Literature review. David Seckington. Can the empirical success of Cognitive Behavioural Therapy be effectively applied

 Cognitive behavioral therapy applied to people with learningdisabilities.
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David Seckington. 96014195.
University Centre Blackburn College.
Can the empirical success of cognitive behavioural therapy be applied successfully
to people with learning disabilities.
A literature review.
Gates (2007) suggests that people with a learning disability represent a significant
proportion of society and so should be entitled, the same as any other citizen to access the
skilled professionals who are trained and able to meet their specific healthcare and social
needs. From a historical and institutional perspective this has not always been so.
People with learning disabilities are a very diverse group of people. Each person has their
own unique personality and characteristics as well as their own history, values and opinions.
They are a group of people who in law have the same rights as any other citizen although in
the past and frequently today they continue to be excluded and discriminated against
(Hardy, Chaplin & Woodward, 2010).
Due to the improved access to healthcare and survival rates for people with learning
disabilities for both young and old and those with profound disabilities, it is vital that
services such as mental health remain efficient, affective and able to meet the needs of this
client group (Emerson & Hatton, 2008).
This literature review will explore the success and difficulties experienced regarding access
too and the application of cognitive behavioural therapy for people with learning
disabilities. Reviews such as this attempt to maintain awareness regarding this complex
group of people.

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Introduction.
What is a learning disability?
Within literature the definition of the term learning disability can become confused and
blurred at times with the term learning difficulty. An individual with a learning disability
according to the Department of Health (2001) Valuing People definition, is a person with a
significantly reduced ability to understand new or complex information and to learn new
skills referred to as impaired intelligence. Together with a reduced ability to cope
independently i.e. impaired social functioning which generally started before adult hood
with a lasting effect upon development.
The term of learning disability was implemented to replace the previous and more
derogatory and negative descriptive term of mental handicap. Many people with a learning
disability prefer to use the title of learning difficulty to describe themselves. This term can
be confused with other conditions such as dyslexia although within the health and social
care sector of the United Kingdom this terminology is interchangeable. People with a
learning difficulty such as dyslexia do not have a learning disability as defined by the
Department of Health (2001). The UK is the only country that uses this interchangeable
description between the two groups whilst other countries prefer to use the term
intellectual disability to describe a person with what the UK would define a learning
disability (Gates, 2007).
For the purpose of descriptive clarity this literature review will use the words ‘person ‘or
‘people’ in reference to an individual with learning disabilities and employ the United
Kingdom term and definition of learning disability as defined by the Department of Health
(2001) Valuing People. Emerson, Hatton, Felce and Murphy (2001) advise caution regarding
the labelling of learning disabilities within society. Historically the use of a label placed upon
this particular group of people has served to segregate them from ‘normal’ society and
potentially conjures up negative imagery.

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Legislative history of learning disability from the 1900’s and early behavioural psychological
approaches towards mental healthcare.
The history of learning disability has been controlled by the ebb and flow of society’s
opinions and attitudes and the governments changing and implementation of law and
legislation.
Gates (2007) suggests that society in the early 1900’s was unable to understand the reasons
why these people looked or behaved the way that they did. Society at the time regarded
these individuals as a threat to their own ideas of what constituted normality, believing that
the degeneration within society was due to these individuals procreating with ‘normal’
people. Through the introduction of the Mental Deficiency Act (1913), individuals could be
removed from society and detained within an institution or asylumif they fitted any of the
four criteria under the act which was idiots, imbecilic, feeble minded and/or morally
defective.
Gates further suggests that the largest influx of people to be detained within asylums or
institutional settings arose from a committee that was originally set up to organise
children’s education but extended its power of control towards the adult sector. With this
diagnosis according to the Mental Deficiency Act (1913) 100,000 people was identified and
recommended for detention. Referred to as The Wood Report (1929), it was responsible for
the removal from society and incarceration of up to 77,000 individuals whom today we
would refer to as learning disability.
Bewley (2008) describes the actions of a chief nurse called George Jepson who was
employed in 1797 by an institution called the Retreat of York. Changes had begun to occur
within established asylums and institutions albeit slowly and with some resistance from
certain members of medical hierarchy. Jepson had become very concerned at the standard
approach of care by staff members towards inpatients and he had expressed doubts that
the reliance on fear which would today be considered physical and psychological abuse to
manage the mentally infirm was completely unnecessary. Jepson assumed that through the
actions and behaviour of the staff towards not only the inmates but also each other, the
inmates would respond and react to positive and friendly stimuli.

