authors is outlined below:
 sessions were one hour long and were conducted in a group setting (15
participants)

sessions were scheduled on the same day each week and at the same
time

‘switching off’ is the goal of muscle relaxation as muscle tension and
nervous activity leads to fatigue

the psychologist should focus on one muscle or muscle group at a time.
Paxton & Estay (2007) suggested the following muscle groups:
Mental Health and Wellbeing for People with Disability January 2016
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Muscle group
Arms
Face
Neck
Shoulder
Chest/ upper
back
Stomach
Legs
Muscles involved
Hands, biceps, forearms
Muscles around the forehead, eyelids, nose,
mouth and jaw
By pressing chin towards neck
Muscles around shoulder blades
Chest muscles and upper back
Stomach muscles
Calves and thighs and feet

ask the individual to tense each muscle just enough to feel the sensations
associated with muscle tension

when the person can understand/feel the difference between tense
muscles and relaxed muscles, the training then shifts to focus on just
relaxing muscles, not tensing them

consider using the following scripting (Smith, 2006, p. 62), to be tailored to
the individual’s communication needs:
‘Attend to your shoulder muscles. While keeping the rest of your body nice
and relaxed, shrug your shoulders now. Create a good shrug. Feel the
sensation of shrugging. Then let go and go completely floppy. Imagine
your shoulders have been held up by strings (like a puppet), and the
strings have been cut. Your shoulders then fall limp. Let them stay limp as
you slowly count to 20’

an example of an amended version is:
‘Feel your shoulders. Keep your body nice and relaxed, and now shrug
your shoulders. Make it a big shrug. Feel your shoulders now while you
shrug. Now let go and go really floppy. Imagine your shoulders are being
held up by string, like a puppet. And now the strings have been cut. Your
shoulders fall down, all floppy again. Keep your shoulders floppy while I
count to 20’

continue through the rest of the muscle groups, using a similar script as
the one above.
6.1.2 Managing stress and distress
Emotional competence
Emotional competence is defined as: ‘…an affect-related skill …[that]…refers
to one’s abilities to identify, understand, use and manage one’s own feelings
and those of others.’
(Rey, Extremera, Durán & Ortiz-Tallo, 2013, p.147).
Emotional competence is considered to be an important factor influencing the
development and prognosis of mental health issues as well as the presence
of adaptive or maladaptive behaviour (Dosen, 2005). Further, the research
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suggests that emotional competence is a predictor of life satisfaction and
psychological well-being (Ciarrochi & Scott, 2006; Extremera et al. 2007).
The Pictures of Facial Affect system (Ekman & Friesen, 1976) is a tool that
assists psychologists to determine an individual’s ability to recognise
emotions such as happiness, sadness, fear, anger, disgust, and surprise.
The administrator names a particular emotion, and the participant is required
to choose the face that matches the emotion from six possible options. This
may be a useful assessment tool for psychologists to obtain a better
understanding of the baseline skills of the individuals they are supporting,
prior to the implementation of any emotion recognition or emotion regulation
training programs.
Blaustein & Kinniburgh (2010) highlighted a range of practical tasks that
therapists can use to teach affect identification, expression and modulation
skills with children and young persons who have experienced trauma; that
may be adapted for use with individuals with intellectual disability. Some
examples of these include: using flashcards featuring magazine pictures
demonstrating various emotions; playing ‘charades’ to act out emotions; using
a drawing of the outline of the body and identifying and drawing somatic
experiences related to emotions on the body (e.g. tightness in the chest area
for anxiety); and teaching grounding techniques, such as deep breathing and
imagery, listening to music, writing or drawing.
Mindfulness
Mindfulness-based therapies aim to assist individuals to attain a clear, calm
mind, to be aware of their internal physiological arousal states as well as their
external surroundings, and to be focused on the present moment (Singh et al.
2003).
Harper, Webb & Rayner (2013) discussed the recent literature in relation to
mindfulness-based approaches for people with intellectual disability. This type
of approach has been used directly with people with intellectual disability
either as a stand alone intervention or as part of a broader Dialectical
Behaviour Therapy or Cognitive Behaviour Therapy program. In addition,
some of the research has focused on mindfulness-based training for
caregivers of people with intellectual disability, and the review found that both
methods are equally effective.
Mindfulness program
Yildiran & Holt (2014) conducted a group mindfulness program, held weekly,
to six participants with a mild or moderate intellectual disability in an acute
psychiatric inpatient unit. Other diagnoses of the participants included:
recurrent depressive disorder; anxiety; paranoid personality disorder; autism;
and epilepsy.
The facilitators taught the participants a range of mindfulness exercises,
which were practiced in the sessions. The number of sessions attended varied
for each individual participant, ranging from 2-23 sessions.
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This program appears to be easily adaptable for practitioners supporting
individuals with intellectual disability and co-occurring mental health issues,
and psychologists could consider facilitating this program with individuals
where groups are not able to be sourced.
The Yildiran & Holt (2014) program included:

