Cognitive behavioural therapy (CBT) is a treatment approach that is based on the concept that the way we think affects the way we respond (O’Sullivan, Ryan & MacDonald, 2003). CBT aims to change unhelpful thoughts or cognitive processes to more helpful thought processes, allowing the client to create positive change emotionally, physiologically and behaviourally.
CBT theory holds that negative thoughts and beliefs can play a role in developing or exacerbating depression, anxiety, anger, low self-esteem, self-defeating behaviours and difficulty with coping. Therefore, CBT works to identify negative beliefs and challenge them, ultimately replacing them with more helpful, realistic beliefs that enhance the client’s ability to cope in everyday life situations (O’Sullivan, Ryan & MacDonald, 2003).
Historically, people with intellectual disability have been thought to lack the ‘cognitive abilities to understand or benefit from CBT’ (Taylor, Lindsay & Willner, 2008). However, using CBT approaches with this group is becoming more widely accepted and recent studies show its effectiveness in treating people with intellectual disability in areas such as anger management, depression, sex offending, victims of crime, and anxiety among others (Hayes, 2007 discusses several relevant studies). Despite promising results from a number of studies, the area is still relatively under-researched and rigorous studies with control groups are few.
Introduction to Cognitive Behaviour Therapy
Example of Cognitive Behaviour Therapy
About Cognitive Behaviour Therapy with counsellor Christine Douglas
Complementary skills and strategies
The CBT treatments that are most supported in the literature incorporate non-cognitive strategies (McClure, Halpern, Wolper & Donahue, 2009). Research suggests that CBT can be most effective when used in conjunction with other skills and strategies, including:
- Mindfulness techniques (Singh, Whaler, Adkins & Myers, 2003)
- Relaxation techniques including massage (Sau-Lai & Hing-Min, 2011)
- Imagery rehearsal therapy (Stenfert Kroese & Thomas, 2006) _ Problem solving and assertiveness training (Anderson & Kazantzis, 2008; Nezu, Nezu & Arean, 1991).
Intellectual disability and CBT
Research suggests that clients with intellectual disability need the following attributes, at least to some degree, for CBT to be an appropriate method of therapy (Haddock & Jones, 2006; Willner et al., in Hayes, 2007):
- Verbal IQ and verbal ability in general
- Capacity to recognise and label emotions
- Ability to differentiate between thoughts, feelings and behaviours
- Ability to link emotions and events
- Ability to express emotions
- Motivation to engage.
The client does not need to possess all of these attributes before commencing CBT. Part of the therapeutic process is to assist the client to recognise and label emotions, express emotions and differentiate between thoughts, feelings and behaviours.
Recognising emotional states is an important part of learning coping skills. It is important to remember that, even though individuals with intellectual disability may have trouble accurately labelling emotional states, they discriminate between pleasant and unpleasant emotions in exactly the same way as people without cognitive impairment (McClure, Halpern, Solper & Donahue, 2009). In general, people with mild or moderate intellectual disability can also recognise and accurately label facial expressions in others and will improve this skill with training.
Lived experience and CBT
The client’s lived experience and context needs to be carefully considered when engaging in any kind of CBT with a client with intellectual disability. People with intellectual disability often experience powerlessness and can experience hostile environments in their day-today lives. Given this reality, it can be unrealistic to expect change by concentrating solely on individual coping strategies. This is particularly the case when the client’s environments are causing or significantly contributing to their emotional states and behaviour (Mirow, 2008).
Adapting CBT for people with intellectual disability
It may be relevant to adapt CBT in some of the following ways to suit the communication needs of clients with intellectual disability (Haddock & Jones, 2006; Mirow, 2008; Willner & Goodey, 2006):
- Assess the client’s suitability for CBT by assessing their abilities and needs in the therapeutic context (expressive/receptive communication skills)
- Concretise abstract and conceptual tasks – provide a grounding and linking of conceptual thought in a way that is meaningful for the client (perhaps by using real-life situations). Clients may find it difficult to imagine hypothetical situations
- Incorporate ‘teaching’ elements, such as how to identify an emotion, how the body responds to emotion, and so on
- Use visual aids
- Adapt tools and techniques so that minimal or no literacy is required
- Simplify tasks – for example, reduce the complexity of a technique, break the intervention into smaller chunks and adjust sessions to be shorter or longe
- Simplify language – for example, reduce the complexity of vocabulary and sentence structure, reduce the length of thoughts and explanations, and use short sentences and simple words
- Use concrete activities – such as drawings, games or activities to practise at home (these can create a more comprehensive learning experience)
- Use flexibility and persistence – accept that progress may be slow and that some things will take longer than you expect. If something isn’t working, be prepared to try a new approach. Be creative
- Repeat concepts and check understanding – be prepared to go over the same material and check the client’s understanding many times within sessions and over the course of the therapy
- Include support people – more support is likely to be needed initially, especially with homework tasks, repeating information, and reinforcing learning between sessions
- Be aware of possible client acquiescence and problems with questioning styles (for example, open versus closed questions), due to CBT’s reliance on verbal IQ and verbal ability (for more information, see the section ‘Questioning’)
- Think about how the client may respond to the term ‘homework’ – many people with intellectual disability have had difficult educational backgrounds.
There is evidence in the research to support the value of involving carers and other support people to help clients to transfer the skills learnt in therapy into real life (Willner, Brace & Phillips, 2005). (For more information, see the section ‘Working well with carers and supporters’.)