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This intervention and approach by Jepson could be compared to Bandura’s (2006) Social
Learning Theory. The theory of vicarious learning and mirroring of appropriate behaviour
which also would have had a strong impact upon the behaviour of inmates due to their
perception of authority of the staff. The display and mirroring of behaviour has a much
greater impact upon a subject when that subject perceives the display coming from a
person in a place of dominance and elevated hierarchy.
Jepson’s approach to the treatment of institutionalised people and the awareness it created
within the staff members and inmates possibly constitutes some of the earliest forms and
attempts at psychological intervention. Bewley (2008) further suggests that the success
shown by Jepson and the Retreat of York paved the way for other institutions and asylums
to adopt this much more psychologically based approach.
Gates (2007) adds that today through public awareness and implementation of both local
and higher government law and legislation, institutions such as these have now closed or
being re-used for other purposes due to the implementation of Valuing People (2001). The
government’s White Paper Caring for People (DOH, 1989) and the NHS Community Care Act
(1990) began to pave the way for inmates to be released back into community based
settings, supported to live within their own homes, able to access the community and health
services with the same rights as any other citizen. Due to the model of care being
institutional, awareness and support by other professionals and services needs to be
directed towards reducing the continuing devaluing psychological effects placed upon these
people. For social inclusion to be truly achieved to enable people with learning disabilities to
successfully access mental health services such as cognitive behavioural therapy, continued
research and monitoring must be carried out nationally as to its effectiveness for this group.
Prevalence of Learning Disability within the United Kingdom.
Emerson and Hatton (2008) argue that it is impossible to accurately determine the numbers
of people with a learning disability within the United Kingdom. If predicted population rates
within England increase from 50.9 million in 2007 to 53.4 million in 2017, it can be assumed
that population numbers of learning disability will also increase. Factors that may also lead
to an increase in learning disability may be attributed to growing numbers of younger males

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from ethnic communities, increased survival rates among young people with learning
disabilities with complex and challenging behaviour and people living longer due to
increased and improved access to healthcare. Emerson and Hatton estimate that 985,000
people within the United Kingdom have a learning disability, this figure includes 828,000
adults aged 18 years and over. Of these adults the estimated number of people known to
use health services is 177,000.
This increase in population of learning disability appears consistent with previous findings.
Hardy Chaplin and Woodward (2010) suggest that learning disability is one of the most
common forms of disability currently within the United Kingdom with approximately 1.5
million people having a lifelong condition.
What is CBT?
Cognitive behavioural therapy is a form of psychotherapy that teaches the client or the
patient to replace dysfunctional self-speech (Colman, 2006).
Within the booklet entitled Making Sense of Cognitive Behavioural Therapy (CBT) produced
by the National Association for Mental Health (MIND). Hatloy (2012) suggests that this form
of therapeutic intervention is referred to as talking therapy. The focus is placed upon how
the person perceives the direction that their life is progressing. It addresses any thoughts,
beliefs and attitudes that may be influencing the way the person behaves. Sessions are
directed towards exploring negative thought patterns particularly those that impact upon
the person’s daily life. Whilst the client is in session they will explore in a structured but also
flexible and adaptable manner, any problems they are experiencing with both parties
agreeing a plan to challenge and change negative cognitions and behaviours. This may
involve the client engaging in certain tasks and homework.
Cognitive behavioural therapy is evidence based. It is a psychological approach that helps
clients to analyse and ‘reality test’ current trends within their thought process, emotional
reactions and behaviour by assessing current difficulties. Sheldon (2011) further suggests
that by both parties agreeing new approaches towards challenging dysfunctional thought

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and behaviour whilst employing small steps towards an achievable goal coupled with
monitoring and evaluation, then progress can be made.
Access to CBT through the NHS.
Due to the cost effective nature and evidence based research, cognitive behavioural therapy
is an attractive option and a source of therapeutic intervention for the National Health
Service in these current times of financial cutbacks. Banerjee, Knapp, Scott, Strang,
Thornicroft and Wessely (2012) argues that if any members of the general population who
are unfortunate to be suffering from any mental illness, then currently they are receiving
insufficient treatment. Banerjee et al further suggests that mental illness is now nearly half
of all ill health suffered by people under the age of 65 years. Despite the empirical success
and effectiveness of cognitive behavioural therapy, NHS commissioners have failed to
properly commission the mental health services that the National Institute of Health and
Clinical Excellence (NIHCE) recommends and that in this day and age the access and the
availability to mental health services and cognitive behavioural therapy should be expanded.
This situation is currently the most glaring health inequality in our country.
This health inequality was also reported within the Commission Guide (2008) Implementing
NIHCE Guidance for Cognitive Behavioural Therapy for the Management of common mental
health problems. The report suggests that in many places around the country NHS services
regarding the access to cognitive behavioural therapy are either unavailable or subject to
long waiting lists. Delays are common due to high levels of demand, limited availability of
therapists and confusion regarding referral criteria and treatment pathways. The report
advises that the NHS and primary care trusts should start preparing and planning for
psychological therapies such as cognitive behavioural therapy to become more widely
available in the future. With effective commissioning, costs and inequality will be greatly
reduced and provide a mental health service available for all.
Banerjee et al further argues that restructuring is now greatly needed within the NHS and
mental health services. The net cost to the NHS would be very small whilst the evidence
within this research and study conducted indicated that the cost of psychological therapy is
low with success rates of treatment are high when compared with physical illness.