setting up the room to include sensory lamps and light background music

the Raisin Exercise (Kabat-Zinn, 2012) was broadened to a range of fruits,
with each participant focusing on a different fruit each week. During each
session, the participants were instructed to focus on various sensory
features of the fruit, such as how it feels in their hand, identifying colours,
noticing the shape, recalling the taste of the fruit and thinking about the
sound it makes when eating the fruit

the fruit was used as the ‘anchor’ to orientate the participants to the
present moment where wandering thoughts occurred

muscle tension and relaxation were used including the ‘body scan’
technique– the participants were asked to observe changes in their bodies
and to locate the areas that feel warm

the program included deep breathing skills and meditation on the breath

participants were asked to focus on the tip of their nose, whilst observing
the sound of their breath and focusing on the air on their face

additional tangible items were used to explore sensory experiences e.g.
olfactory experiences using incense sticks, candles, and flowers.
Soles of the feet program
This mindfulness-based program developed by Singh, Wahler, Adkins, &
Myers (2003) has been used successfully to reduce the incidence of high
intensity aggressive behaviour in individuals with intellectual disability. It was
also used for an individual with intellectual disability and co-occurring
psychosis (Singh et al. 2003; Singh et al. 2008), and to address overeating in
an individual with Prader-Willi Syndrome (PWS) (Singh et al. 2008).
The aim of the program is to assist the person to shift their attention away
from a highly emotional thought or situation, and to move their attention to a
neutral part of their body. This facilitates a calm mental state where they are
able to consider their actions first and avoid impulsivity.
The meditation technique is taught to the individual, and following this they
are assisted to recognise their own triggers for the emotion or behaviour being
targeted, and finally they are guided to apply the meditation technique across
multiple contexts.
Though the available research into this program for people with intellectual
disability is related to aggression and overeating, the technique is likely to be
useful across a range of presenting issues. An additional benefit is that is a
program that can be implemented in a very short-time frame.
The program outline is as follows:
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
the person is guided to identify their own triggers/precursors for verbal or
physical aggression. In the PWS example, the individual was taught to
visualise and label their hunger as a cartoon character, “Mr Hunger”,
running alongside them

individual sessions were conducted twice per day for 5 days of 30 minutes
duration, for initial skill acquisition

the first five days (10 sessions) involved supervised role plays using real
life examples, and skills practice

the specific scripting used in ‘Soles of the Feet’ training is available in
Singh et al. 2003, p. 163

homework assignments were given to participants for a week following the
initial 5 day training period, to promote mastery of the skill

when the individual was assessed as being able to automatically use the
meditation technique, they are taught to generalise the skill for use in
multiple contexts – sitting, standing or walking

the individual is taught to use the meditation technique in response to their
triggers and/or to avoid engaging in undesirable behaviour (eating when
not supposed to in the case of PWS) until a calm state is achieved.
6.1.3 Problem solving
Effective problem solving involves a series of cognitive-emotional skills. Nezu,
Fiore, & Nezu (2006) outlined three main components involved in adapting to
problem situations, including problem orientation, behavioural response
styles, and rational problem solving skills.
Problem orientation is a term to describe the manner in which an individual
observes, understands and reacts to perceived problems. Behavioural
response styles are the ways in which an individual goes about managing
their problems.
Two maladaptive response styles have been identified in the literature. These
are: the impulsive-careless style, which is marked by impulsive and rushed
efforts to resolve the problem, and the avoidant style which is marked by
denial, procrastination and dependency on others.
Rational problem solving skills involves the ability to identify appropriate
solutions or coping strategies for managing the problem, as well as the ability
to plan out their implementation.
Problem solving techniques
Agran, Blanchard, Wehmeyer, & Hughes (2002) successfully taught a selfregulated problem solving technique to high school students with intellectual
disability or autism in order to improve participation and appropriate behaviour
in the classroom. The technique includes a means-end sequence, aimed at
connecting needs to actions and results using goal setting.
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More specifically, the training involves three phases supplemented by cue
cards, which are outlined below:
1) Set a goal – the student is taught to define, “What is the problem?” and to
state the problem out loud
2) Take action – the student is taught to consider, “What can I do about it?”
and to state out loud the identified solution
3) Adjust goal or plan – the student is taught to determine, “Did that fix the
problem?”
When the students are able to recall the three steps in the sequence, they are
supported to apply the strategy to accomplish their target goals. Psychologists
supporting people with intellectual disability may be able to teach this
technique in order to improve their coping skills, particularly those who
demonstrate high levels of impulsivity or avoidance.
6.1.4 Communication skills
Communication impairments are common in people with intellectual disability,
and this is often related to the degree and etiology of intellectual disability, as
well as related issues such as sensory processing disorders (Blackwell et al,
1989; Bray, 2003).
The ability to communicate effectively is crucial for participation in a range of
life roles, and it can have a positive impact on social behaviour (Kouri, 1988).
Speech pathologists may assess people’s communicative skills in order to
develop therapeutic goals to support the individual to further enhance their
skills (Speech Pathology Australia).
It is important that psychologists working with people with intellectual disability
are familiar with the individual’s expressive and receptive communication style
and incorporate this into their work (Hagiliassis et al, 2006).
A coordinated, integrated transdisciplinary approach is recommended for
individuals who have complex communication needs. Hagiliassis et al (2006)
highlighted some specific considerations for psychologists or other clinicians
supporting people with intellectual disability, and these included:

incorporating Augmentative and Alternative Communication (AAC) into
sessions and tailoring communication to meet the individual’s needs

ensuring the clinician is comfortable with silences, breaks and delayed
responses

considering incorporating frequent breaks into sessions

increasing the use of closed questions/ reducing the number of open
ended questions

encouraging recall of information by using summaries

giving one piece of information at a time and allowing processing time.
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6.1.5 General health and fitness
Research has demonstrated that regular exercise is effective in reducing
anxiety (Carraro & Gobbi, 2012) and depression (Carraro & Gobbi, 2014) in
people with intellectual disability.
In the general population, physical exercise has been shown to assist those
diagnosed with schizophrenia by reducing symptomatology related to
psychosis and depression, and need of care (Scheewe, et al. 2012). The
World Health Organisation (2010) has identified that lack of physical exercise
is, ‘the fourth leading risk factor for global mortality’ (WHO, 2010, p. 10).
It is known that people with an intellectual disability are more likely to lead a
sedentary lifestyle in comparison to the general population, therefore placing
their health at risk (Beange et al. 1995b). Robertson et al (2000) found that up
to 84% of people with intellectual disability did not consume the
recommended five servings of fruit and vegetables per day.
These findings suggest that people with intellectual disability would benefit
from engaging in regular exercise of moderate intensity and a dietary review
with a dietician. While it is not likely to be the role of the psychologist to
ensure a person’s physical fitness and diet are addressed, it is important that
the psychologist is aware of the significance of health and physical activity in
supporting positive mental health and well-being.
6.1.6 Individual and group treatment for mental disorders
As noted earlier, although individuals with intellectual disability are more
vulnerable to developing psychiatric disorders, they are less likely to access
mental health services. Individuals with intellectual disability have the same
right to access forms of treatment that may be beneficial for their mental
health as those in the general population, in line with the human rights, equity
and social inclusion principles contained within the Disability Inclusion Act
2014 (NSW). Research on the use of traditional psychological therapies for
people with intellectual disability is growing, with promising results.
The following section is aimed at guiding practitioners in treatment modality
selection, adaptation of treatments for people with intellectual disability, and
treatment planning.
Psychologists should always ensure that the treatment selection is based on a
comprehensive assessment of the individual. The intervention should be
appropriate for the individual in terms of their presenting issue, skill set, and
previous response to treatment. Psychologists should consider a wide range
of treatment options and consider the evidence base underpinning each one.
In addition, psychologists should ensure they have attained competence in
the chosen treatment modality, in line with the Australian Psychological
Society (APS) Code of Ethics.
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6.1.7 Evidence-based treatment modalities and research designs
The following table highlights some of the recent research involving facilitation
of adapted, manualised treatments for people with intellectual disability, in
either an individual or group formats. This may assist practitioners in the
selection of an evidence based treatment modality that is appropriate for the
presenting issue.
It should be noted that evidence demonstrating the efficacy for the following
treatment modalities could not be sourced for people with an intellectual
disability: interpersonal therapy schema therapy, cognitive-behavioural
analysis system of psychotherapy, and metacognitive therapy. In addition,
there is no evidence demonstrating efficacy of Acceptance and Commitment
Therapy (ACT) for people with intellectual disability. ACT was combined with
a Stepping Stones Triple P parenting program for parents of children with an
acquired brain injury and improvements were noted in child behavioural and
emotional problems and parenting styles (Brown, Whittingham, Boyd,
McKinlay, & Sofronoff, 2013).
Cognitive Behaviour Therapy (CBT)
Recent
Presenting
Research
Issue
Hassiotis,
Depression and
Serfaty, Azam,
anxiety
Strydom, Blizard,
Romeo, Martin, &
King (2013)
McManus,
Chronic pain
Treacy, &
McGuire (2014)
Rose, O’Brien &
Rose (2009)
Anger
Barrowcliff (2008)
Command
hallucinations
Design and Participants
Findings
16 x 1 hour sessions
Participants had a mild to
moderate intellectual
disability
Individual treatment
8 sessions
All participants had a mild
intellectual disability.
Individual treatment.
Findings not maintained
at follow up.
Reduction in
depressive
symptoms and
anxiety
16 weekly 2 hour
sessions (group) and 1418 weekly session of 3060 minutes (individual).
Both individual and group
treatments, and they
were equally as effective.
Single case study of an
individual with mild
intellectual disability.
20 sessions (including
assessment).
Mental Health and Wellbeing for People with Disability January 2016
