Cognitive behavioural therapy from the perspective of clients with mild intellectual disabilities: a qualitative investigation of process issues

Cognitive behavioural therapy from the perspective ofclients with mild intellectual disabilities: a qualitativeinvestigation of process issuesjir_1546 1..11

C. Pert,1 A. Jahoda,1 B. Stenfert Kroese,2 P. Trower,2 D. Dagnan3 & M. Selkirk4

1 Institute of Health andWellbeing, College of Veterinary Medical and Life Sciences, University of Glasgow, Glasgow, UK2 School of Psychology, University of Birmingham, Birmingham, UK3 Cumbria Partnership NHS Trust, Cumbria, UK4 University of Abertay, Dundee, UK

Abstract

Background Clinicians working with clients whohave mild intellectual disabilities (IDs) have showngrowing enthusiasm for using a cognitive behav-ioural approach, amid increasing evidence of goodtreatment outcomes for this client group. However,very little is known about the views and experiencesof clients with IDs who have undergone cognitivebehavioural therapy. This study aims to explore theperspective of these clients.Methods Fifteen participants with borderline tomild IDs and problems of anxiety, depression andanger were interviewed regarding their experienceof cognitive behavioural therapy (CBT). Two semi-structured interviews were carried out in the firstphase of therapy between session four and sessionnine. An interpretive phenomenological approachwas taken to seek out themes from participants’own personal accounts.Results Participants valued the opportunity to talkabout problems with their therapist and benefitted

from therapeutic relationships characterised bywarmth, empathy and validation. Participants iden-tified areas of positive change; however, manythought that this may be short lived or not main-tained beyond discharge.Conclusions The supportive aspects of therapeuticrelationships were particularly important to partici-pants undergoing CBT. The clinical implications areconsidered.

Keywords cognitive behavioural therapy, emotionalproblems, intellectual disability, self-efficacy,therapeutic process, therapeutic relationship

Introduction

Research looking at the effectiveness of cognitivebehavioural therapy (CBT) for clients with mildintellectual disabilities (IDs) has shown some prom-ising findings (e.g. Beail 2003; Willner 2005; Tayloret al. 2008). While the evidence has mainly beendrawn from single case studies, where CBT hasbeen used to alleviate a range of emotional prob-lems (Lindsay & Michie 1998; Haddock et al. 2004;Willner 2004; Stenfert Kroese & Thomas 2006), the

Correspondence: Dr Carol Pert, Berryknowes Resource Centre,14 Hallrule Drive, Cardonald, Glasgow G52 2HH, UK (e-mail:[email protected]).

Journal of Intellectual Disability Research doi: 10.1111/j.1365-2788.2012.01546.x1

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© 2012 The Authors. Journal of Intellectual Disability Research © 2012 Blackwell Publishing Ltd

robustness of evidence has been strengthened bycontrolled studies that have shown good outcomesfor CBT when used for problems of anger control(Taylor et al. 2002, 2004, 2005; Willner et al. 2002),and depression (McCabe et al. 2006). However, asmost controlled studies to date have concernedgroup therapy carried out in secure settings, furtherinvestigation is needed. Clinicians working in theIDs field have shown enthusiasm for using indi-vidual CBT; however, very little is known aboutintellectually disabled clients’ own experience of, orsatisfaction with this approach.

While therapeutic process is a neglected area ofstudy for individuals with IDs, there is a rich litera-ture spanning more than 40 years, relating to otherclient groups. Various strands of research haveemerged over the years. Some studies consider linksbetween treatment outcomes and specific events intherapy while others adopt a ‘discovery orientated’approach, where the objective is to explore thetherapeutic experience from the vantage point ofclients, therapists or an independent observer.Other studies have applied theoretical models ofchange to therapeutic processes to explore the spe-cific conditions thought necessary for the key com-ponents of therapy to be effective (Stiles et al. 1990,1995). This includes two studies carried out withclients who have mild IDs (Newman & Beail 2002,2005).