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Banerjee et al continues to suggest that when a person with a physical illness and symptoms
receives psychological therapy, the average improvement in the condition and symptoms
displayed by the patient is so great that the resulting costs and savings upon NHS services
would completely outweigh the cost and pay for psychological therapy. Current service
provision for people with mental health concerns is lacking and inadequate.
CBT success and barriers of application for people with learning disabilities.
Pilling and Burbeck (2006) conducted randomised trials regarding the application of CBT
applied to the condition of depression, alone and in conjunction with medication. This
report is one of many that has been published within the area of depression research and
provides a sweeping statement that CBT is an effective treatment.
The study which was conducted involving the general population of non-learning disability
participants concluded by suggesting CBT is effective both when applied either on its own
compared to just administering medication or when used in conjunction with medication. It
will significantly improve the outcome for people with depression. Rates of depression
within those people defined as mild learning disabilities are similar to that of the general
population but the diagnosis and treatment of depression for people with severe learning
disabilities is much more difficult define with a low research and evidence base(Gates, 2007:
Jahoda, Dagnan, Jarvie & Kerr, 2006). Communication and the inability to express their
distress effectively to others leads people with a severe learning disability to increased
levels of frustration, anger and anxiety which becomes displayed in behaviours such as
screaming, irritable moods, aggression, self-injurious behaviour and incontinence.
Professional’s such as doctors and nurses who have had no training within the field of
learning disability support and care are likely to miss-diagnose psychological states such as
depression (Willner, 2007).
Historically services for people with learning disabilities have been delivered separately
from the mainstream population. Treatment such as cognitive behavioural therapy have
been excluded from research trials coupled with systemic underreporting of mental health
problems associated with this group of people. This approach is linked to the beliefs of

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clinicians who believe that people with learning disabilities do not have the cognitive
capacity to undertake and benefit from cognitive therapy (Leahy, 2003).
Cognitive behavioural therapy is a psychological approach that is based upon scientific
principles and research which has shown to be effective. Grazebrook and Garland (2005)
argues that as regards the approaches and techniques used within cognitive behavioural
therapy, it can be used to help anyone irrespective of ability, race, gender or sexual
preference.
Gates (2007) argues that the approach and techniques employed by cognitive behavioural
therapy may be applicable to society in general and to people with a mild learning disability
but when applied to people with moderate, severe and profound disability then certain
considerations must be considered. The mental capacity of a person and any cognitive and
information processing impairment they may have that impacts upon their level of
understanding must be accounted for.
Psychological and social factors linked to people with a learning disability may also prevent
therapeutic intervention occurring. This person may have experienced past verbal, physical
abuse and social stigma leading to feelings of vulnerability, anxiety and anger. If the person
has a history of institutional care then this is a very de-personalising and de-humanising
experience where everyone within that establishment being treated the same. Staff
numbers were small and organised activities rare so interaction and stimulation was very
minimal. For a person to have lived within and experienced this environment or even born
there, social skills will be affected with reduced self-esteemand increased uncertainty and
self-doubt.
Can CBT be applied to people with learning disabilities?
Cognition and Information Processing.
Oathamshaw and Haddock (2006) suggests that the full approach of cognitive behavioural
therapy focus is upon challenging and changing dysfunctional cognitive operations of an
individual as well as the ability to make links between activating events, cognitions/beliefs