Increase in
knowledge of
pain
management,
wellness-focused
coping and
effectiveness of
coping. Not
maintained at
follow up.
Reduction in
factors related to
anger as
measured by an
anger
provocation
inventory
Reduction in
positive
symptoms of
psychosis;
positive changes
in core beliefs
25
Recent
Research
Presenting
Issue
Design and Participants
McCabe,
McGillivray &
Newton (2006)
Depression
5 x 2 hour group
treatment sessions.
Participants had a mildmoderate intellectual
disability.
McGillivray,
McCabe, &
Kershaw (2008)
Depression
12 week group treatment
program, involving 2 hour
sessions once per week.
Treatment was
administered by support
staff to participants.
9 session group
treatment program, each
session lasted 90
minutes.
Ghafoori,
Depression,
Ratanasiripong, & anxiety and
Holladay (2010)
global distress
Kellett, Matuozzo, Hoarding
& Chandanee
(2015)
12 individual sessions.
All participants had a mild
intellectual disability.
Hartley,
Esbensen,
Shalev, Vincent,
Mihaila, &
Bussanich (2015)
Depression
Group intervention
10 sessions.
All participants had a mild
intellectual disability.
Treatment included a
caregiver component.
Marwood &
Hewitt (2012)
Anxiety – mixed
group (social
6 week group
intervention, each
Mental Health and Wellbeing for People with Disability January 2016
Findings
related to
auditory
hallucinations
Improvement in
symptoms related
to depression,
increase in
positive feelings
about the self,
and a reduction in
automatic
negative
thoughts.
Decrease in
symptoms of
depression.
Decrease in
symptoms of
depression,
anxiety and
distress. Not
maintained at
follow up.
Reduction in
hoarding
behaviour as
measured by selfreport and
environmental
assessment.
Decrease in
symptoms of
depression,
reduction in
behaviour
problems,
improvements in
their ability to
understand the
links between
events, thoughts
and emotions.
Reduction in
anxiety
26
Recent
Research
Presenting
Issue
anxiety,
obsessional
anxiety, phobia,
anxiety and
depression,
anxiety and
autism,
suspicion,
generalized
anxiety)
Design and Participants
Findings
session was 1 hour
duration.
All participants had a mild
intellectual disability.
symptomatology.
Eye Movement Desensitisation and Reprocessing (EMDR)
Recent
Presenting
Design and Participants
Research
Issue
Barrrowcliff,
Post traumatic
Participants diagnosed
Evans, & Gemma stress disorder
with a mod-severe
(2015)
intellectual disability.
Series of preparatory
meetings and 4 sessions
of EMDR.
Mevissen,
Psychological
Participants diagnosed
Lievegoed,
trauma
with a moderate
Seubert, & De
intellectual disability.
Jongh (2011)
8 phase protocol of
EMDR.
Dialectical Behaviour Therapy (DBT)
Recent
Presenting
Research
Issue
Lew, Matta,
Risk taking
Tripp-Tebo &
behaviour
Watts (2006)
Sakdalan, Shaw
& Collier (2010)
Forensic group
with history of
violent crimes,
behavioural and
emotional
Findings
Reduction in most
symptoms related to
post traumatic
stress disorder.
Post traumatic
symptoms
decreased in all
cases.
Design and Participants
Findings
Participants were all
female, diagnosed with a
mild to moderate
intellectual disability, and
with co-occurring
diagnoses such as
depression or personality
disorder.
Individual and group
program.
13 week group treatment
program, not
supplemented by
individual treatment.
Reduction in risk
taking behaviour
Mental Health and Wellbeing for People with Disability January 2016
Significant
improvements in
dynamic risks,
relative strengths,
coping skills and
27
Recent
Research
Brown, Brown, &
Dibiasio (2013)
Presenting
Issue
dysregulation.
Behavioural
disturbance
such as self
harm,
aggression,
sexual
offending.
Psychodynamic Psychotherapy
Recent
Presenting
Research
Issue
Beail, Warden,
The 20
Morsley, &
participants had
Newman (2004)
a range of
presenting
issues,
including:
aggression,
inappropriate
sexual
behaviour,
psychotic/
bizarre
behaviour, self
injury,
depression,
relationship
difficulties,
bulimia, and
OCD.
Behavioural Activation
Recent
Presenting
Research
Issue
Jahoda, Melville, Depression
Design and Participants
Standard individual DBT
program plus Skills
System DBT-SS.
Wide spectrum of
cognitive abilities (mild,
moderate, borderline and
average IQ).
Wide range of cooccurring diagnoses
including personality
disorder, conduct
disorder, psychosis,
PTSD, depression,
anxiety, pedophilia, etc.
Findings
global functioning.
Reductions in
behaviour of
concern including
aggression, selfinjury, sexual
offending, etc.
Design and Participants
Findings
Weekly sessions (50
minutes). The number of
sessions varied, from 548, with a mean of 13.2
sessions. Level of
intellectual disability not
reported.
Significant reduction
in psychological
distress and
interpersonal
problems; and an
increase in selfesteem.
Design and Participants
Findings
10-12 weekly or
Reduction in
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28
Recent
Research
Pert, Cooper,
Lynn, Williams, &
Davidson (2015)
Presenting
Issue
Design and Participants
Findings
fortnightly sessions.
Majority of participants
had a mild intellectual
disability, though some
participants had
moderate or severe
intellectual disability.
depressive
symptoms.
Adapting traditional treatment therapies for people with intellectual disability
A range of adaptations to the implementation of therapies for people with
intellectual disability have been suggested in the literature, and these are
summarised below:

involving direct support workers (or families) to assist with generalisation
of skills across situations and to assist in skill maintenance (Kroese et al.
2014)

incorporating role play into the sessions to reduce confusion related to
deficits in abstract thinking (Allt et al. 1997)

increasing opportunities for the participant to practice their new skills in a
group setting (Marwood & Hewitt, 2012).

encouraging the person with intellectual disability to bring a support person
into the sessions to assist in practicing skills (Marwood & Hewitt, 2012)

the use of visual aids (McNair, Woodrow & Hare, 2015)

simplified language and concepts (McNair, Woodrow & Hare, 2015)

consider seating positions and the potential for postural issues (Hagiliassis
et al. 2006)

flexibility in number and duration of sessions (Hagiliassis et al. 2006).
6.2 Person centred treatment planning
The American Psychological Association & Jansen (2014) developed a guide
for psychologists in developing a person-centred [treatment] plan, to be
implemented as part of the recovery process for those in the general
population affected by mental ill-health. It was largely based on the literature
regarding person-centred planning in individuals with intellectual disability.
The emphasis is on ensuring the individual is involved in all aspects of
treatment planning, including identification of goals, objectives, interventions
and evaluations. It is suggested that the goals identified are those that build
on an individual’s existing strengths and encompass their values.
The objectives are the steps required to assist the individual to reach their
goal/s. Interventions are the actions others will take to support the individual
Mental Health and Wellbeing for People with Disability January 2016
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to attain their objectives and goals. There should be regular reviews of the
person’s progress and the plan should be updated accordingly.
The following sample template is provided to assist psychologists in their
treatment planning, below.
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[name]- INDIVIDUAL TREATMENT PLAN
Recipient Information
Provider Information
Name:
Name:
Address:
Designation:
DOB:
Agency:
Identification Number:
Date of Treatment Plan:
Other Agencies Involved
Plan to Coordinate Services
Background to the Treatment Plan
e.g. history of the presenting issue, strengths, formal diagnoses, reason for
seeking assistance, existing coping strategies, etc.
Presenting Issue 1:
Long term goal/s:
Short term goal/s or objectives:
Date achieved or progress
towards goal attainment:
Interventions/actions taken:
Summary of Progress:
Presenting Issue 2:
Long term goal/s:
Short term goal/s or objectives:
Date achieved or progress
towards goal attainment:
Interventions/actions taken:
Summary of Progress:
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6.3 Improving social and economic circumstances
It is generally not the role of the psychologist to provide services that are likely
to directly impact on an individual’s access to their support network or
economic circumstances. Psychologists may have an indirect role in this by
supporting the individual to develop interpersonal and intrapersonal skills
which may increase their opportunities.
The Ageing, Disability and Home Care (ADHC) Lifestyle Planning Policy and
Lifestyle Planning Guide (March 2011; amended August 2012) are two key
documents that provide detailed information regarding the process of
supporting an individual to achieve their preferred lifestyle. This includes
supporting the individual in recognising and building on their strengths,
developing a vision of what they would like their life to be like, setting goals for
the future, making decisions, and developing action plans.
The aim is to promote the principles of social inclusion, self determination and
shared commitment. It is important that this process includes avenues for
individuals to access their social support network, and to enhance the quality
of the support provided. Psychologists may provide some clinical input into
the Lifestyle Planning process, either directly with the individual or indirectly
through the surrounding support system, and when doing so they should
consider the following factors:
6.3.1 Social support network:
Research suggests that individuals with intellectual disability often have
smaller social networks and it often consists of family members, paid support
workers (approximately 40% of the network), and other people with
intellectual disability (Duggan & Linehan, 2013).
Further, this outcome has remained fairly consistent over time despite the
shift away from institutionalisation decades ago. Older adults with are likely to
have a smaller social network than younger people with intellectual disability.
People with intellectual disability have reported that services and families
often neglect to provide the support that is required to maintain their existing
friendships (McVilly et al. 2006b). In addition, several barriers to social
inclusion have been noted by people with intellectual disability including:

greater staff focus on care tasks rather than tasks related to promoting
social inclusion

lack of interpersonal skills/knowledge

the location and layout of group homes preventing contact with their
neighbours.
Staff members play an important role in building support networks for people
with intellectual disability. Direct support workers, psychologists and one
social worker were interviewed to determine the types of interventions that
strengthen existing relationships, and those that help in expanding social
networks (van Asselt-Goverts, Embregts, Hendricks, & Frielink, 2013). Their
findings are summarised in Table 3 below.
Mental Health and Wellbeing for People with Disability January 2016
32
Psychologists and other clinicians supporting individuals with intellectual
disability may be in a position to provide some of these interventions directly,
or they may provide guidance to other staff (e.g. accommodation managers)
to ensure a greater focus is placed on maintaining, building and strengthening
the individual’s support system.
Interventions to strengthen social
networks
Encourage the person with
intellectual disability to utilise their
network more often
Discuss disturbances
Attend to maintenance of network
Teach social skills
Share and exchange information
Provide psycho-education
Restore contact
Inform network members of their
importance
Support network members
Interventions to expand
social networks
Encourage the person to
increase involvement in leisure
activities
Joint activities
Encourage internet use
Education/work options
Facilitate access to volunteer
work
Be of service to others
No internal specialised care
Teach social skills
Create opportunities for the
person to meet others
Mention positive things
Map social networks
Show interest
Discuss differences in opinion
Contact professionals of network
members
Table 3: Interventions to expand and strengthen social networks for people with intellectual
disability (van Asselt-Goverts et al. 2013)
6.3.2 Positive family interaction
Families of people with intellectual disability are at higher risk of
discrimination, socio-economic disadvantage, prolonged engagement in tasks
related to the caring role, and complicated interactions with disability services.
Family well-being is more likely to be compromised when the individual with
intellectual disability has greater levels of maladaptive behaviour.
Mothers of children with intellectual disability may experience greater levels of
stress, higher parenting demands, and reduced physical and psychological
health compared to mothers without a child with intellectual disability. Siblings
often move into the caring role later on as their parents become older
(Families Special Interest group of IASSIDD, 2014).
Fredman (2014) drew from systemic, constructionist and narrative
approaches in supporting efforts to bring families, practitioners, and
communities together for individuals in mainstream mental health services.
The author created opportunities for therapeutic intervention and future
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33
planning through the introduction of ‘network meetings’, featuring key
individuals in the referred person’s social network. The practitioner’s involved
reported increased engagement with families and more clarity around how to
progress their work.
The underlying aim of the network meetings was to increase communication
between stakeholders and to enhance relationships, through enabling all
participants to feel listened to and understood. A distinction is made between
the ‘host’ and ‘conductor’ of the meetings, with the conductors taking the
position as peer, that is, a ‘decentered yet influential’ position. This approach
assists practitioners to maintain the focus on the client and reduces the
likelihood of bias (White, 2000a).
Preparation for the meeting includes consideration of the likely emotional
responses of family members prior to arrival by ‘stepping into their shoes’. An
ideal atmosphere is created by consideration of the most appropriate seating
positions. The meeting is introduced using the terms ‘respect’ and ‘comfort’ to
set the emotional context e.g. ‘We have been arranging how we sit so you
both can feel comfortable and respected by us all. Can you let me know if this
arrangement suits you?’ (Fredman, 2014, p.61).
Fredman (2014) then goes on to describe how the meeting is conducted with
an emphasis on strengths and abilities (of all participants), an avoidance of
laying blame or attribution for perceived problems on any individual, and
appreciating the available resources within the network. A reflective technique
known as outsider witnessing is used to promote shared knowledge and
understanding of challenges and opportunities.
White (2000a) described four steps to the witnessing technique:

‘identifying the expression’ – the practitioner (witness) provides comment
on statements that were made which resonated with them or ‘struck a
chord’

‘describing the image’ – the practitioner makes links between the
statements made and the underlying values, beliefs, purposes, hopes,
dreams, and commitments

