It is often thought that people with intellectual disability cannot participate fully in (and therefore gain full benefit from) counselling and psychotherapy, due to difficulties with verbal expression and communication. Success in therapy is typically seen to rely on the client’s ability to verbally express and reflect on their story or their life narrative. The self-reporting of a person’s narrative in counselling is also expected to be directly presented and grounded in fact (that is, actually reflecting their direct experience) (Upton, 2009).
Many people with intellectual disability have difficulty expressing their narratives verbally – due to poor memory, difficulty with sequencing and understanding the causal relationship between thoughts and behaviour, and difficulty in naming their emotional and subjective states. Direct communication of highly traumatic experiences is also extremely challenging (if not impossible) for many individuals (Upton, 2009).
Despite these difficulties, people with intellectual disability have great capacity to express their story. The real issue is not that individuals cannot express their narrative, but that therapists’ rigid expectations of the way this is done make it seem difficult or even impossible. Clients with intellectual disability can express their life stories, experiences, and subjective and emotional states, if supported to do so in a way that suits their communication ability and style.
Every person, regardless of their verbal communication ability, has a vast array of communication tools at their disposal. It is the counsellor’s responsibility to find what works for each individual. The analogy of working with a person from another cultural background can be useful: when a counsellor begins to work with a person from a different language and cultural background, they assess the person’s communication ability and any other factors that influence the telling of their narrative, and then adapt the counselling practice accordingly. The same principle should be applied when working with clients with intellectual disability. If counsellors have a responsibility to work appropriately and sensitively with their client’s cultural background, they have the same responsibility to adapt their practice to accommodate the communication needs of clients with a disability. As Upton (2006) notes:
Psychotherapists need to be open and sensitive to the vast array of expressive means that these clients already have at their disposal, and be willing to enter into an encounter where that expression can be nurtured and heard as meaningful articulations of their lived experience. (Upton, 2006, pp. 32)
Creative techniques and the use of non-verbal or indirect communication can be crucial in overcoming the communication problems of people with intellectual disability and achieving positive outcomes in therapy (Upton, 2009).
There are two broad categories of creative expression that can be used to help clients with intellectual disability to tell their story (Upton, 2009): embodied expression and projected expression.
Embodied expression includes:
- Whole-person movement
- Dancing and music
- Acting, characterisation, masks and role play
- Embodied games.
Projected expression includes:
- Drama to express the person’s story through an external character
- Art, such as painting and drawing
- Sand tray with symbols
- Written stories and poetry.
In using these creative expression techniques, it is important to define where the creative narrative will take place – either involving the whole person (where the client uses their whole body or mind to describe or show their story), or projected onto something other (where the client uses other mechanisms such as symbols or toys to act out the narrative) (Upton, 2009). These techniques of embodied and projected expression can be of great benefit for clients with intellectual disability because the techniques:
- Are not dependent on verbal communication
- Allow for indirect communication
- Work with imagined and/or factual narratives.
The embodied and projected expression techniques allow for a self expression that matches the client’s ability emotionally and cognitively, while still enabling the client to express their lived experience (for further detail see Upton, 2009). (For more information about using creative practices in therapy, see the sections ‘Exploring feelings through art’, ‘Narrative therapy’, ‘Sand tray therapy’, and ‘Art work therapy’.)