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and consequent emotions. This ability of the participant to be capable of appropriately
linking activating events and emotional responses may be necessary for an individual with
learning disabilities to successfully participate in cognitive behavioural therapy. Sams,
Collins and Reynolds (2006) agree adding that people with good language skills together
with a high IQ make people more aware and likely to recognise and identify different
emotions among thoughts, feelings and behaviours. Sams et al further suggests that there is
a need for a structured approach to simplify the concepts of cognitive behavioural therapy
linked together with methods of socialization and education to aid therapeutic participation
for people with learning disabilities.
The motivation and determination of the person with learning disabilities is also a
contributing factor for the successful outcome of any therapeutic interaction. The person
must be willing to engage with the therapist who must also in turn recognise if their client is
lacking in confidence, is uncertain of the environment they are in and the tasks that are
involved within cognitive behavioural therapy. This skill of the therapist must be taken into
account, to be able to adapt to the client that is sat before them whilst managing any
hindrance from support staff and family members that may have a negative impact upon a
client’s willingness to participate. If managed appropriately the therapist could enable the
person with learning disabilities to make therapy much more understandable, accessible
and achievable (Taylor, Lindsay & Willner, 2008).
The capacity, cognition and information processing of an individual underpins and
determines the suitability and potential effectiveness of cognitive behavioural therapy as an
approach for psychological therapy and intervention for people with a learning disability.
Kroese, Dagnan and Loumidis (2005) further argues that currently there is a wealth of
evidence suggesting people with a learning disability are often unclear and become
confused within a therapeutic setting. It is important for any valued outcome within therapy
that the person is first assessed regarding their cognitive ability and also ability to recognise
causes and consequences of cognition before any therapy takes place. If the therapist is to
use and apply humour within therapy then it is advised there is a relaxed atmosphere to
increase the positive effect of any discussion. The therapist must be confident that the

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person has the cognitive ability to understand and comprehend humour and is not laughing
with the therapist because they perceive it to be what is socially expected of them at that
specific moment in time. The application of humour within a cognitive behavioural therapy
session must also be accurately assessed by the therapist. There may be a possibility that
humour may be linked by the person themselves to historical verbal abuse. Any negative
aspects of humour that may have experienced could directly impact upon the therapy
session, increasing the anxiety of the person which in turn provides a negative experience
making future therapeutic meetings, involvement in tasks and potential future success will
be more difficult to attain.
The Department of Health (2001) Valuing People refers to the lack of cognition and
information processing as a significantly reduced ability to understand new or complex
information. Oathamshaw and Haddock (2006) argues that people with learning disabilities
do have the ability to undertake cognitive behavioural therapy. Through trials conducted
the ability of several people with learning disabilities was assessed regarding recognition of
emotions, behaviours and linking together events and emotions. Their results indicated that
the majority of the 50 participants who took part were able to recognise and link emotions
and events and differentiate between emotions. Although tasks that involved cognition
were found to be significantly difficult. Results suggest that some difficulty experienced by
the participants was found to be associated with receptive language ability. This study
concluded that people with learning disabilities have some of the skills able to undertake
cognitive behavioural therapy although it was found that the area involving cognitive tasks
and the recognition of being in therapy is particularly challenging. Oathamshaw and
Haddock suggests that clinicians should consider applying cognitive behavioural therapy for
people with learning disabilities due to a small but increasing evidence base that indicates
and supports successful application of this therapy to this population.
Success has been shown regarding training methods to teach people with learning
disabilities to recognise the core concepts of cognitive behavioural therapy.
Bruce, Collins, Langdon, Powlitch and Reynolds (2010) conducted research with the aim to
investigate if people with learning disabilities can learn the skills and concept of cognitive

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behavioural therapy, the ability to link, learn and distinguish between thoughts, feelings and
behaviours. Results indicated that training techniques taught to a group of thirty four adults
prior to commencing a therapeutic session led to significant improvements in therapy
participation concluding that with prior training of this population , people with learning
disabilities can successfully receive and engage within a therapy session.
Dagnan, Chadwick and Proudlove (2000) argue that whilst conducting research, their results
indicated that the participants, who involved forty people with learning disabilities, had
encountered difficulties within the set activities. Only several people had passed the tasks
regarding their ability to link and identify emotions and situations. Dagnan et al concluded
and agree that with preparatory training, the individuals would benefit greatly and be able
to grasp the concept of cognitive behavioural therapy.
Cosden, Patz and Smith (2009) suggest problems linked to auditory processing and attention
may be a contributing factor in relation to a successful therapeutic outcome for people with
learning disabilities. A study was conducted with 52 adults with learning disabilities and 87
adults who had attention deficit hyperactivity disorder (ADHD). All of the participants were
identified as not having any cognitive or information processing deficits and was conducted
using a computer and web based survey gathering data that dealt with perceptions and
explored the effectiveness of psychotherapy. The study concluded that all the participants
thought the therapeutic process conducted in this manner was helpful although the people
with auditory processing problems were much less likely to reach and attain any goals and
be successful within any therapeutic program. Also 44% of the group who had learning
disabilities within this study also stated that their condition affected the effectiveness of
therapy and this group also stated that they would not seek therapy again. The rationale
behind this research attempted to ascertain the problems associated with information
processing and the affects it has upon the process of psychotherapy for people with learning
disabilities using computer and web based approaches. Research and study that involves
any population must also take into consideration the cognitive ability as well as the complex
nature of that group.