Although the size and diversity of the process lit-erature makes it difficult to summarise the findings,in their review paper Llewelyn & Hardy (2001) drawout a number themes. A strong finding of manystudies is the importance of the therapeutic alliance,both in terms of treatment outcomes (Beutler et al.1994; Horvarth & Greenberg 1994; Bachelor & Hor-varth 1999), and what is found to be helpful byclients (Elliot 1986). From the clients’ perspective,therapeutic relationships characterised by warmth,empathy and understanding have been found to bebeneficial ( Joyce & Piper 1998), and having someoneto talk to is shown to be of value in itself.The qualityof client participation in therapy sessions has beenlinked to good outcomes (Orlinsky et al. 1994). Bothclients and therapists report that therapeutic discus-sions that have depth (Stiles 1980; Pesale & Hilsen-roth 2009), and lead to new insights and awareness,are helpful (Elliot 1985; Mahrer & Nadler 1986;Martin & Stelmaczonek 1988).

While some of the findings from the processliterature may equally apply for clients with IDs,there is good reason to assume that processesmay differ in some important ways for this clientgroup. Clients’ cognitive and communication limi-tations may disrupt the flow and ease of sessions,and place limits on the depth of therapeutic con-versations (Jahoda et al. 2009a). Willner (2005)discusses a number of difficulties that clients withIDs may experience during therapy and the likelyimpact on therapy processes. He suggests thatmotivation may be low for this client group, partlybecause of a lack of control over their referral fortherapy. He also discusses the impact that lowself-efficacy (Bandura 1977, 1982, 1986), a rela-tively common presentation in clients with IDs(Gresham et al. 1988; Slemon 1998) may have onclients’ engagement in the therapy process. Jahodaet al. (2009b), offer some encouragement in theirstudy showing that clients with IDs played anactive part in therapeutic conversations. Kilbane &Jahoda (2011) explored the therapy expectanciesand motivation of participants with IDs. Theyspeculate that low self-efficacy and differences inthe relational characteristics of this client group,such as an external locus of control (Zigler &Balla 1972; Wehmeyer 1993; Wehmeyer & Palmer1997), could result in clients taking a less activerole in therapy. In keeping with this, a recentstudy carried out with clients without IDs whohad social anxiety problems found that thoseclients who had external locus of control engagedless well with therapy and had poorer treatmentoutcomes (Delsignore et al. 2008).

Two studies have considered process issues forclients with IDs undergoing psychodynamic psycho-therapy. McDonald et al. (2003) carried out a quali-tative study exploring the experiences of individualswith an ID attending group psychotherapy. Nineparticipants took part in the study. This comprisedof four men who attended a sex offenders psycho-analytic group, and five women who attended awomen’s group. Participants had been attendinggroup sessions for a period of between 2 monthsand over 1 year.

A semi-structured interview that focussed looselyon general experiences as well as positive and nega-tive aspects of therapy was carried out. Themes thatemerged were categorised into positive and negative

2Journal of Intellectual Disability Research

C. Pert et al. • What clients with intellectual disabilities say about CBT


experiences. Positive comments showed that clientsfelt valued by the therapist and enjoyed talking.They felt able to talk about difficult experiencesand felt that the therapist and others in the groupunderstood their problems. Clients enjoyed a senseof inclusion in the group and the opportunity tohelp others. Negative comments were that talkingwas emotionally painful for some clients, with somesaying that they had found it difficult to identifywith other group members. A few clients said theyfelt that the therapists were too confrontational attimes.

McDonald et al. (2003) suggest that a qualitativeapproach looking at clients’ views of therapy canprovide clinicians with useful feedback regardingaspects of therapy that are either valued or unpopu-lar with their clients. Perhaps a limitation ofMcDonald et al.’s study was that participants weredrawn from two contrasting groups and hadattended group sessions for varying lengthsof time.

