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Copyright The British Psychological SocietyReproduction in any form (including the internet) is prohibited without prior permission from the Society

Does training improve understanding of coreconcepts in cognitive behaviour therapyby people with intellectual disabilities?A randomized experiment

Melanie Bruce1, Suzanne Collins1, Peter Langdon1,2,Stephanie Powlitch1 and Shirley Reynolds1*1School of Medicine, Health Policy and Practice, University of East Anglia,Norwich, UK

2

Broadland Clinic, Norfolk Learning Difficulties Directorate, Little PlumsteadHospital, Norfolk Primary Care NHS Trust, Norwich, UK

Background. People with intellectual disabilities (ID) experience similar or even

higher rates of mental health problems than the general population and there is a need

to develop appropriate treatments. Cognitive behaviour therapy (CBT) is effective for a

wide range of disorders in the general population. However, there is some evidence

that people with ID may lack the cognitive skills needed to take part in CBT.

Aims. To test if people with ID can learn skills required for CBT, specifically the

ability to distinguish between thoughts, feelings, and behaviours and to link thoughts and

feelings (cognitive mediation).

Method. A randomized independent groups design was used to examine the effect

of training in CBT on two tasks measuring CBT skills. Thirty-four adults with ID were

randomly allocated to the experimental conditionN 18or to the control condition

N 16. CBT skills were assessed blind at baseline and after the intervention.

Results. The training led to significant improvements in participants ability to link

thoughts and feelings, and this skill was generalized to new material. There was no effect

of training on participants ability to distinguish amongst thoughts, feelings, and

behaviours. People with ID can, therefore, learn some skills required for CBT. This

implies that preparatory training for CBT might be useful for people with ID. The

results might be applicable to other groups who find aspects of CBT difficult.

Establishing valid estimates of the prevalence of mental health problems amongstpeople who have intellectual disabilities (ID) has been problematic and wide variations

* Correspondence should be addressed to Professor Shirley Reynolds, School of Medicine, Health Policy and Practice, Universityof East Anglia, Norwich NR4 7QH, UK (e-mail: [email protected]).

The

British

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British Journal of Clinical Psychology (2010), 49, 113

q 2010 The British Psychological Society

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in prevalence have been reported (Borthwick-Duffy, 1994). This has been attributed todifferent reasons including the use of inconsistent and perhaps unsuitable assessment

methods and the extent to which challenging behaviours are considered to be indicativeof mental health problems (Moss, 1999). However, there is evidence that people with IDexperience the same types of mental health problems as the general population with atleast equivalent, if not even greater prevalence (Emerson & Hatton, 2007; Smileyet al.,2008). The reasons offered for this include increased genetic and biological vulnerabilityas well as adverse life experiences such as institutionalization, separations, stigma, and

social exclusion.Despite this context, the development and evaluation of therapeutic interventions

for mental health problems in this population has been slow (Hatton, 2002) andinadequate (Martin, Roy, & Wells, 1997; Patel, Goldberg, & Moss, 1993).

Pharmacological and behavioural interventions have been the primary interventionsavailable to adults with ID (Stenfert Kroese, 1997). It has been suggested that therapistsdo not engage in psychotherapy with people with ID because of general assumptionsthat their restricted cognitive ability and communicative skills would prevent them fromengaging in or benefiting from therapy (Hurley, Pfadt, Tomasalo, & Gardner, 1996).Currently, there is increasing interest in developing and adapting interventionsspecifically for use with people who have ID.

Cognitive behaviour therapy (CBT) has been demonstrated to be effective andadaptable to a wide range of mental health problems across a number of different

populations. There is some evidence that the underlying cognitive model is applicableto people with ID in people with ID. For example, symptoms of depression and anxietywere associated with negative cognitive styles, e.g. negative automatic thoughts and

hopelessness (e.g. Nezu, Nezu, Rothenberg, & DelliCarpini, 1995; Glenn, Bihm, &Lammer, 2003). In addition, there are reports of successful case studies of CBT withpeople with ID (e.g. Barrowcliff, 2008; Lindsay, 1999; Willner & Goodey, 2006).