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Peterson, Maier and Seligman (1993) suggest that when people experience uncontrollable
events and that future events also elude their control, problems may occur regarding
motivation, emotion and learning. Learned helplessness theory has three components.
Contingency refers to any positive or negative outcomes for the person within the situation
they are in. Cognition is the way the person perceives the contingency and evaluates the
future for them. If they have experienced a failure or something negative then this
expectation can stay with them driving the person’s behaviour which may result in future
helplessness, depression, low self-esteemand extreme passivity. If research’s expectations
about the capabilities of people with learning disabilities ultimately affects the way they are
treated then their behaviour may in turn be influenced confirming research's ’expectations
of this population in a self- fulfilling prophecy.
The assessment criteria for people with learning disabilities to detect mental health
problems are not well developed often lacking in reliability and validity (Taylor, Lindsay,
Hastings & Hatton, 2013).
Individuals diagnosed with a learning disability have not been offered cognitive behavioural
therapy to the same degree as the general population who have been diagnosed with the
same conditions. Despite the interventions shown to be effective for the disorder, people
with learning disabilities are known to have enduring life experiences that may expose them
to an increased risk of depression (Taylor, Lindsay & Willner, 2008).
Wilner (2005) suggests there is increasing improvement regarding people with learning
disabilities gaining access to mental health services and cognitive behavioural therapy which
historically was not the case for this population. Wilner further adds that cognitive
behavioural therapy has shown to be successful for mild learning disabilities and some
others diagnosed with more severe conditions but argues that documented reports
regarding the effectiveness of therapy with learning disabilities is extremely limited with a
distinct lack of randomised trials in relation to the effectiveness of the various components
of cognitive behavioural therapy and the level of IQ applied to learning disabilities.

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Whitehouse, Tudway, Look and Kroese(2006) agree that historically people with learning
disabilities have had little or no access to mental health services and although there is
increasing literature regarding this population, knowledge and research could and should be
greatly improved. In a literature review involving twenty-five studies regarding the effective
application for people with learning disabilities of both psychodynamic and cognitive
behavioural therapy, a total of 94 recommended adaptions were identified within cognitive
behavioural therapy. The most frequently considered and consistent adaption for increasing
the effectiveness of therapeutic intervention being the adoption of a flexible approach by
the therapist and having a person specific plan.
The suitability of cognitive behavioural therapy for short term therapy (SSCT) consists of an
interview and a rating procedure which explores whether a person has the potential to gain
maximum benefits whilst engaging in cognitive behavioural therapy. The process consists of
a one hour semi-structured interview which is focused upon gaining information according
to a nine part selection criteria. The scores provided predict the outcome of short term
cognitive therapy for the individual. This approach regarding the use of a predictive scale
not only accurately assesses the suitability or un-suitability of a person but could also save
time, money and reduce waiting lists (Safran, Segal, Vallis, Shaw, Samstag, 1993).
Oathamshaw and Haddock (2006) argues that the use of an interview and a rated scoring
system to assess the suitability of applying cognitive behavioural therapy may be effective
and applicable to some people but there are many more skills involved in receiving and
engaging in successful cognitive therapy other than verbal. The verbal skills of a person do
not totally predict success although it has been established that verbal skill and ability has
been linked with positive outcomes of CBT.
Cognitive Behavioural Therapy and the application of IQ.
The definition of learning disability and the application of IQ to categorise and help identify
and quantify the mental health needs of people with learning disabilities have begun to be
questioned. Historically a person with an IQ of seventy and below was deemed and labelled
as having a learning disability. Whittaker (2008) argues that IQ is not an accurate measure
of a person’s ability, cognition and information processing skills. The use of applying IQ to

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the broad spectrum of learning disabilities helps to define, categorise and identify this
population enabling others such as local health authorities, care providers and social
workers an aid to help identify those who may be vulnerable and at potential risk. But a
strong, unwavering belief is placed upon IQ. This method of labelling and categorising has
the great potential for miss and under diagnosing conditions of people with learning
disabilities. Whittaker further argues that the definition of learning disabilities provided by
Valuing People (2001) could also lead to negative and confusing labelling of people. The
definition states that people with a learning disability suffer a deficit in social functioning.
This term must be made much more defined and measured before the person is labelled in
such a way. This categorising and labelling of people with learning disabilities can and does
impact upon their lives and future. It can also impact upon the services that may or may not
be available to them with some people slipping through the net unable to receive the
support they need.
Whitaker (2003) suggests that the rating of IQ 70 in relation to people with mild learning
disability is totally arbitrary and has been chosen simply because it is two standard
deviations below the mean. Any person labelled with such an IQ is immediately assumed as
being unable to cope with the pressures of modern living than those with an IQ of above 71.
IQ is not a predictor of adaptive behaviour or social ability. Many people below IQ 70 have
the social and cognitive ability to learn, adapt and cope within a variety of conditions
despite this categorical label placed upon them. Conversely there are people with learning
disabilities with IQ above 70 who are unable to cope and adjust. Whitaker further suggests
that the continued use of IQ as a way of identifying people with learning disabilities that
may need certain services is a wholly inaccurate predictor of that person and their cognitive
abilities. There should be another definition and title that is applicable to this population
due to this term ‘learning disability’ being so reliant upon IQ. The use of IQ to categorise and
quantify this client group by health authorities and other services is essentially flawed.
Either these people labelled with IQ 70 are coping very well against the definition imposed
upon them or there are many people who have been missed, not been identified by services
and deemed as needing help and support by local health authorities.