More recently, Merriman & Beail (2009) carriedout a similar process study to look at clients’ viewsof individual psychotherapy. Six participants withIDs who had been attending psychotherapy sessionsfor approximately 2 years were interviewed abouttheir experiences of therapy. The main reason forreferral was said to be ‘inappropriate behaviour’.A semi-structured interview incorporating topicssimilar to those covered in McDonald et al.’s (2003)study was used. Findings showed that participantsfound talking beneficial and had a positive view oftheir therapeutic relationships. It was noted thatparticipants described a dependence on their thera-pist, and appeared to adopt a somewhat passivestance. Participants found it difficult to deal withdisruptions to therapy, such as therapists leaving orbeing absent. The authors suggest that it may bebeneficial to establish explicit processes to enhanceclients’ sense of control over endings in the thera-peutic relationship.

In this study we sought to explore the views ofparticipants with an ID who were all attending indi-vidual CBT for emotional problems. Interviewswere carried out at the same stage in therapy foreach participant. We were interested in participants’own personal accounts of their experience of CBTto establish what aspects of therapy were of signifi-cance to them.

Method

Participants

Participants were recruited from three learning dis-ability psychology services, one in Scotland and twoin England. Ethical approval was obtained from thehealth board ethics committees at each of the sites.Potential participants attended an initial screeningsession to ensure that those recruited were suitablecandidates for CBT and that the participants them-selves wished to engage in this therapy. Twenty-twoparticipants were recruited into the study; however,seven participants either withdrew from treatmentor did not wish to be interviewed.

The 15 participants who took part in the studycomprised eight men and seven women. Fourclients were referred for depression, four foranxiety, four for anger and three clients had amixed presentation. Participants’ ages ranged from26 to 52 with a mean age of 38.8 years. The Wech-sler Abbreviated Scale of Intelligence (WASI; Psy-chological Corporation 1999) was administered toall participants to determine their level of cognitivefunctioning. The Vocabulary and Matrix Reasoningsub-scales were used in this study. The mean WASIscore was 67 (SD = 8.98, 55–79).

Procedure

Participants attended therapy sessions for approxi-mately one hour either weekly or fortnightly. Allparticipants were interviewed twice during the firstphase of therapy. The first interviews were carriedout between the fourth and fifth therapy sessions.The second interviews were carried between theninth and tenth session. Each interview lastedapproximately one hour. Five researchers who hadexperience of working with individuals with IDscarried out the interviews. The researchers allreceived training to ensure that they were familiarwith the interview protocol. All interviews wererecorded and transcribed verbatim with the consentof participants. A topic guide was followed for theinterviews to explore (1) the nature of the person’sreferral for psychological help; (2) the nature ofemotional problems that they were experiencing; (3)past experience of therapy or professional help fortheir problems; (4) their knowledge and expecta-tions of CBT; (5) the perceived impact of therapy




on their broader lives; and (6) future help that par-ticipants thought they might require. The aim of theinterviews was to develop a dialogue with partici-pants and cover the topics outlined above, whileremaining open to other subjects raised by the par-ticipants themselves.

Adherence to cognitive behavioural therapy

Six therapists took part in the study, all of whomhad experience of working with clients with IDs. Toensure that therapists adhered to a CBT approach,video-taped sessions were rated by a CBT expertusing the CTS-Psy (Haddock et al. 2001). Goodfidelity to the model was established, the details ofwhich are reported by Jahoda et al. (2009b).

Analysis

Data were transcribed and analysed using interpre-tive phenomonological analysis (IPA). A phenom-enological stance was considered most appropriateas the goal was to establish participants’ therapeuticexperience in the context of their broader lives andsocial circumstances. IPA is phenomenological inthat it is concerned with an individual’s personalaccount of an event or experience; however, it alsorecognises the researcher’s role of interpreting data.Transcripts of the interviews were read through anumber of times and text considered to be signifi-cant was extracted in order to identify themes.Potential connections between the emergent themeswere then mapped out and overarching themes wereidentified when links across topics were drawn out.The participants’ two interviews were analysedtogether, providing a broader sense of their views ofthe therapeutic process and its impact. A secondresearcher reviewed the analysis (Smith & Osborn2008). Transcripts of the first three interviews werealso independently analysed by the second authorand the themes emerging were compared and theprocess discussed. Care was taken to ensure thatthe final themes were grounded in examples fromthe interviews (Elliot et al. 1999).

