Assessment of cognitive therapy skills for people with learning disabilities

Adapting cognitive behaviour therapy for people with intellectual disabilities: an overview for therapist working in mainstream or specialist services

This paper is an introduction to adaptations to make cognitive behaviour therapy (CBT) more accessible to people with intellectual disabilities. It is intended to inform therapists who may work with people with intellectual disabilities in mainstream services.

The paper describes adaptations that consider neuropsychological processes, such as memory, and executive functions, such as planning, problem solving and self-regulation, and identifies that these factors are not unique to people with intellectual disabilities. We describe adaptations based on a review of literature describing CBT for people with intellectual disabilities (Surley and Dagnan, 2019) and draw on clinical experience to give examples of adaptations where possible. The paper particularly emphasises the generalisability of adaptations used with people with intellectual disabilities to therapy with wider populations and suggests that CBT therapists working in mainstream services will have the skills to be able to adapt therapy for people with intellectual disabilities.

Key learning aims

(1)

Role of anxiety, depression and neurocognition for cognitive behavioural therapy pre-therapy skills in people living with dementia, older and younger adults✰

BACKGROUND

Anxiety and depression are common in people living with dementia (PLWD) and Cognitive behavioural therapy (CBT) seems to be one of the few efficacious interventions. However, PLWD's ability to engage with CBT has been questioned due to the presumed impact of neurocognitive impairment on core skills necessary to engage with CBT (pre-therapy skills). Here, we (i) compare CBT pre-therapy skills in PLWD to older and younger adults (OA, YA), (ii) examine potential confounders and mediators and (iii) explore associations of neurocognition, anxiety and depression with pre-therapy skills in PLWD.

METHODS

Pre-therapy skills were compared between PLWD (n = 102), OA (n = 77) and YA (n = 56). Structural equation modelling was used to assess mediators and confounders of differences in pre-therapy skills between groups. Spearman's rank correlations were used to examine the relationship of pre-therapy skills with neurocognition and mood in PLWD.

RESULTS

Group differences in pre-therapy skills were found, following the pattern YA>OA>PLWD. Neurocognition mediated the difference between OA and PLWD. In PLWD, language was associated with performance on all skills. There was little evidence that anxiety or depression contributed to variability in skill performance within PLWD.

LIMITATIONS

Cross-sectional design limited ability to ascertain cause and effect. Pre-therapy skill measures have not been used in the context of actual CBT; consequently, their relationship with CBT outcomes needs to be established.

CONCLUSIONS

PLWD may have a relative difficulty in CBT pre-therapy skills. Yet, there seems to be substantial variability of skill level, independent of mood. Therefore, mild dementia does not necessarily preclude CBT readiness.

Thought-feeling discrimination in people with dementia: adaptation and preliminary validation of the first dementia-specific measure

OBJECTIVE

There is emerging evidence that cognitive behavioral therapy (CBT) can be effective for treating anxiety and depression in people living with dementia (PLWD). Discriminating between thoughts and feelings is a critical element of CBT and also of relevance to emotional understanding more generally. The aim of the present study was the structured adaptation and preliminary validation of an existing measure of thought-feeling discrimination for use in PLWD.

METHODS/DESIGN

The Behavior Thought Feeling Questionnaire (BTFQ) was adapted via expert and service-user consultation for use in PLWD. One hundred two PLWD and 77 people aged over 65 years who did not have measurable cognitive impairments completed the adapted measure along with two measures of emotional recognition and reasoning. The factor structure of this measure was examined and the measure reduced.

RESULTS

Factor analysis suggested a two-factor solution with thought and feeling items loading on separate factors. The behavior items were not included in scoring due to high cross-loading and ceiling effects, leaving a 14-item measure with two subscales. Thus, an adapted measure was created (named the BTFQ-D), which showed moderate convergent validity in the PLWD but not the older adult sample. Both thought and feeling subscales showed good internal consistency.

CONCLUSIONS

The BTFQ-D showed preliminary validity as a measure of thought-feeling discrimination in PLWD. It may have utility in measuring readiness for CBT as part of clinical assessment. Further validation is required.

Cognitive mediation in people with dementia: Development, structural, and construct validity of the first dementia-specific measure

OBJECTIVES

Anxiety and depression are common and deleterious comorbidities in people living with dementia (PLWD). Cognitive behavioural therapy (CBT) is one of the few promising treatments; however, it is unclear whether PLWD have the necessary prerequisites to engage in this. Having an understanding of cognitive mediation, that a thought mediates the relationship between an antecedent event and its emotional consequence, is key for engaging with CBT and is also a critical component of emotion regulation. There are no measures of this construct validated for PLWD. This study aims to adapt and validate an existing measure for this population. A secondary aim is to assess its applicability in older adults (OA) without a recognised neurocognitive impairment.

METHODS

A measure of cognitive mediation was adapted via expert and service user consultation for use in PLWD. A total of 102 PLWD and 77 OA without neurocognitive impairments completed the adapted measure along with two measures of emotion recognition and reasoning. Factor structure was examined separately in both samples, and the measure reduced, with convergent validity assessed.