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Whitaker (2003) argues that it is far more important to recognise and regard a person’s
developmental milestones whilst in their infancy. Their level of communication, social and
economic position, personal achievements and their level of cognitive ability together whilst
also taking into account a wide variety of other aspects concerning their lives is a much
more valid and accurate assessment of a person rather than be limited and restricted with a
single test involving the use IQ. The use and application of IQ to determine cognitive ability
regarding people with a learning disability is being drastically reduced as this is now
recognised as an imprecise, inaccurate and unreliable science.
From a positive standpoint regarding application of IQ for people with mild to moderate
learning disabilities, the rating and testing may help to monitor and raise concerns about
possible further deterioration of cognitive ability regarding certain metabolic disorders and
in particular Downs syndrome. Also certain cognitive deficits being experienced by the
person such as dyslexia or reading problems, memory or organisational difficulties can be
identified and if they occur can be compensated for within any therapeutic intervention
(Perry, Hammond, Marston, Gaskell & Eva, 2010).
Success and limitations treating depression, anxiety and anger management.
Jahoda, Dagnan, Jarvie and Kerr (2009) points out that it is striking that cognitive
behavioural therapy was developed to treat common mental health disorders such as
depression and anxiety within the general population but for people with learning
disabilities there is a gap. Research regarding this population needs to be addressed due to
the importance of understanding the distress experienced by these people in relation to
their life experiences.
Hassiotis, Serfaty, Azam, Strydom, Martin, Parkes, Blizard and King (2011) agrees suggesting
that due to the nature of people with mild to moderate learning disabilities they are more
likely to suffer from depression and/or anxiety when compared to the general population
due to their negative experiences of society. Cooray and Bakala (2005) agree that people
with learning disabilities are much more vulnerable to psychiatric illness. Due to people with
learning disabilities gradual increasing presence within the community, there will also be an
increase of this group accessing mental health services. Hassiotis et al continues and

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suggests that today the NHS now recognises and applies cognitive behavioural therapy as
treatment of choice for conditions such as depression and anxiety although this therapeutic
intervention is not readily available for people with learning disabilities due to the need for
modification and tailoring to meet the specific needs of the person whilst taking into
account the persons cognitive problems and complex communication issues.
Haddock and Jones (2006) argues against a need for extensive adaptation. Regarding the
results of a questionnaire passed to eight clinical psychologists engaged in applying
cognitive behavioural therapy for people with learning disabilities suggests that the
consensus of opinion reached is therapeutic results can be gained for people with learning
disabilities if therapy was delivered creatively.
For people with more severe and profound learning disabilities, the diagnostic criteria for
anxiety are difficult if not impossible to apply. The clinician must rely on observable
behaviour by themselves or other care givers rather than self-reported measures (Cooray &
Bakala, 2005). Hassiotis et al suggests that there is a developing evidence based group of
research that shows cognitive behavioural therapy to be effective and successful in the
treatment of psychosis, obsessive compulsive disorder, anxiety, depression and anger
management for people with learning disabilities. Previous studies have concentrated upon
the behavioural aspect rather than addressing the cognitive. Hassiotis et al conducted a
study with the aim of developing an individualised cognitive behavioural manual for the
treatment of several common mental health disorders that could be applied to the
complexity of mild learning disabilities and could be used as a guide by other professionals.
Through the application of randomised trials the manual was tested to see if it was suitable
for people with mild to moderate learning disabilities which could also improve the
symptoms regarding depression and anxiety. Phase one involved the development of the
cognitive behavioural therapy manual which involved a very wide ranging and varied
consultancy base involving contributions from professionals and specialists working with
learning disabilities. Information was also acquired from various literary sources such as
books, journals and published research trials where cognitive behavioural therapy has seen
positive effects. The manual is intended as a step by step guide that provides advice