Results

Three overarching themes emerged from the data:(1) Talking in therapy; (2) Feeling valued and vali-

dated; and (3) Change in therapy. Sub-themes wereevident within each of the overarching themes.These will be described in turn, and illustrated withrelevant quotations. For purposes of confidentialityall names have been removed from quotations andthe local dialect changed to a more standard formof English. Where changes have been made theedited text will appear in brackets.

Theme 1. Talking in therapy

All participants saw therapy as being characterisedby the process of talking about problems. This over-arching theme breaks down into three sub-themes.

(i) Talking is helpful

All participants said that talking in sessions abouttheir problems was helpful in itself. Participantsspoke of a sense of relief and immediate benefitgained from talking about their problems.

I felt a lot better, relaxed. I feel this great bigweight come off my shoulders and I felt thingy,and that weight can stay away altogether and Ifeel a lot better.

(Male, aged 52, referred for anger)

Many participants said that they valued having anidentified person with whom they could talk abouttheir problems. Some of the comments contrastedparticipants’ experience of talking to their therapistwith that of talking to others in their life.

I find it easy to talk, oh absolutely. It helps (totalk). I feel great it absolutely relaxes me. It’swhen I have no-one to talk to that I get myselfreally frustrated and I get really down there whenthere’s no-one to talk to.

(Male, aged 50, referred for anger and anxiety)

I love it. I love talking to another adult. It’ssomebody that understands how you feel.Because for all my family talk to me, but theydon’t talk to me in the way I want them to talkto me.

(Female, aged 49, referred for depression)

(ii) Talking in private

A number of participants said that they valued theopportunity for confidential discussions, as they did




not wish carers to know what was said in sessions,or felt that it was easier to talk to someone outwiththeir staff team. Even those participants who werehappy for information to be passed on to carersappeared to highly value the fact that confidentialitywas discussed with them and they had been giventhe option of privacy.

I thought (staff) at the office were using (staff) tocome here to find out what I was saying and that.

(Female, aged 36, referred for anxiety)

It’s easier to talk to someone outside the fourwalls.


I felt a bit more comfortable one to one, becauseyou can talk about things that are private andconfidential. Any, like. . . . eh problems thatyou’ve got that you don’t want anybody else toknow because it’s private, you know.


(iii) Talking can be difficult at first

While all participants said that they valued talking,some clients said that talking was difficult at first, orsaid that they found particular topics difficult totalk about.

That’s why I was a bit, well, it’s going to be oneof those new faces again who I don’t know.

(Male, aged 32 referred for anxiety and anger)

Well, to start off with I did find it a bit hard.Coming about two or three times, I find it morerelaxing and I can open up.


Theme 2. Feeling valued and validated

The second overarching theme was ‘Feelingvalued and validated’ with three sub-themes asfollows.

(i) Being treated as an equal

Many participants’ commented that they had ben-efited from a therapeutic style characterised byapproachability and easiness. A number of partici-pants’ spoke of being treated as an ‘equal’ or ‘likean adult’. This was often spoken about in contrast

to experiences of being ‘treated like a child’ withinother contexts.

It’s none of that ‘you better watch what yoursaying’. With (therapist) you can just let it allhang (out).


So like it’s not, emm, it’s not like how can I putit, what’s the word I’m looking for, eh, I’m likethe professional and you’re something. It’s liketwo people going in for a (chat).


Well my (therapist) seems to think I’ve got thebrain of an adult, she seems to think I speak likean adult and I do things in an adult way.


(ii) My problems are taken seriously

Participants commented that talking to therapistswas different to talking to other professionals orcarers, saying that therapists talked in depth aboutproblems and took a thorough approach.

(Therapist) likes to get in depth about whatyou’re thinking and tries to put himself in yoursituation.