RESULTS

A final measure of 10 items (named the CM-Dem) was subject to factor analysis yielding a single factor solution. The measure showed good psychometric properties in PLWD, including good model fit, high internal consistency, inter-rater reliability, and moderate convergent validity with related constructs. In contrast, poor validity was found in OA, especially a lack of convergent validity.

CONCLUSIONS

The CM-Dem has clinical and research utility as a measure of cognitive mediation in PLWD, but less so in OA.

A case series to examine whether people with learning disabilities can learn prerequisite skills for cognitive behavioural therapy

Although cognitive behavioural therapy (CBT) is recommended for the treatment of a number of mental disorders among the general population, the ability of individuals with learning disabilities (LD) to understand CBT concepts and engage in CBT has been questioned. Aims: To examine whether specific prerequisite skills for CBT can be taught to people with LD using a newly developed training intervention and to investigate the acceptability of the intervention. Method: The study adopted a within-subjects case series research design. Quantitative assessment methods were used to evaluate the CBT skills of six adults with mild to moderate LD pre-intervention, following intervention and at 1-week follow-up. Participants were also asked to provide some qualitative feedback about how they had experienced the intervention. Results: The cognitive mediation skills and the ability of most participants to link activating events to emotions increased following intervention training and this improvement was maintained for four of them at follow-up. The feedback of participants regarding the process and content of the task demands was positive. Conclusions: The findings suggest that people with LD can learn some of the skills considered necessary to participate in CBT, such as cognitive mediation. However, further and more robust research is required to substantiate these findings.

Measures of readiness for cognitive behavioural therapy in people with intellectual disability: A systematic review

BACKGROUND AND AIMS

Cognitive behavioural therapy (CBT) is a promising treatment for mental health problems in people with intellectual disabilities but some may not be suited or ready. This review critically evaluates the quality and utility of measures of CBT readiness in people with intellectual disabilities.

METHODS AND PROCEDURES

Twelve studies of six measures based on three aspects of CBT readiness were identified through systematic review.

OUTCOMES AND RESULTS

Across measures, measurement quality was largely poor or un-assessed. Only one study evaluated measurement change over the course of CBT. Not all participants with intellectual disabilities could 'pass' readiness measures and performance may be affected by levels of language and cognitive functioning. There was some evidence that CBT readiness is trainable with brief interventions.

CONCLUSIONS AND IMPLICATIONS

Before using readiness measures in a clinical context, further work is needed to extend initial evidence on recognising cognitive mediation as a CBT readiness ability. Given the lack of consensus as to the definition of CBT readiness and the heterogeneity of CBT interventions, future research could also focus on developing readiness measures using a bottom up approach, developing measures within the context of CBT interventions themselves, before further refining and establishing their psychometric properties.

WHAT THIS PAPER ADDS

This paper is the first to systematically review measures of skills thought necessary to be ready for cognitive behavioural therapy in intellectual disabilities. The findings suggest that while readiness skills may be trainable with brief interventions, the available measures of these skills have not been fully evaluated for quality. Levels of functioning on these measures have yet to be established relative to those without intellectual disabilities and critically, there is very little evidence as to whether these skills are important in cognitive behavioural therapy process and outcome. We suggest that future research could focus on those constructs where there is preliminary evidence for utility such as recognising cognitive mediation and also on developing the concept of readiness perhaps by developing measures within the context of specific CBT interventions. Until this is done, clinicians should exercise caution in using these measures to assess readiness for cognitive behavioural therapy in people with intellectual disabilities.

Using computers to teach people with intellectual disabilities to perform some of the tasks used within cognitive behavioural therapy: A randomised experiment

AIMS

Training has been shown to improve the ability of people with intellectual disabilities (IDs) to perform some cognitive behavioural therapy (CBT) tasks. This study used a computerised training paradigm with the aim of improving the ability of people with IDs to: a) discriminate between behaviours, thoughts and feelings, and b) link situations, thoughts and feelings.

METHODS

Fifty-five people with mild-to-moderate IDs were randomly assigned to a training or attention-control condition in a single-blind mixed experimental design. Computerised tasks assessed the participants' skills in: (a) discriminating between behaviours, thoughts and feelings (separately and pooled together), and (b) cognitive mediation by selecting appropriate emotions as consequences to given thoughts, and appropriate thoughts as mediators of given emotions.

RESULTS

Training significantly improved ability to discriminate between behaviours, thoughts and feelings pooled together, compared to the attention-control condition, even when controlling for baseline scores and IQ. Large within-group improvements in the ability to identify behaviours and feelings were observed for the training condition, but not the attention-control group. There were no significant between-group differences in ability to identify thoughts, or on cognitive mediation skills.

CONCLUSIONS

A single session of computerised training can improve the ability of people with IDs to understand and practise CBT tasks relating to behaviours and feelings. There is potential for computerised training to be used as a "primer" for CBT with people with IDs to improve engagement and outcomes, but further development on a specific computerised cognitive mediation task is needed.