The successful use of CBT for use with people who have ID is likely to need someadaptation and currently there is interest in identifying elements of therapy which areappropriate for use with this group of people. Hatton (2002) identified three aspects ofcognitive ability required for CBT; (1) cognitive capacity (e.g. understanding ofmore/less, memory), (2) the ability to identify different emotions, and (3) the ability tounderstand the cognitive model.

A number of authors have examined if people with intellectual difficulties canunderstand the cognitive model. Dagnan and colleagues (Dagnan & Chadwick, 1997;Dagnan, Chadwick, & Proudlove, 2000) found that most participants with IDunderstood the antecedents, beliefs, and consequences model (Ellis, 1977) and couldidentify basic emotions. However, they found that only around 10% of participants couldunderstand cognitive mediation, i.e. the ability to identify what emotion would beexperienced given a specific situation and belief. Successful performance was positivelycorrelated associated with language comprehension. The authors concluded thatpeople with mild ID may possess some of the skills required for CBT, but may require

preparatory training.Subsequently, other researchers (e.g. Joyce, Globe, & Moody, 2006; Sams, Collins, &

Reynolds, 2006) have reported that people with ID can identify some emotions but findit more difficult to link thoughts, feelings, and events. Oathamshaw and Haddock (2006)

examined CBT abilities in a sample of people with ID and psychosis and again,participants could identify emotions but found tasks involving cognition more difficult.In general, variations in performance are associated with IQ score (Sams et al., 2006)

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Measures

Two standardized measures of cognitive ability and language and two tasks to measure

specific CBT skills were used. At baseline (Time 1) both standardized measures and thetwo CBT tasks were completed. At Time 2 (following the intervention period) extendedversions of the two CBT tasks (including novel items) were completed.

The Wechsler Abbreviated Scale of Intelligence (Wechsler, 1999)

The Wechsler Abbreviated Scale of Intelligence (WASI) is a short, reliable measure ofintelligence, designed for use with people aged from 6 to 89 years. The measure yieldsthree categories of ability: verbal IQ, performance IQ, and full scale IQ. It provides anestimate of intellectual functioning calibrated to the Wechsler Intelligence Scale for

Children (WISC-III, UK) and the Wechsler Adult Intelligence Scale (WAIS-III, UK). Thereliability (0.98) and validity (0.92) of the WASI have been established, as have normaldistributions (Mean 100 and SD 15; Wechsler, 1999). The WASI takes approxi-mately 2030 min to complete and is therefore, well suited to rapid assessment andscreening in research settings.

The British Picture Vocabulary Scale-II (Dunn, Dunn, Whetton, & Burley, 1997)

The British Picture Vocabulary Scale-II (BPVS-II) is a test of receptive vocabulary for

standard English which was originally designed for use with children aged between3 years and 15 years 8 months. It has since been widely used with people who have ID inboth clinical and research settings. The measure is administered individually andprovides norm-referenced scores. No reading or writing is required of participants andthe measure is brief and easy to administer. Raw scores are converted into an ageequivalent score in years and months.

The measure has a well-established normal distribution (Mean 100 andSD 15).The BPVS-II has good reliability (median Cronbachs a: .93; median split half: 0.85,

Glenn & Cunningham, 2005). The validity of the test is assumed because it wasdeveloped from the original version. For stratified random allocation BPVS-II scoreswere categorized as high or low defined from a cut off score of 7 years. This figure was

based on previous research using a comparable population (Sams et al., 2006).

The ThoughtFeelingBehaviour task (TFB task; Quakley, Reynolds, & Coker, 2004; Sams et al., 2006)This task was adapted from previous research to measure the ability to differentiateamongst thoughts, feelings, and behaviours, a skill considered necessary in order toengage in CBT. In the task the researcher reads short stories to the participant. There areequal numbers of positive and negative stories. In each story the focal character (for

males Peter and for females Sarah) completes an action and experiences a thought and afeeling. An example story is as follows:

Sarah is going on a trip to the beach. Sarah is very excited (feeling). Sarah hoped that she

could have an ice cream there (thinking). Sarah put one pound in her purse ready to buy the

ice cream (behaviour).

