CBT for people with learning disabilities and autism

This section is to give an overview of different models, different therapeutic orientations and techniques
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CBT for people with learning disabilities and autism

Post by Ruthie »

CBT for people with a learning disability and/or autistic spectrum disorder

Cognitive deficit vs cognitive dysfunction
The main difference between CBT for people with learning disabilities and for those without is that the emphasis is more on cognitive deficit rather than cognitive dysfunction. Therefore, there will be a large psychoeducational component, although the person will need to have some basic understanding of what thoughts, emotions and behaviours are. The level you work at may be a lot more concrete and you will probably need to use lots of labelling, repetition, practice and prompting due to the memory and executive functioning impairments associated with LD or ASD. It is extremely useful to involve the person's family/carers/support workers as co-therapists so that they can practice anything learned outside of the therapy session, aiding generalisation to everyday life. Child CBT resources such as the Huge Bag of Worries or Think Good Feel Good can be useful too. However, care should be taken to ensure that adaptations are made to materials to ensure they are developmentally age-appropriate and not patronising to the individual. The main thing is to ensure that the formulation and intervention are meaningful to the person.

Behavioural activation
Behavioural activation (helping the person to increase their engagement in activities that they find pleasureable and/or those that give a sense of achievement) can be extremely helpful to increase mood and a sense of self-achievement with this client group. Activities should be developmentally and age appropriate and meaningful to the individual. Take the lead from the individual but it can be helpful to have a range of possible activities to suggest. Support from the system around the person (e.g. families, care staff) may be vital to support access to activities and gentle encouragement to engage in them. It is important to consider systemic factors (e.g. impoverished environments, over-stretched care staff) that may make access to such activities difficult.

Importance of considering level of cognitive functioning, language and emotional literacy
You would need to make sure you were working at the correct cognitive level for the person (but that is no different than any other good CBT), within their zone of proximity. People with a learning disability often use fewer words for emotions and that is often the same for people with an autistic spectrum disorder so its a good idea to check that out (generally referred to as emotional literacy). It is really important to have an idea of the person's level of learning disability (if applicable), language ability and their level of understanding of emotions and to tailor any intervention accordingly. Most people in this population who can benefit from CBT interventions have a mild-moderate learning disability or autistic spectrum disorder without a learning disability, it may not be possible for someone with a moderate/severe/profound learning disability to participate in CBT interventions due to their level of cognitive functioning and communication. However, CBT based formulations and techniques may be usefully applied with the systems and people around the person (e.g. helping staff make more balanced attributions about a person's behaviour or using the four systems formulation model to encourage a family to think about all the different aspects of an issue their child is presenting with).

Working creatively using different mediums to reinforce and practice skill development
Generally I think it is important to work on the same theme through a variety of mediums: talking, if their language is up to it (and be aware that people with LD can 'pretend' to know what you are going on about so that the extent of their disability is not uncovered [the cloak of competence/handicapped smile]), getting creative with art, role play, lots of role play, modelling, supported experinces, which all helps with conserving and accommodating new ideas and behaviours, in order for change to be facilitated as you are inputting in a multi-sensory way.

Think about working creatively using symbols (e.g. from clipart, Boardmaker), pictures from magazines and photographs, videos (e.g. from soaps - these are really good as people are often displaying very extreme emotions!) and role playing. I would use lots of labelling of thoughts and emotions too and practical activities. However, you may find that some people find this extremely difficult and you need to be very creative with the activities you devise and how you socialise the person to the basic tenets of the model.

The emphasis is on repetition, psychoeducation, and working systemically with family/staff/carers to ensure the work is continued outside of the therapy setting. Training carers in the methods can be very useful and if you personalise it well to suit the individual's levels and needs then CBT can be an effective method for people with a mild learning disability and/or ASD. Autism has the additional problem of rigidity, over and above that of the rigidity in thinking other people do. But then there are some very rigid people that have got an IQ higher than 70 too.

It is worth pointing out that "diagnostic overshadowing" can occur and some people may put a symptom down to their learning disability. In essence this means that sometimes staff members may struggle to make sense of why an individual is experiencing difficulties. So for example, if an individual with a learning disability behaved in an 'angry' way, which can be challenging to services, staff members may attribute this anger to the learning disability or ASD. In reality, whilst this may contribute to how the individual's experience of anger manifests itself in terms of behaviour, the anger may be driven by another difficulty e.g. a recent bereavement. Although most psychologists are aware of this, some members of a team may attribute a behaviour to the learning disability. Identifying psychological distress in people with LD can be difficult if they have problems with communication, but spending time with an individual, even when they cannot talk can highlight a lot of information. Creativity and taking a personal approach, and involving carers can be the keys to improved outcomes.

Useful papers and resources

For working with adults with a learning disability and/or ASD:

Royal College of Psychiatrists report on psychotherapy and learning disabilites: http://www.rcpsych.ac.uk/files/pdfversion/cr116.pdf

- Stenfert Kroese et al (1997) Cognitive-Behaviour Therapy for People with Learning Disabilities

- Kirkland, J. Cognitive-behaviour formulation for three men with learning disabilities who experience psychosis: how do we make it make sense? British Journal of Learning Disabilities, 33(4), 160-165

- Sams, K., Collins, S., & Reynolds, S. (2006). Cognitive therapy abilities in people with learning disabilities. Journal of Applied Research in Intellectual Disabilities, 19(1), 25-33

- Stenfert Kroese, B. (1998). Cognitive-behavioural therapy for people with learning disabilities. Behavioural and Cognitive Psychotherapy, 26, 315-322

- Willner, P. (2005). The effectiveness of psychotherapeutic interventions for people with learning disabilities: a critical overview. Journal of Intellectual Disability Reseach, 49(1), 73-85

For working with children and young people with ASD, these might be interesting reading:

- Susan W. White, Thomas Ollendick, Lawrence Scahill, Donald Oswald & Anne Marie Albano "Preliminary Efficacy of a Cognitive-Behavioral Treatment Program for Anxious Youth with Autism Spectrum Disorders", J Autism Dev Disord (2009) 39:1652–1662

- Karen M. Sze & Jeffrey J. Wood "Cognitive Behavioral Treatment of Comorbid Anxiety Disorders and Social Difficulties in Children with High-Functioning Autism: A Case Report", J Contemp Psychother (2007) 37:133–143

- Jeffrey J. Wood, Amy Drahota, Karen Sze, Kim Har, Angela Chiu & David A. Langer "Cognitive behavioral therapy for anxiety in children with autism spectrum disorders: a randomized, controlled trial", Journal of Child Psychology and Psychiatry 50:3 (2009), pp 224–234

The Research Autism website has a useful summary of the literature on CBT and ASD and below are a couple of papers about CBT and Asperger syndrome:

- Anderson, S. & Morris, J. (2006). Cognitive behaviour therapy for people with Asperger syndrome. Behavioural and Cognitive Psychotherapy, 34(3), 293-303

- Hare, D.J. (1997). The use of cognitive-behavioural therapy with people with Asperger syndrome: A case study. Autism, 1(2), 215-225

With thanks to: choirgirl, Dr.Dot, h2eau, sarahlb100, dwrein, steve79, and michael2806 for their contributions.

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Content checked by trainee clinical psychologist on 12/02/13
Last modified by Borrowed_Cone on 12/02/13
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