‘embodying responses’ – the practitioner expresses their own personal or
professional experiences that align with statements or images of the other
participants

‘acknowledging transport’ – the practitioner comments on where the
process has ‘taken’ them, that is, what they have learnt or how they have
changed as a result of what they have heard.
Psychologists supporting individuals with intellectual disability may consider
using a similar process to enhance the interactions between their clients and
those in their surrounding network.
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34
6.3.4 Sense of achievement in academic or vocational pursuits
‘Employment, like all aspects of human life, can be affected by social
devaluation.’ (Tyree, Kendrick & Block, 2011, p. 198). In line with the principle
of social inclusion, it is important that individuals with intellectual disability are
provided with training and employment opportunities, and to achieve the
social role of ‘valued employee’. Tyree et al. (2011) made a number of
recommendations in relation to improving supported employment for people
with intellectual disability, these included:

providing genuine choice from a selection of valued options

employee is not the only valued social role the individual can attain, and
efforts can be directed towards attaining other valued roles such as
coworker, mentor, confidante, and friend

acknowledging the individual’s vulnerability but not avoiding valued adult
roles, opportunities for the person to contribute, and providing
encouragement for building a life that is personally meaningful

staff to align themselves with jobseekers and having a clear purpose,
whilst recognising that there may be challenges along the way.
6.4 Environmental factors
6.4.1 Access to services
The rights for people with intellectual disability to have access to the same
health services as the general population is now being increasingly
recognised, in line with the United Nations Convention on the Rights of
Persons with Disabilities (2006).
Ensuring that individuals with intellectual disability can not only access
services, but also receive services of a high quality that aligns with their
support needs may be a more complex issue.
Garwick et al. (1998) surveyed parents of 124 adolescents with a chronic
disorder and found that emotional and tangible support was most likely to
arise from other family members, whereas helpful information generally came
from health professionals. It was also identified that around one third of
unsupportive behaviour came from health professionals, and another one
third arose from the general community and school providers (the final one
third arose from family members).
Unsupportive behaviour from providers included: rudeness and insensitivity;
negative attitudes toward the child or family; lack of information; inadequate
services or referrals; and insufficient treatment for the child.
Sloper (1999) identified that many parents of a child with disability have unmet
needs including information and advice about services, diagnoses, ways to
support the child, support with transport and housing, and respite from care. It
is not only important that individuals are able to access the services that they
require, but that those services are responsive, validating, and tailor support
to individual and family needs.
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35
Psychologists may support this process through the development of strong
communication channels with the individual with intellectual disability, family
members and/or other key support persons, and other service providers. It is
particularly important that psychologists work closely with mental health
services, treating psychiatrists and other allied health professionals where
they are involved, and where the individual and/or family provides consent for
exchange of information.
Close collaboration ensures that a person centred approach is implemented,
service expectations and treatment goals are well defined and aligned, and
that all individuals are up to date regarding progress toward goals.
6.4.2 Social integration/inclusion
Psychologists can support social integration and social inclusion directly
through the development of social and interpersonal skills (see Section 5.1.1,
above) and by supporting the individual to access and build upon their social
network (see Section 5.3.1, above).
6.4.3 Physical safety and feeling secure
People with intellectual disability are at increased risk of physical and sexual
abuse and neglect (van der Put, Asscher, Wissink, & Stams, 2014). Children
with disability in out of home care are more likely to be victims of sexual
abuse than those without disability (Euser et al. 2016). Individuals with
intellectual disability and co-occurring mental disorders are up to four times
more likely to experience violence (Mikton, Maguire, & Shakespeare, 2014).
The World Health Organization (2013) identified the main types of
interpersonal violence: child maltreatment, youth violence, intimate partner
violence, sexual violence, and elder maltreatment. The NSW Disability
Inclusion Act 2014 emphasises that individuals with intellectual disability have
the right to live free from abuse, neglect and harm. Additional safeguards
were implemented in order to promote safety for people with intellectual