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regarding changing cognition, therapy duration, behavioural techniques and length of
treatment. This research and following trials associated with the cognitive behavioural
therapy manual is a two and a half year project with trials still currently being conducted
and data gathered regarding the effectiveness of the manual and assessments involving the
interviewing of the trial participants to find out how they feel, any positive or negative
changes they may have felt or experienced also to see if any further adaptations can be
made to the manual. Hassiotis et al adds that this trial is the first of its kind to evaluate a
manualised individual cognitive behavioural therapy to treat common psychological
disorders for people with mild learning disability. The results of this trial are likely to have
considerable impact regarding the accessibility of psychological therapy and treatments for
this client group adding to current research evidence base for interventions in people with
learning disabilities which is sparse.
Borsay (2012) suggests that regarding anger, a quarter of people with learning disabilities
living within the community currently have difficulty controlling and managing this emotion.
An unfortunate consequence of this inability to control their anger can sometimes result in
the person becoming socially isolated and excluded, suffering loss of day care centres or
residential care as well as having a negative psychological impact upon paid carers and
family members.
Willner, Jahoda, Rose, Kroese, Hood, Townson, Nuttall, Gillespie and Felce (2011) suggests
that anger management through the application of cognitive behavioural therapy for people
with learning disabilities has the most developed base of evidence. Anger within this
population is generally associated with verbal and physical aggression which may lead to a
negative impact upon the quality of care and support the person is receiving whilst if anger
is not properly managed it may lead the person into criminal behaviour. Cognitive
behavioural therapy has become the first line of intervention for anger management for
people with learning disabilities. Willner et al further suggests that anger is the only
psychological condition in which controlled trials have been used properly to evaluate the
effectiveness of this therapeutic intervention for people with learning disabilities. Wilner et
al conducted a review involving seven studies of anger management in settings such as

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community based day care and one study involving cognitive behavioural therapy within a
forensic setting which involved people with learning disabilities. The review concluded that
published studies are fully consistent in reporting positive outcomes from cognitive
behavioural therapy interventions and are also effective for people with mild to moderate
learning disabilities helping the person to manage their anger. The review also indicated
that treatment gains were maintained after three and six month follows up interviews.
Wilner et al adds that evidence also shows cognitive behavioural therapy to be effective
across a varied range of settings although currently there is little evidence as regards which
key components of CBT are crucially involved within the therapeutic intervention.
Willner (2007) suggests that there is growing and convincing evidence that anger
management therapy that takes place within a group setting for people with learning
disabilities can be a successful approach and provide effective results.
Mishna and Muskat (2001) agree suggesting that group cognitive behavioural therapy
sessions has shown to be effective for certain young people with learning disabilities who
also affend. Despite the very high prevalence of learning disability within young offenders,
research has indicated that this group do not receive interventions that also address their
learning disability. Mishna and Muskat further suggests that to date studies have shown
that cognitive behavioural therapy is less effective involving youths who have not only
suffered academic delays but also have problems at home with dysfunctional families which
ultimately impacts upon the homework tasks involved within the participation of cognitive
behavioural therapy. This group of people has also shown difficulties in completing cognitive
tasks.
Willner (2007) adds that the growth of evidence regarding the effectiveness of cognitive
behavioural therapy as an intervention for people with learning disabilities remains painfully
slow. The conducting of research and trials with such a limited client group are usually small
and often with non-random allocation to groups. The gathering together of information
regarding such a complex group of people currently remains difficult.

19
Conclusion.
Common themes throughout the literature review.
Continued research and in-depth study of this highly complex group of people is needed
upon conditions such as depression, anxiety and anger. To date research regarding cognitive
behavioural therapy and its effectiveness is slow whilst only the effective management of
anger having the largest research base. More clinical research and research based practice is
needed before any professional can justify withholding potentially helpful treatments for
people with learning disabilities (Taylor et al, 2008: Wilner et al, 2011: Willner, 2007).
Other health professionals who may also come into contact with people with learning
disabilities must also receive training and awareness of the needs of this client group. Due
to their gradual improving access to health services and to help reduce the devaluing effect
and possible negative experiences they, society and others can have upon them (Emerson &
Hatton, 2008: Gates, 2003: Hassiotis et al, 2011: Willner, 2005).
Success has been shown within research that prior to cognitive behavioural therapy, if
training sessions are employed then there is an increased level of engagement and
participation for people with mild to moderate learning disabilities (Bruce et al, 2010:
Dagnan et al, 2000: Oathamshaw& Haddock, 2006). People with learning disabilities do have
the ability to engage and participate within cognitive behavioural therapy although their
level of motivation and determination to become involved within a therapeutic session and
the tasks involved are a contributory factor (Oathamshaw & Haddock, 2006: Taylor et al,
2008).
From a historical and cognitive perspective it is important to be aware of how the use of
labels upon a person or group of people can mislead and potentially be abusive. This can
give a preconceived idea regarding the actual ability of a person or client group which may
impact upon their potential to engage within therapy such as the application of IQ and the
possibility that it may conjure up negative imagery of that person or group. The application