Evidence of a thorough approach was thattherapists listened attentively to what participantshad to say. Indeed the therapists’ listening skillsappeared particularly salient to a number of partici-pants, many of whom commented specifically ontheir therapists’ body language and eye contact. Afew participants liked the fact that their therapistwrote down what they said during sessions, seeingthis as a validation of their problems and evidencethat what they said was given importance. Theyappreciated that their therapists had experience ofworking with emotional problems and appearedconfident that they were skilled and equipped tohelp.

Emm, we just talk about how to deal with ourdepression and anxiety and that. But she writesthings, and she’s doing the flipcharts. That’s quitegood that. She writes what you think and howyou feel at the time. And how to try and copewith them, then she writes the speech bubbles.




It’s quite funny, she’s trying to teach me how tomake myself feel better.


But you can actually see by (therapist) that she’slistening, because she’s looking straight at youwhen, when you’re talking to her and she justlistens as well.

(Male, aged 32, referred for anxiety and anger)

When I sit there (therapist’s) eyes are pointing atyou. He’s looking at you. He doesn’t look at thewall or the (window), or you know, he’s staring atyou. But if he takes his eyes off you he’s maybelike writing down or you know taking notes.


(iii) Feeling cared for and understood

Most participants saw their therapist as an ally whocared about their difficulties. It seemed that overtime the participants had developed greater trust inthe therapeutic relationship and valued anempathic, validating therapeutic style.

The most helpful thing was she was there. Sheknew I had a problem, she seen it. And that wasthe most helpful thing.

(Male, aged 52, referred for anger problems)

(Therapist) seems to understand how I feel and Iget something out of it, you know what I mean, Iget a lot of pleasure (out) of it.

(Female, aged 29, referred for depression andanger)

Theme 3. Therapy and change

All participants acknowledged that they had prob-lems and said they wanted to engage in a therapeu-tic approach. A number of common sub-themesemerged when clients spoke of change.

(i) Therapeutic goals

While many participants spoke of goals directly rel-evant to the problem for which they were referred,participants also identified broader life goals such aspositive changes in relationships, and social oppor-tunities. Another broad aim was to feel better aboutthemselves. Participants wanted to show others thatthey could change, express themselves better, and

build confidence in themselves. Table 1 showsexamples of participants’ therapy goals.

(ii) Change in therapy

Participants did identify positive changes that theyattributed to receiving therapy.

And I seem to find I’m feeling a hell of a lot, lotbetter and happier and I mean I’m not hittinganybody. I’m not falling out with anyone.


If it wasn’t for (therapist) then I would probablybe the same now. Probably I would be commit-ting suicide or something. Do you know what Imean? But because of (therapist) I didn’t go thatfar.


Table 2 shows that participants referred to differ-ent kinds of change, from coping techniques theyhad learned in therapy to changes in their self-perceptions and the quality of their relationships.There was a sense that therapy did have a perceivedimpact on many participants’ broader lives.

Table 1 Clients’ therapeutic goals

Self LifeChange the way others see me To do things for myselfFeel better about myself To get a jobBuild my confidence To get something to do

Emotional/coping RelationshipsStop letting things get to me To get out more and

meet new peopleStop being aggressiveTo make friendsExpress myself better

Table 2 What clients say has changed

Self LifeFeel great about self Getting out moreMore confident More sociable

Emotional/coping RelationshipsCan understand my

problems betterGetting on better with

othersMore patience People see me differentlyI can express myself

better




(iii) Change is fragile

Participants expressed a cautious optimism aboutthe outcomes of therapy. For example, they hopedthe therapist could help, but believed that it wouldtake time. Other participants were more ambivalent,at times being optimistic about change, while alsomaking conflicting statements suggesting doubtsthat change could happen. Many participants spokeof it being difficult to know what will happen in thefuture.

I just take one step at a time and see how it goesI can’t really think that far ahead.

(Female aged 45, referred for depression)

Despite noting progress, many participants saidthat they felt that they required longer-term input.A common concern highlighted by participants wasthat progress made in therapy may not be main-tained beyond discharge.