Each story is read out in full; then the thinking, feeling, and behaving sentences, written

on card are selected at random and read out to the participant one at a time. The card isgiven to the participant who is then asked if the sentence is about something thecharacter had been thinking, feeling, or doing and is asked to post the card into one of

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This face is a happy face). Standard written instructions were used and these are

available from the authors on request. For each item of the task the participant was asked

to imagine him/herself in the specific situation and having a specific thought. For each

item the emotional impact of the situation was modified by the thought. For example,

Imagine that you are going away for a while. You say goodbye to your family. (indicate stick

person).

You think: I cant wait for my holiday. (indicate thought bubble).

How do you think you would feel if you thought, I cant wait for my holiday? (indicate

Makaton faces).

After answering, participants were asked Why do you think you would feel (insert

answer)?

Participants were encouraged to respond either verbally or by identifying the

appropriate Makaton face. If the answer was not clear and did not indicate if the

participant had connected the thought to the feeling (i.e. indicated that they would

experience positive affect rather than negative affect), the researcher prompted further,

OK, can you say a bit more about why you think you would feel like [insert answer]?

and invited the participant to show them how they would feel using the Makaton

symbol, Can you show me how you would feel?.

Two demonstration items were used to explain the task and to show the participantwhat was required. At Time 1, six test items taken directly from Samset al.(2006). Four

new items were introduced at Time 2 to assess generalization. One point was awarded

Figure 2.Makaton faces representing emotions (Walker, 1982).

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for correctly connecting the thought to the feeling for each scenario. The maximumscore at Time 1 was therefore 6; at Time 2 it was 10 points. Items were presented in a

random order. Fifty percent of items were mildly positive and 50% were mildly negative.The Thought to Feeling task has good inter-rater reliability (Doherret al., 2005).

Experimental and control interventions

The interventions were delivered in a single session and were manualized to maximize

internal validity. They each took approximately 1 h and were delivered by the sametrainer. The experimental intervention focused on identifying feelings, behaviours, andthoughts, and on linking thoughts and feelings. Each part had up to three graded levelswith more focused teaching provided if the participant found initial material toodifficult. For example, in the section on feelings, initially the trainer talked to the

participant about different feelings. If participants could spontaneously name differentfeelings (i.e. specific emotions happy, sad, worried, and angry) this was recorded andthe participant was encouraged to describe or mime as many different types of emotions

as they could. They would then move on to the thoughts and then the behavioursection. For participants who could not identify different feelings, the trainer usedmime, repetition, simple language, pictures, and personal examples of the participant,e.g. to identify times when the participant had experienced positive and negativefeelings. These were elaborated and labelled where possible.

A similar method was used to identify thoughts and behaviours using pictures,thought bubbles, mime, and drawing on personal experiences as much as possible. Forlinking thoughts and feelings, the participant and trainer discussed specific scenarioswhere a feeling would be elicited by a thought. Descriptions, coaching, repetition,

pictures, and personal experiences were all used to convey meaning.The relaxation training was based on the behavioural relaxation procedure described

by Lindsay and Morrison (1996). Full instructions for both training interventions areavailable on request from the authors.

Ethical issues

Ethical approval was sought and obtained from Norfolk (1) Local Research EthicsCommittee and Norfolk Consortium Governance Committee. Particular attention was

given to consent, confidentiality, and potential distress. Information sheets and consentforms were reviewed by user groups to aid this process. The study was also explained

verbally to each potential participant. They were encouraged to discuss the study withtheir carer and with staff at the service they used. Specific attention was given to ensurethat participants understood the principle of random allocation, that they were free to

take part in the study or not, and that they could withdraw at any time. It was made clearto each participant that there would not be any direct benefit to them. Informed consentwas obtained from each participant and this was witnessed by staff member at theservice they used.

Procedure

Information about the study was distributed to service managers. Staff members

identified individuals who they thought would be eligible to take part in the study.Potential participants were then approached in person at the day centre or college and,if interested, were given information about the study.