disability, including tighter employment screening and changes to reporting
serious incidents of abuse and neglect.
6.5 Standardised outcome measures of well-being
The use of standardised measures to assess client progress is an important
aspect of the therapeutic intervention carried out by psychologists.
Standardised measures are not only considered to be useful for the
psychologist but also for the person receiving support. Further, outcome
measures ensure accountability; can provide an additional layer to support the
findings arising from clinical judgment about the individual’s progress; and
when used to make decisions about treatment direction they can improve the
service and reduce the risk that treatment will be ineffective (Hatfield & Ogles,
2004; Holt et al. 2015). It should be noted that the use of standardised
measures is considered to be an ethical obligation (Clement, 1994).
Mental Health and Wellbeing for People with Disability January 2016
36
Psychologists should ensure they choose outcome measures that have
demonstrated validity and reliability for the relevant population, in this case,
people with intellectual disability. Psychologists also need to ensure that the
outcome measures selected will provide data that is relevant to the
intervention they are carrying out (Hatfield & Ogles, 2004).
A list of standardised tools used as outcome measures in recent research for
people with intellectual disability is included below. Please note that this is not
an exhaustive list.
Outcome measures for adults:
Social Construct
Emotional
Intelligence
Happiness
Life Satisfaction
Affect
Quality of Life
Anxiety
Global functioning
Self-esteem
Negative evaluations
/ world view
Measurement Tool
Wong and Law
Emotional Intelligence
Scale
(WLEIS, Wong & Law,
2002)
Subjective Happiness
Scale (SHS)
(Lyubomirsky & Lepper,
1999)
Satisfaction with Life
Scale
(Diener et al, 1985)
Positive and Negative
Affect Scale (PANAS)
(Watson et al. 1988)
Quality of Life Scale
(Andrews & Withey,
1976)
Glasgow Anxiety Scale
for people with an
Intellectual Disability
(GAS-ID)
(Mindham & Espie,
2003)
Health of the Nation
Outcome scale-Learning
Disability Version
(HoNOS-LD) (Roy et al.
2002).
Adapted six-item
Rosenberg Self-Esteem
Scale (used in Johnson,
2012).
Adapted Evaluative
Beliefs Scale (Chadwick
et al. 1999)
Description
16 items self-rated on a
5 point scale.
Four items rated on a 7point Likert scale.
5 self-referencing
statements.
Two 10-item mood
scales.
One item only, rated on
a 5-point Likert scale.
27 items, self-rated on a
3-point Likert scale.
18 items, self reported
on a 5-point scale.
6 items, self report.
18 items, self report.
Mental Health and Wellbeing for People with Disability January 2016
37
Social Construct
Comparisons of self
to others
Depression
Distress
Behaviour and
emotional difficulties
Measurement Tool
Social Comparison
Scale (Allan & Gilbert,
1995)
(Adapted by Dagnan &
Sandhu, 1999)
Beck Depression
Inventory – II (BDI-II),
(Beck, Steer, & Brown,
1996)
Symptom Checklist-90 –
Revised (SCL-90-R;
Derogatis, 1983)
Developmental
Behaviour Checklist –
Adult version
(DBC-A; Einfeld &
Tonge, 1992, 2002)
Description
11 items, self report.
21 items, self report, for
individuals 13 years
plus.
90-items on a 5-point
rating scale, for ages 13
years plus.
107 item questionnaire
rated by parents or
carers, using scores of
0, 1 or 2.
Table 4: Outcome measures validated for adults with intellectual disability.
Outcome Measures for children and young persons:
Social Construct
Measurement Tool
Description
Resiliency (strengths
and vulnerabilities)
Resiliency Scales for
Children and
Adolescents (RSCA)
(Prince-Embury, 2007).
64 items self-reported
on a 5-point scale, for
children 9-18 years.
Resiliency (strengths
and difficulties)
i.e. hyperactivity,
emotions, friendship
difficulties, conduct
problems, pro-social
behaviour
Strengths and
Difficulties
Questionnaire (SDQ;
short-version)
(Goodman, 1997).
Anxiety
Mood
Mood
Revised Children’s
Manifest Anxiety Scale:
Second Edition
(RCMAS-2). (Reynolds
& Richmond, 2008).
Intellectual disability
Mood Scale (IDMS)
Argus, Terry, Bramston,
& Dinsdale, 2004).
Moods and Feelings
Questionnaire (Short
form) (MAF) (Angold et
al, 1995).
25-items, self report.
37 items, self report, for
children 6-19 years.
12 item, self report on a
5-point scale.
13 items self reported
on a 3-point scale, for
children 8-18 years.
Mental Health and Wellbeing for People with Disability January 2016
38
Social Construct
Behaviour and
emotional
disturbances
Distress
Depression
Measurement Tool
Description
Developmental
Behaviour Checklist
(DBC)
(Multiple versions
including a parent
version, teacher
version)
(Einfeld & Tonge, 1992,
2002)
Symptom Checklist-90 –
Revised (SCL-90-R;
Derogatis, 1983).
Beck Depression
Inventory – II (BDI-II),
Beck (1996)
96-items (or 24 in the
short version),
completed by parent,
carer or teacher, for
children with intellectual
disability or
developmental
disabilities, 4-18 years
of age.
90-items on a 5-point
rating scale, for ages 13
years plus.
21 items self reported
for individuals 13 years
plus.
Table 5: Outcome measure validated for children with intellectual disability.
Mental Health and Wellbeing for People with Disability January 2016
39
7
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