Cognitive‐Behavioural Therapy for Command Hallucinations and Intellectual Disability: A Case Study

Background There is a paucity of literature detailing cognitive‐behavioural therapy (CBT) for psychosis in people with intellectual disability. Of the available literature, only two case studies involve people with command hallucinations and these do not address specific issues of intervention indicated in the wider literature for this type of presentation. Methods The present paper reports a case study documenting the successful application of CBT targeting the treatment of command hallucinations for mild intellectual disability. Results A range of measures (including positive and negative syndrome scale, beliefs about voices questionnaire and psychotic symptom rating scale for auditory hallucinations) collected at pre‐ and post‐intervention indicates successful reduction in positive symptoms, with 3‐ and 6‐month follow‐up data indicating maintenance of improvements. Critically, positive clinical changes in core beliefs regarding the power of the hallucinatory voice are also observed. Conclusions Cognitive‐behavioural therapy for command hallucinations can be successfully adapted and applied to people with a mild disability.     

A Comparison of Anxiety and Depression in Sex Offenders with Intellectual Disability and a Control Group with Intellectual Disability

The aims of this study were to employ modified versions of the 21-item Beck Anxiety and Depression Inventories with a group of 16 sex offenders with mild intellectual disability and borderline intelligence and 16 control participants with similar levels of intellectual disability. Test-retest correlations found high reliability for both assessments across all participants. There was a significant difference between the scores of the 2 groups with the sex offenders reporting significantly lower levels of anxiety and depression than the control participants. The results are discussed by presenting hypotheses on the emotional stability in each group.     

Depression,Social Context and Cognitive Behavioural Therapy for People who have Intellectual Disabilities

Background It is striking that although cognitive behavioural therapy was developed to treat depression in the general population, there remains a paucity of research concerning its application to people with intellectual disabilities. Recent research points to the importance of understanding people's distress in the context of their particular life experience. Areas to be addressed This paper examines how the life experience of people with intellectual disabilities may influence the nature of their self‐perceptions and their vulnerability to depression. In addition to considering the impact of experience on the content of participants’ self‐perceptions, evidence concerning the mediating role played by cognitive factors in the genesis and maintenance of depression is also reviewed. Conclusions These strands of research are discussed in the light of existing CBT models of depression, along with potential adaptations of interventions for people with intellectual disabilities.     

Hospital Utilization among Persons with an Intellectual Disability,Ontario, Canada, 1995–2001

Background It has been suggested that persons with an intellectual disability consume a disproportionate amount of hospital services. Policy changes in Ontario in the 1970s and 1980s made it necessary for community health services to accommodate this population that formerly received most of its medical care in the institutions where they lived. It is frequently suggested that community health services are currently inadequate to care for this population. Methods The study was a retrospective analysis of routinely collected hospitalization data for persons living in Ontario with an intellectual disability, between 1995 and 2001. Results A substantial proportion of hospitalizations of persons with an intellectual disability were for mental disorders and dental diseases. Of all in‐hospital stays, one‐third were for mental disorders such as schizophrenia and depression. Of all day‐surgery admissions, almost 40% were for dental diseases corresponding to a high rate of dental procedures. The study also identified high ambulatory care‐sensitive condition hospitalization rates. In‐hospital surgical procedure rates, however, were low. Interpretation This study is the first to fully describe patterns of hospitalization for persons with an intellectual disability in Ontario, Canada. A recurring finding is the large discrepancy between statistics for persons with an intellectual disability and published data for the general population. The study limitations mean further research is required to confirm the results and to determine if persons with an intellectual disability are receiving the health care they are entitled to in Ontario.     

Adapting Individual Psychotherapy for Adults with Intellectual Disabilities: A Comparative Review of the Cognitive–Behavioural and Psychodynamic Literature

Background Historically, adults with intellectual disabilities have had little access to individual psychotherapy. Over the last 20 years an increasing body of literature has described psychotherapy with this client group and reported methods for adapting traditional psychotherapeutic techniques. Method The current review identified the frequency of adaptations suggested by Hurley et al. (1998) [Journal of Developmental and Physical Disabilities, vol. 10, pp. 365–386] within cognitive behavioural and psychodynamic studies with adults with intellectual disabilities. Twenty‐five studies were reviewed, 10 cognitive–behavioural and 15 psychodynamic. Results A total of 94 adaptations were identified. Within cognitive behavioural therapy (CBT) studies, flexibility in method was the most frequently considered adaptation whilst transference and countertransference issues were most frequently considered within psychodynamic studies. Across the two approaches, disability and rehabilitation issues were given the least consideration. Conclusions Implications for practitioners and services are highlighted along with recommendations for future research.     

Stigma,Social Comparison and Self‐Esteem in Adults with an Intellectual Disability

Background The paper examines the perception of stigma in 43 adults with an intellectual disability, the relationship this has with their psychological well‐being and whether the process of social comparison has a moderating effect on this relationship. Materials and Methods A questionnaire‐based, within‐participant design was used. Participants completed three self‐report measures of perception of stigma, self‐esteem and social comparison. Results Perception of stigma was found to be significantly related to negative social comparisons, which in turn was significantly related to low self‐esteem. No difference was found between social comparisons made with other service users and those made with people in the community. Social comparison was not found to have a moderating effect on the relationship between stigma and self‐esteem. Conclusion This study provides support for the influence of the perception of stigma and social comparison on the self‐concept of individuals with an intellectual disability.     

Do People with Intellectual Disabilities and Psychosis have the Cognitive Skills Required to Undertake Cognitive Behavioural Therapy?