Can a computerised training paradigm assist people with intellectual disabilities to learn cognitive mediation skills? A randomised experiment

AIMS

The aim was to examine whether specific skills required for cognitive behavioural therapy (CBT) could be taught using a computerised training paradigm with people who have intellectual disabilities (IDs). Training aimed to improve: a) ability to link pairs of situations and mediating beliefs to emotions, and b) ability to link pairs of situations and emotions to mediating beliefs.

METHOD

Using a single-blind mixed experimental design, sixty-five participants with IDs were randomised to receive either computerised training or an attention-control condition. Cognitive mediation skills were assessed before and after training.

RESULTS

Participants who received training were significantly better at selecting appropriate emotions within situation-beliefs pairs, controlling for baseline scores and IQ. Despite significant improvements in the ability of those who received training to correctly select intermediating beliefs for situation-feelings pairings, no between-group differences were observed at post-test.

CONCLUSIONS

The findings indicated that computerised training led to a significant improvement in some aspects of cognitive mediation for people with IDs, but whether this has a positive effect upon outcome from therapy is yet to be established.

The Development of a Measure of Confidence in Delivering Therapy to People with Intellectual Disabilities

Current policy in UK health services emphasizes that, where possible, people with intellectual disabilities should access the same services as people without intellectual disabilities. One of the barriers to this is the confidence of clinicians and therapists. In this paper, we report on the development of a scale to describe the confidence of therapists in working with people with intellectual disabilities (the Therapy Confidence Scale-Intellectual Disabilities [TCS-ID]). One-hundred and eighty-one therapists who provided talking therapies but who did not work primarily with people with intellectual disabilities completed the scale; 43 people completed the scale twice for test-retest reliability purposes. One-hundred and seven people also completed a scale of general therapy self-efficacy. The TCS-ID has a single factor structure accounting for 62% of the variance, Cronbach's alpha for the scale is 0.93 and test-retest reliability is 0.83. There are significant differences in confidence based upon participants experience in working with people with intellectual disabilities and their therapeutic orientation, and there is a significant association between the TCS-ID and the General Therapy Self-efficacy Scale. Sixty clinicians working in mainstream mental health services received training on adapting their therapeutic approaches to meet the needs of people with intellectual disabilities. The TCS-ID was used pre-training and post-training and demonstrated a significant increase in confidence for all group. We suggest that the scale has good psychometric properties and can be used to develop an understanding of the impact of training for mainstream therapist in working with people with intellectual disabilities.

KEY PRACTITIONER MESSAGE

There is increasing emphasis on people with intellectual disabilities receiving services from mainstream mental health services. There is no research describing the experiences and outcomes of people with intellectual disabilities receiving mainstream talking therapy services. The confidence that clinicians have in working with people with intellectual disabilities may be a barrier to them receiving mainstream services. The Therapy Confidence Scale-Intellectual Disabilities is a psychometrically sound scale for measuring the confidence of therapists in working with people with intellectual disabilities and is a useful outcome measure for training clinicians to work with people with intellectual disabilities.

Pain in people with an intellectual disability

PURPOSE OF REVIEW

Pain is a near-universal experience and research suggests that chronic pain, defined as pain lasting longer than 3 months, affects around 20% of the general population. However, there is relatively little awareness of the problem of pain amongst people with an intellectual disability.

RECENT FINDINGS

Recent prevalence studies indicated that chronic pain affects around 15% of people with an intellectual disability. Although prevalence can be estimated based on third-party reports, there are methodological limitations that suggest this way of detecting pain may be unreliable. Other methods, such as structured behavioural observation, offer a reliable and valid alternative. Once pain has been recognized, however, there has been limited research to evaluate pain management interventions for people with an intellectual disability, especially in the area of self-management.

SUMMARY

There is good evidence to support behavioural observation methods for recognition of pain in people with limited ability to communicate about their pain. Psychological interventions for pain management are widely used in the general population and may also have a useful role in assisting people with an intellectual disability who are affected by persistent pain. However, there is an ongoing paucity of research in this area.

Fact or faith?: on the evidence for psychotherapy for adults with intellectual disability and mental health needs

PURPOSE OF REVIEW

This article summarizes research and commentaries on psychotherapy for adults with intellectual disabilities published since 2008.

RECENT FINDINGS

There have been very few empirical studies of the effectiveness of psychotherapy in this context over recent years despite a strong perception that such approaches are not only necessary but also of great value. There have been some interesting, though so far only suggestive, findings concerning the relationship between intellectual level and suitability for treatment, primarily with cognitive behavioural therapy. Therapies based on mindfulness are emerging as important new developments. Despite their heritage, psychodynamic approaches continue to rely on opinion over evidence to support their use.

SUMMARY

Research on both processes in therapy and its outcomes needs to be undertaken with renewed vigour if specialist psychotherapy for people with intellectual disability is to flourish, or indeed survive, in the public healthcare system. However, it may have much a broader value for people with intellectual disability, especially those in residential services, than can be easily quantified.