20
of IQ to quantify people with learning disabilities is not an accurate predictor of the
cognitive ability of a person (Emerson et al, 2001: Whitaker, 2003).
Due to the complexity of this client group there is a need for any therapeutic intervention to
be adapted to meet the needs of the person by simplifying the concepts of cognitive
behavioural therapy and having a defined and structured approach whilst research has
shown group therapy to be successful for people with learning disabilities (Gates, 2003:
Hassiotis et al, 2011: Mishna & Muskat, 2001: Sam et al, 2006: Willner, 2007).
There are currently strong indications that health services and practitioners are offering
cognitive behavioural therapy to people with learning disabilities in line with the general
population and that contrary to historical belief the vast majority of this client group are
able to participate and benefit from cognitive behavioural interventions (Taylor, Lindsay &
Willner, 2008: Whitehouse, Tudway, Look & Kroese, 2006: Willner, 2004).
Alternative approaches and future research.
Difficulties can arise regarding the participation within cognitive behavioural therapy tasks
for people with learning disabilities when not only there is a deficit of capacity and cognitive
impairment present but also elevated levels of anger and anxiety. Foster and Banes (2009)
adopted a narrative psychological intervention for a man who in the study was named Paul.
This gentleman had mild learning disabilities and had previously attempted to engage in
cognitive behavioural therapy to help manage high levels of anger and anxiety but had
failed. By the use of speaking and conversation this person was placed central to his own
world and as Foster and Banes describes, enabled Paul to be an expert in his own life. The
use of dialogue was intended to assist himto access his own strengths, resources and
enable him to view himself as being separate from the problem. As the intervention
continued Paul expressed feelings of being more in control of his own life and emotions
whilst also experiencing a greater sense of wellbeing and calmness. Foster and Banes
concludes that with modifications to standard techniques, a narrative therapeutic approach
offers a viable alternative to cognitive therapy for people with learning disabilities who have
previously encountered difficulties engaging in therapy sessions and tasks.

21
The effectiveness of cognitive behavioural therapy applied through different mediums is
currently being researched, one such method is cognitive behavioural therapy by telephone.
Jones (2012) suggests that this method is of therapeutic application is as effective as and
more accessible than face to face therapy for the majority of clients whilst also saving the
NHS money and time. Study data was gathered from 39,000 patients through the Improving
Access to Psychological Therapies Services (IAPT) in collaboration with Midlands and East
NHS, National Institute for Health Research Collaboration for Leadership in Applied Health
Research and Care in conjunction with University of Cambridge researchers. A comparison
with both face to face and phone therapy results showed that phone therapy was as
effective as face to face with overall costs per session being 36.2% lower although there was
an identifiable group of people within the study whose psychological conditions displayed
more severe illness, results indicated that phone therapy would not be suitable for this
client group. These results have been so encouraging that Midlands and East NHS have
instigated a training programme to start and standardise service delivery of cognitive
therapy by telephone ensuring therapists are competent at phone contacts.
For many years self-help books have been a popular resource for people seeking help,
advice and guidance with a wide and varied range of problems. Haeffel (2010) suggests that
current research regarding self-help books can do more harm than good. Popular books
such as the ‘Dummies’ series and in particular those based upon principles of cognitive
behavioural therapy have shown that people who engage in regular ruminative thinking
have a high propensity to develop depression. Research results indicated that the research
group who read and followed the self-help book based upon cognitive behavioural therapy
displayed more depressive symptoms than the other groups. Haeffel suggests that the
current results suggest that self-help books currently sold in high numbers in many stores
may not work for people with ruminative thinking; these people may need a modified form
of cognitive skills training.
The effectiveness of cognitive behavioural therapy needs to be not only adaptable for
people with learning disabilities but also flexible in its delivery. Brown and Marshall (2006)

22
suggest that people with a learning disability are a growing section of the community with a
growing evidence base regarding their mental health needs and the services they require.
The success of applying cognitive behavioural therapy to this client group is also growing
showing improved mental health support within certain key areas whilst the best persons to
deliver this therapeutic intervention would be registered and trained learning disability
nurses. Research and training for qualified nurses would be needed to be able to implement
cognitive behavioural therapy through this group of clinicians. They are well placed within
their role and within the community to apply this therapeutic approach. Brown and Marshal
adds that there is a need for leadership and direction regarding this extended role within
learning disability nursing and action is required to support education and practice
development that will contribute to addressing the mental health and emotional needs of
people with learning disabilities whilst also contributing to the preparation of registered
learning disability nurses to practice cognitive behavioural therapy and the on-going
research within this area of clinical practice.

23
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