Training in CBT for people with ID 7

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significant group difference on either task; TFB task,F1; 32 1:0,p , .32, TF task,F1; 32 0:33, p , :57.

To test the first hypothesis, we compared group performance at Time 2 on theoriginal tasks (i.e. the same items that were presented to the participant at Time 1).To test the second hypothesis, we compared performance on the four new items onboth tasks to assess if learning could be generalized to new material.

For performance on the original items there was a significant multivariate groupdifference at Time 2, F2; 31 6:57, p , :005. Univariate Fvalues showed that theeffect was due to a significant group difference on the Thought to Feeling task,

F1; 32 13:56, p , :0001; there was no significant group difference in the TFB

discrimination task, F1;

32 2:

3, p ,:

14. Performance on the original items for theexperimental and control groups at Time 1 and 2 are shown in Figure 3.

We examined performance on the new items also. Mean scores for the new items onthe Thought to Feeling task were 2.4 SD 0:8for the CBT group and 1.2 SD 1:1for the control group. For the TFB task the respective means were 6.9 SD 2:9and6.6SD 3:4. There was a significant multivariate difference between the CBT trainingand the relaxation training groups, F2; 31 6:53, p , :004. Univariate F valuesshowed that this was due to a significant difference on the thought to feeling task,

F1; 32 12:89, p , :001; there was no significant group difference in the TFBDT,

F1; 32 0:12, p , :73. After the training intervention, participants in theexperimental group scored significantly better on the six familiar items of the Thoughtto Feeling task (mean item score 0.75) than on the four new items (mean score 0.59),t15 3:31,p , :004. This was likely to be due to practice effects. Their score on the

new items at Time 2 (0.59) was, however, significantly higher than their mean score(0.37) at baseline; t17 5:29, p , :00001, demonstrating that their performancehad significantly improved and could not be attributed to the effect of practice onthose items.1

Discussion

This experimental study showed that the CBT training intervention increasedparticipants ability to link thoughts and feelings, a skill which has previously beenreferred to as cognitive mediation (Dagnan et al., 2000), which has been deemedcritical for successful engagement in CBT (Willner, 2006) and which, it has been

Table 1. IQ and receptive vocabulary scores by group

CBT training Relaxation training

Median Mean SD Median Mean SD u p

FSIQ 55 56.4 3.3 56 57.1 4.9 138.00 .85

VIQ 55 58.2 6.0 55 58.6 5.8 132.00 .69

PIQ 60 61.4 6.0 61 61.3 5.7 142.50 .96

BPVS 7.1 7.7 3.1 7.6 6.7 2.9 125.00 .53

1 Thanks to an anonymous referee who drew our attention to the difference in performance on the old and new items of theThought to Feeling task.


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suggested, may be beyond the capabilities of most people with ID ( Joyceet al., 2006).

Thus, this study shows that with suitable adaptations and support people with ID can

learn these skills and generalize their learning to new material. This is consistent with

the views that training and socialization into the cognitive model should be an integral

part of therapy for people with ID (e.g. Stenfert Kroese, 1997). If significant

improvement can be observed after one standardized, brief intervention, a longer,

individually tailored intervention delivered in the context of a therapeutic relationship

may be even more effective. However, this sample was not clinically referred or in

distress, and therefore, it is not clear how much the results would generalize to a clinical

population. The effect of the intervention was measured after an interval of 1 week and

we cannot infer that learning would be maintained over a longer period. However, in the

context of CBT, maintenance of learning may not be a critical concern as there would be

regular opportunities to review the training and to repeat it if necessary.Unexpectedly, we found that the effect of training was specific to the ability to link

thoughts and feelings (or cognitive mediation). Participants ability to discriminateamongst thoughts, feelings, and behaviours, which would seem to be a more basicrequirement of CBT, did not change as a result of the training intervention.

The design had a number of strengths; the confounding effect of receptive languageability was minimized through stratified randomization, assessments were conductedblind to avoid potential biases, and we controlled for the non-specific effects ofindividual attention. All instructions, tasks and interventions were standardized,

therefore increasing the internal validity of the study, but inevitably limiting theflexibility with which the intervention was delivered. The sample IQ scores which weresomewhat lower than those of individuals who have been treated with CBT and

Figure 3. Group performance (Mean andSEM) on (a) the TFBDT and (b) the linking thoughts to feeling

task.