Things take time. For a while I was doing notbad and then everything as I say happened. I justwent down hill. So, right it was like I went upand then back down again. So, it could takesome, some time for that to come back again youknow. Like, everything’s a time consumingprocess. Take one day at a time, one step at atime you know.

(Male aged 28, referred for anger)

I don’t know but I think my anger will be back.(Male, aged 52, referred for anger)

I just don’t want to stop seeing (therapist),because it’ll take some time to get to see her again.


Other participants said they felt that there was noprospect of change in key aspects of their livesbecause of their disability.

But I’m still staying the same. It’s really frustrat-ing. They’re all getting on with their lives but I’mnever going to have a relationship I’m alwaysgoing to be the odd one (out).


Hence, some clients seemed to feel that theyrequired a long-term supportive relationship. Theyseemed to have an external locus of control withregard to their emotional difficulties or feel theycould not maintain progress made in therapy.

Discussion

These findings indicate that in many respects clientswith IDs have similar experiences of therapy asother client groups, and value similar aspects of thetherapeutic process. It is striking that the mainthemes emerging from the interviews indicate thatparticipants placed most importance on generaltherapeutic factors that are relevant to a broadrange of talking therapies, rather than factors spe-cific to CBT. While a few participants alluded toCBT strategies used in sessions such as ‘thoughtbubbles’ and role play, this did not emerge as astrong theme on analysis. However, the significanceparticipants attached to being ‘treated as an equal’may suggest benefits that are linked to the collabo-rative approach used in CBT. This sense of paritywas in contrast to Merriman & Beail’s (2009)finding that intellectually disabled clients’ receivingpsychodynamic psychotherapy appeared to adopt asomewhat subordinate position.

All participants taking part in this study said theyenjoyed talking to their therapist about their difficul-ties and felt they were able to engage well withtherapy sessions. In common with findings from thegeneral adult mental health population (Pesale &Hilsenroth 2009), many participants said they foundtalking beneficial in itself, and appreciated that theirtherapists spoke to them in an in-depth fashionabout their difficulties. Participants found therapyvalidating, saying that they felt they were listened toand that their problems were acknowledged andtaken seriously. It is notable that participants specifi-cally commented on their therapists’ attentivenessand active listening skills. Overall, a particularemphasis was placed on the therapeutic relationship,with considerable value placed on a therapeutic stylecharacterised by warmth, empathy and easiness.While this is a common finding in the wider processliterature (e.g. Bohart & Greenberg 1997; Orlinskyet al. 2004), these processes may be especially impor-tant for people with IDs, as they often have fewersupportive relationships in their life compared withtheir non-disabled peers, and, therefore, fewerexperiences of being listened to and accepted on anequal basis by others, e.g. McDonald et al. (2003).Thus, this client groups’ distinct life experiencescould cause them to place special value on someaspects of therapy. In keeping with this argument,




some participants said they appreciated being‘treated like an adult’ by their therapist as this con-trasted with their treatment from others.

Thwaites & Bennett-Levy (2007) point out thattherapeutic empathy has been a relatively neglectedtopic in the CBT literature. This is surprising asBohart et al. (2002) found higher effects sizes forempathy in CBT compared with other types oftherapy when conducting their meta-analytic reviewof this topic. When seeking to explain this findingthe authors argue that empathic therapeutic rela-tionships may be even more important inintervention-based therapies such as CBT, as clientsare required to engage in emotionally demandingtasks. Leahy (2008) also emphasises the importanceof the therapeutic alliance in CBT and cautionsagainst an overemphasis on CBT techniques andprotocols to the detriment of the therapeutic rela-tionship. He points out that many common conflictsand barriers in the therapeutic relationship can beunderstood and addressed from a cognitive behav-ioural theoretical model. Compassion focussedtherapy (CFT) places particular importance onempathy as an active ingredient of therapy (Gilbert2005, 2009, 2010). Drawing from an evolutionarymodel, Gilbert explores how CFT can help clientswho may be unable to access positive affect regula-tion systems that allow self-soothing and self-reassurance. He suggests that by assuming acompassionate and empathic stance the CFT thera-pist can help to foster clients’ sense of being caredabout and validated, and ultimately support clientsto adopt a self-nurturing approach to regulate theirown distress. The findings of this study suggest itmay be worth exploring the benefits of using acompassion-based approach for clients with IDs,many of whom will have suffered repeated disrup-tion to care giving relationships.