Background Cognitive skills thought to be necessary to undertake cognitive–behavioural therapy (CBT) include the ability to recognize emotions, link events and emotions, and recognize cognitive mediation. These skills have been assessed in people with intellectual disabilities, but not in those who also have psychosis. Materials and methods Tasks assessing receptive language ability and cognitive skills including the ability to differentiate between behaviours, thoughts and feelings were administered to 50 participants who had intellectual disabilities and psychosis. Results The majority of participants were able to link events and emotions and differentiate behaviours and feelings. Participants found any task involving cognitions significantly more difficult. Performance on recognizing emotions, linking events and emotions and on some of the cognitive mediation and differentiation tasks was associated with receptive language ability. Conclusions People with intellectual disabilities and psychosis have some of the skills thought to be required to undertake cognitive behaviour therapy. Recognizing cognitions and cognitive mediation is particularly challenging. The differentiation task introduced in this study may usefully supplement existing assessments.     

Readiness for Cognitive Therapy in People with Intellectual Disabilities

Aims Cognitive therapies are increasingly being offered by clinical psychologists to people with intellectual disabilities. This paper reviews some of the factors that influence people's readiness to engage in cognitive therapy. Literature review Limited verbal ability, psychological‐mindedness (particularly in relation to the understanding of emotions and the mediating role of cognitions), and self‐efficacy, are all likely to present significant barriers. There may also be motivational barriers to treatment, including the functionality of some psychological presentations, maladaptive beliefs promoting resistance to change, the intellectually challenging nature of cognitive therapy, and external factors such as inappropriate settings. Engagement with therapy can be promoted by involving carers to support the therapy, but carers may themselves display a range of limitations of ability and motivation similar to those displayed by clients, which need to be recognized, and where possible addressed, in order for their involvement to be effective. Recommendations If barriers to treatment are recognized, significant steps can be taken to increase accessibility. In addition to simplifying the delivery of therapy, there is also scope to simplify the model; this point is illustrated by case examples, and some principles for formalizing modifications to standard procedures are suggested. As barriers to treatment can often be surmounted, a decision whether or not to offer cognitive therapy should be derived from a comprehensive formulation, and should never be based solely on a client's performance on tests of cognitive ability.     

Interaction of Cognitive Distortions and Cognitive Deficits in the Formulation and Treatment of Obsessive–Compulsive Behaviours in a Woman with an Intellectual Disability

Aims This case study describes the formulation and cognitive–behavioural treatment (CBT) of obsessive–compulsive thoughts and behaviours in a woman with an intellectual disability. The report aimed to distinguish the cognitive deficits that reflect her disability from the cognitive distortions integral to her obsessive–compulsive disorder. Case study Hence, we present one account of the cognitive–behavioural interventions aimed at correcting the cognitive distortions, and a separate account of the modifications necessary to compensate for specific cognitive deficits, which include impairments not only of ‘cognitive therapy skills’, but also of aspects of memory and executive functioning skills. Discussion We suggest that this analysis may provide a rational approach to the problem of simplifying CBT to meet the needs of people with intellectually disabilities, by identifying more clearly the specific adaptations that are needed by a particular individual. We also discuss the assessment of cognitive deficits that might impact on CBT, and some implications of this approach for research and training.     

Students’ Behavioural Intentions Towards Peers with Disability

Background The objectives of this study were: (i) to compare the behavioural intentions of high school students towards individuals with intellectual disabilities and individuals with physical disabilities and (ii) to explore reasons for these behavioural intentions. Materials and methods A sample of 319 Grade 9 and Grade 12 students in Ontario, Canada, completed a questionnaire regarding their behavioural intentions towards peers with intellectual or physical disabilities. They also responded to open‐ended questions concerning their feelings about participating in a class task or social activity with these individuals. Results Behavioural intentions towards students with intellectual disabilities were significantly more negative than were those towards students with physical disabilities. This difference was also reflected in responses to the open‐ended questions. Common reasons for discomfort were perceived dissimilarities in interests or abilities. Conclusions Future efforts should aim to help students with and without disabilities find commonalities and to encourage reciprocity in their interactions.     

Affiliate Stigma Among Caregivers of People with Intellectual Disability or Mental Illness

Background Affiliate stigma refers to the extent of self‐stigmatization among associates of the targeted minorities. Given previous studies on caregiver stigma were mostly qualitative in nature, a conceptually based, unified, quantitative instrument to measure affiliate stigma is still lacking. Materials and Methods Two hundred and ten caregivers of people with intellectual disability (CPID) and 108 caregivers of people with mental illness (CPMI) were recruited to validate the 22‐item Affiliate Stigma Scale with caregiving stress, subjective burden and positive perceptions. Results Exploratory factor analysis suggested that the scale was unidimensional, with excellent internal consistencies for both CPID and CPMI. It showed good predictive validity on subjective burden, after the extent of caregiving involvement and caregiving stress were controlled for. Conclusion Implications on psychoeducation and stigma reduction were discussed. The newly developed scale provided a quantitative instrument with which affiliate stigma can be compared across different conditions.     

Issues of Informed Consent in Conducting Medical Research Involving People with Intellectual Disability

Background People with severe intellectual disability are considered vulnerable to exploitation in research. Discovery of exploitative practices in recent history has motivated the development of guidelines for informed consent and proxy decision‐making procedures when involving these individuals in research. Methods Issues for determining capability to provide informed consent and the proxy decision process are reviewed according to the literature, current ethics guidelines and recent legislature in Victoria, Australia. Results The complex process of involving in research people with severe intellectual disability who are particularly vulnerable by virtue of their institutionalized residential status is discussed within the context of a recent project into examining potential nutritional determinants of Pica behaviour (i.e. the eating of inedible items). Conclusions This example serves to highlight the role of legislation, various government bodies and researchers in balancing principles of protection of vulnerable groups and rights to self‐determination.