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reported in published case studies. Thus, whilst the sample do not represent thebroader ID population, it may reflect those individuals who use day service provision.

Some sampling bias was unavoidable because, for ethical reasons potential participantswere identified by staff members. However, very few potential participants wereunwilling to take part and there was no evidence of a self-selection bias into the study.Although not explicitly required by the design, all participants had some verbalcommunication. The ethical challenges of carrying out research with participants whohave ID have been highlighted elsewhere (e.g. Iacono, 2006; McCaron & McCallion,

2006) and we took steps to enhance the extent to which participants could give fullyinformed consent.

A key assumption in this experimental study (and in other related studies of CBTabilities in people with ID) is that the assessments of CBT skills are valid. This presents a

challenge as research in this area is relatively new, tasks to assess CBT skills have notbeen fully developed, therefore whilst their face validity to researchers is good, theirpredictive validity is unknown. The specific tasks used in this study were adapted fromtasks developed for use with young children and were adapted to be suitable for, andacceptable to, adult participants. Some features of the tasks may have overcomeproblems identified in previous research. Dagnanet al.(2000) identified that their tasksmay not have adequately assessed individuals ability to understand the role of cognitivemediation. The Linking Thoughts to Feelings Task (Doherret al., 2005) used in thisstudy gave participants the opportunity to use their own language to explain their

reasons and may be more flexible than the tasks developed by Dagnan et al. (2000).The finding that specific training did not improve participants ability to discriminate

amongst thoughts, feelings and behaviours was unexpected. The nature of the tasks may

be relevant in that the discrimination task involved stories describing a fictionalcharacter, whereas the linking task asked participants to imagine themselves in asituation and to consider their own thoughts and feelings. This may have been moremeaningful to them. Alternatively, it is possible that discriminating amongst thoughts,feelings, and behaviours is a basic skill and that people with learning disabilities haveregular opportunities to learn it thought day-to-day experiences. In comparison, linkingthoughts and feelings (cognitive mediation) may not be something to which individualsare regularly exposed and thus the training intervention may offer a more novelopportunity for learning this specific skill.

Although preliminary, these results could have important implications for thedelivery of CBT to adults who have ID. The data suggest that some aspects of thecognitive model can be taught to adults with ID in a single session of training. Ifreplicated clinically this may mean that this group of people can have access to aneffective psychological intervention. The results may also have relevance for thedelivery of CBT to other groups who may find the initial model unfamiliar or cognitivelychallenging and who might benefit from specific training in the early stages of therapy.This training would fit naturally within the psycho-education and socialisation phases oftherapy.

Many other factors also influence the success of CBT including the quality of thetherapeutic relationship, the clients willingness to engage in therapy, their self-efficacyand motivational barriers (Willner, 2006). The extent to which the skills assessed in thisstudy are associated with engagement, understanding and outcomes in CBT has yet to

be established. In addition, for people with ID, systemic issues may be of particularimportance given their typically complex social network of family, carers andprofessional staff. The delivery of CBT for adults with ID requires substantial further


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development and systematic evaluation. However, this study demonstrates that lack ofskills in specific areas need not be an absolute barrier to CBT, but should highlight areas

in which therapists could begin to enable individuals to develop specific skills.

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Appendix: Additional items for the TFBDTItem 7: Sarah is on her way to watch her favourite football team. She hopes that they winthe match. Sarah is excited when her team scores a goal. Sarah cheers and claps.

Item 8: Tomorrow Sarah has an appointment at the dentist. Sarah is very worried. Sarahwonders if her teeth are ok. Sarah goes to clean her teeth.Item 9: Sarah is playing her new CD. Sarah dances to the music. Sarah wonders if herfriend will like her new CD. She is happy when her favourite song comes on.Item 10: Sarah wonders where her bag is. Sarah is angry that she cant find it. Sarah asksher friend to help her look for her bag.


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