The importance placed on a confiding therapeu-tic relationship is further underpinned by thefinding that participants valued having a choiceabout the involvement of carers and whether infor-mation was shared with carers. Clearly, there can besubstantial benefits of involving carers in therapy(Rose et al. 2005). However, given the importanceparticipants attached to the confidential nature oftherapy, therapists need to manage this in a bal-anced way that does not preclude the opportunityfor private conversations.

Although most participants recognised areas ofchange as they began therapy or showed some cau-tious optimism about the likelihood of change,many voiced a general concern about being dis-charged from therapy, apparently viewing change assomewhat fragile and possibly short lived. As inter-views were carried out within the first phase oftherapy, it is possible that participants wouldbecome more optimistic as therapy progressed.However, it may be that some participants viewedprogress as being dependent on the input of theirtherapist, suggesting issues of low self-efficacy oftenfound in individuals with an ID (Gresham et al.1988; Slemon 1998). This could clearly be a barrierto the maintenance of therapeutic change and high-lights the benefit of working in a planned waytowards discharge. Clients with low self-efficacymay benefit from the use of role play, homeworktasks and behavioural experiments specifically toaddress this issue. Concerns about discharge mayalso be partly alleviated by the involvement ofcarers who can support the use of coping strategiesin the longer term. The importance of paid carersas agents of change is well documented (e.g. Allen1999). The tendency has been for clinicians toinvolve carers in supporting the use of techniquesand strategies learned in individual CBT sessions.However, given the value participants placed onwarm, empathic therapeutic relationships, perhapsmore consideration should be given to influencingthe carers’ style of support and responsiveness. Staffmembers trained exclusively in behavioural prin-ciples may be cautious about validating clients’experiences or empathising with feelings for fear of‘reinforcing’ behaviours. Perhaps by increasingcarers’ awareness of the benefits of adopting anempathic stance and helping them to develop goodlistening skills and empathic communication skills,we could go some way to ensure that clients receivefitting emotional support. This would in turnenhance clients’ sense of acceptance, value andsocial safeness (Gilbert & Leahy 2007).

Limitations and future research

A limitation of this study is that the interviews werecarried out only during the first phase of therapy. Itwould be helpful to consider clients’ views regard-ing therapy at the point of discharge and at follow-




up. The findings were not validated, and it wouldhave been beneficial to consult people with IDsduring the development and analysis of theinterviews.

The group of participants who took part in thisstudy had a relatively wide range of IQ scores. Infuture studies it might be interesting to compare theexperiences of clients across different levels of ID.If level of ability has an impact on the therapeuticprocess, then the clients’ perceptions might differmarkedly, in addition to their ability to report theirviews. Finally, it may be illuminating to comparetherapists’ and clients’ views of the same therapysessions, and examine whether they share commonviews about key ingredients and processes.

Conclusions

This study has shown that clients with mild to bor-derline IDs felt they had engaged well with a CBTapproach and had benefitted from strong therapeu-tic relationships.Yet, they voiced concerns thatprogress may be temporary and that problemswould return following discharge. This finding hasimportant implications that deserve further investi-gation. Overall, it is hoped that this paper highlightsthe benefits of exploring clients’ perceptions of thetherapeutic process when seeking to enhance clini-cal effectiveness, rather than relying on profession-als’ insights or outcome data.

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Accepted 15 February 2012




Documents

Cognitive behavioural therapy from the perspective of clients with mild intellectual disabilities: a qualitative investigation of process issues