Increasingly, services need to demonstrate their effectiveness and measuring quantitative change in symptoms, distress, or other measures of wellbeing is one of the best ways of showing that to commissioners. However, historically, people with learning disabilities have been excluded from trials of mainstream psychological therapies.
Often researchers claim that as a group, people with learning disabilities are too diverse, so no meaningful, reliable, replicable data can be gathered from these studies. It can also be difficult to effectively develop evidence based therapies for people with learning disabilities, because each individual client may need the therapy to be adapted significantly to meet their needs or abilities. So people with learning disabilities can be disenfranchised from a lack of large-scale research into psychological therapies.
This is of particular concern because repeated studies have suggested that the prevalence of emotional difficulties in people with learning disabilities is at least consistent with data from the general population at between 4% and 8%.
As an aside, it should be noted that there is extensive research into investigating the effectiveness of treatment for anger in people with learning disabilities. This raises questions about the priorities of people who refer into clinical services. It is possible that the expression of anger could be more of a ‘problem’ for services or families of people with learning disabilities, but the lived experience of other emotional difficulties may not be so visible, or so anxiety provoking for others.
Cognitive behavioural therapy (CBT) is one of the interventions that can be used to address emotional difficulties and in mainstream research, there is an extensive body of research demonstrating the effectiveness of CBT for a variety of emotional issues. There have been several clinical case studies published that used CBT for depression and anxiety.
However, not including the current paper, there have only been three controlled treatment trials of CBT in people with learning disabilities with emotional difficulties other than anger. Two of these studies reported positive results for CBT treatment, while the third did not. However, in the third study, while the people delivering the therapy were trained CBT therapists, it was unclear whether they had any skills or experience in working with people with learning disabilities.
Therefore, in order to address this gap in the research literature, Lindsay et al (2014) developed and piloted a trans-diagnostic treatment for CBT in people with learning disabilities. Trans-diagnostic treatment refers to a therapy approach that applies the same underlying treatment principles across mental health diagnoses, therefore not tailoring the therapy to specific diagnoses.
The participants from the study were drawn from two different services. Twelve treatment participants were drawn from a private hospital setting and a community residential setting for people with a learning disability. The control group consisted of 12 people who were referred to a clinical psychology department which worked with community and inpatient learning disability services. The control group were retrospectively selected by a graduate psychologist, blind to the nature of the study and they received ‘treatment as usual’, not including CBT.
All of the participants had a mild learning disability and were admitted for emotional difficulties, excluding psychotic disorder (including anxiety, depression, mixed anxiety and depression, pathological jealousy, interpersonal conflict, bereavement with anxiety and depression and previous experience of sexual abuse, with current anxiety and depression).
All participants were assessed on: the Global Severity index (GSI) of the Brief Symptom Inventory (BSI), The Glasgow Anxiety Scale (GAS-ID) and Glasgow Depression Scale (GDS-ID).
The treatment was conducted weekly by three primary therapists, one of whom was a senior psychologist with experience in CBT and two assistant psychologists under supervision from the senior psychologist. Treatment lasted between 8-14 sessions, but this variation in treatment length, or how the different number of sessions may have affected the outcomes was not discussed further in the paper.
When developing the CBT treatment manual that was used in the current research, the authors retained the essential principles and components of CBT:
- Increasing emotional awareness
- Facilitating flexibility in thinking patterns
- Identifying and preventing avoidance of behaviours and emotions
- Exposure to emotional cues
The treatment manual comprised of five modules:
- Assessing whether the client could use the CBT approach
- Preparing the client to use CBT and promoting their ability to engage with the work, including identifying a key family member or carer to support the client outside of sessions
- Helping the client understand the links between thoughts, feelings and behaviour using a variety of learning methods, including role play and discussing relevant situations
- Developing a shared understanding of the person’s difficulties, why they developed and how they are being maintained and using this to form the intervention and achieve therapy goals.
- Relapse prevention and promoting resilience
Large effects were found in favour of the CBT treatment group for the BSI outcome scores on the GSI. This suggests that the severity of the distress and symptoms experienced by people who received the treatment reduced compared to the control group. Reductions were also found in the scores of specific measures of anxiety and depression.
The results also indicated statistically significant reductions in self-reported anxiety and depression and carer-reported depression after treatment compared to before treatment.
In addition, there were no statistically significant changes in the GAS-ID or the GDS scores, suggesting that treatment gains maintained three to six months after treatment.
Strengths and limitations
Overall, this is an interesting pilot study, which could act as an invitation for others to use a trans-diagnostic CBT approach. However, as is the case with many pilot studies, there are some major limitations. The authors were thoughtful about these limitations, including drawing control and treatment participants from different populations.
As the authors acknowledge, the treatment group were more distressed than the control group, which may well be expected given that those participants were distressed enough to require residential or inpatient services. In addition, it is different working with people who are living on the same site as where the therapy takes place, so there may not be as many barriers to accessing the therapy, compared to community settings, where people may not always be supported to attend their sessions. Therefore, these findings may not be applicable to community settings.
In addition, the authors acknowledged that they had no data on how well the therapists who delivered the treatment adhered to the manual or how therapeutic alliance or medication regimes may have affected the change found in clients. It would have been useful to present data on how the results from participants who received therapy from the qualified clinical psychologist may have differed from those of the assistant psychologists.
Furthermore, given that the all participants’ (across the control and treatment groups) medication may have been changed, added to or discontinued, without controlling for this in the analysis, it is difficult to say for sure whether the changes found were as a result of the transdiagnostic CBT.
The authors also did not mention whether the participants in the trial had a diagnosis of an autistic spectrum disorder (ASD). Given that some people with ASD may struggle to generalise knowledge learned from one experience and use it in another, it would have been interesting to know whether the authors considered that trans-diagnostic CBT could also benefit people with ASD. Perhaps it may be beneficial to assess people to see whether they can use CBT before starting the intervention. I would have also appreciated an acknowledgement of how the researchers went about obtaining informed consent from the participants, especially as some of the participants in the treatment group were in a ward setting and implicit power dynamics may have potentially affected the participants’ ability to decline being involved in the research.
Nevertheless, given the real dearth of controlled trials for all types of psychological therapies for people with learning disabilities, the authors should be applauded for conducting this preliminary study, which leaves room for more robust and powerful studies to build on this research.
In addition, I consider that the use of trans-diagnostic CBT is an interesting and potentially very useful clinical approach, and a useful way forward for clinicians to work with people who may have overlapping or multiple emotional difficulties.
It was also very useful to complete follow up measures on the last therapy session and again three to six months after the end of treatment, to see whether the gains achieved in therapy resulted in longer term, sustained change.
One of the most exciting things about being a therapist working with people with learning disabilities is that we are not constrained by manualised approaches, because we have to adapt the therapy to meet the needs and abilities of the individual client. However, the lack of a robust evidence base for psychological therapies for people with learning disabilities can leave our client group vulnerable in terms of practitioners using therapies developed for use in mainstream populations that may be ineffective at best, or potentially harmful, at worst.
This research highlights the potential value and efficacy of using a trans-diagnostic model of CBT for people with learning disabilities. Given that there may well not be a clear distinction between presenting issues in people with learning disabilities, this current research gives a promising way of helping people with learning disabilities learn skills that are transferable to other areas of their lives.
Lindsay, W. R., Tinsley, S., Beail, N., Hastings, R. P., Jahoda, A., Taylor, J. L. and Hatton, C. (2015), A preliminary controlled trial of a trans-diagnostic programme for cognitive behaviour therapy with adults with intellectual disability. Journal of Intellectual Disability Research, 59: 360–369 [abstract]