Psychotherapy (IAPT) for people with learning disabilities

Psychological therapists and occupational therapists were not included in this qualitative study of 27 mental health staff, which is a shame.

People with learning disabilities frequently experience mood difficulties such as anxiety and depression (Cooper et al., 2007). UK policy and legislation says they should receive help for this in mainstream mental health services (Department of Health, 2011) with “reasonable adjustments” (Equality Act, 2010) made so this can happen.

Although there is mounting evidence for the effectiveness of psychological therapies for people with learning disabilities (see Taylor et al., 2013), it has been found that they cannot always access therapy through mainstream mental health services such as those provided under the Improving Access to Psychological Therapies (IAPT) initiative (Chinn et al., 2014). This raises questions as to whether the statutory rights of people with a learning disability to receive therapy in mainstream mental health services are being upheld.

This blog looks at a recent study which aimed to examine the experiences and views of IAPT workers about providing therapy for people with learning disabilities. The authors hoped to examine therapists’ views of perceived barriers, solutions, and any relationships between therapist factors (i.e. training, experience) with their attitude and confidence when working with people with learning disabilities.

This study examines IAPT workers’ experiences of providing therapy for people with learning disabilities.

Methods

The research used both qualitative and quantitative methods. An electronic survey was sent to IAPT staff across four sites in the North West of England. Fift-five people responded:

42.9% were Psychological Wellbeing Practitioners (PWPs) providing guided self-help and education
30.4% were High Intensity Therapists (HITs) providing psychological therapies
26.8% were unspecified ‘others’

The survey collected quantitative data using closed-ended questions where participants answered ‘yes’ or ‘no’ or responded using a Likert-Scale, and collected qualitative date using open-ended questions where participants could respond using free text.

Results

There was a significant positive correlation between therapist confidence in providing therapy for people with learning disabilities and how much they agreed they had seen positive outcomes.
There was also a positive correlation between therapist confidence and perceiving more barriers to working with people with learning disabilities.
There was no relationship between whether therapists had received training in working with people with learning disabilities and their confidence, or whether they felt they’d seen positive outcomes.

Qualitative data were organised into a number of themes pertaining to therapist experience. Altogether the authors present 14 themes pertaining to the broad areas of: whether therapy could be provided in a mainstream service; problems experienced and positive outcomes; and barriers. Themes included areas such as service users’ ability to learn new skills; struggling with communication; participants’ views on equality; and barriers faced due to limitations associated with the therapist, service user, or system.

Themes developed from the data included respondents’ perceptions of various barriers faced when providing therapy to people with learning disabilities.

Conclusions

The authors conclude from the qualitative data that most respondents felt psychological therapy for people with learning disabilities can be provided in IAPT, were keen to provide therapy, and reported positive experiences of doing so.

From the quantitative data, the authors suggest that successful experiences of providing therapy for people with a learning disability led to increased confidence, which led to a more positive attitude about providing such therapy again in future. They also suggest that experiencing barriers to working with people with learning disabilities might have led to respondents feeling more confident due to eventually overcoming these barriers.

Strengths and limitations

This study addresses an important area; in my experience there is great regional variability as to whether IAPT services are willing to provide therapy to people with a learning disability. Unfortunately, it also has several limitations that detract from its conclusions.

In terms of the quantitative elements, the authors rely on correlational analyses but frequently go beyond their data to suggest specific causal links (even though correlation doesn’t equal causation). When suggesting such causal links the authors do not consider alternative explanations or give any evidence as to why you should believe their interpretation over any alternatives. Furthermore, the authors do not consider possible confounding factors such as overall therapist training or experience (inherent in the sample due to the inclusion of both PWPs and HITs; not to mention the unspecified ‘others’). The authors’ conclusions therefore seem to be insufficiently backed up by their quantitative data.

As for the qualitative elements of the study, we are not told which qualitative methods were used; this is important as methods are based on distinct philosophical assumptions and involve different ways of analysing data. We are also not informed of any mechanisms used to ensure rigour in the analysis. These two facts together mean that, for all we readers know, the themes presented are not based on any systematic analysis and could well have been pulled out of thin air. Furthermore, the 14 themes provided are very descriptive with no deeper interpretation of participants’ responses. The qualitative analysis therefore reads as a selection of interesting quotes rather than an analysis which helps us reach a detailed understanding of participants’ experiences.

Because of all the issues above, neither the qualitative nor the quantitative data presented lends itself to conclusions that will influence practice. From the confusing and poorly defined ‘aims’ section it is unclear exactly what questions the researchers were trying to address, and this seems to have led to a confused design and analytic strategy.

The methodological limitations of this study make it difficult to apply the findings in practice.

Summary

Given the shortcomings highlighted above, any conclusions that can be drawn from this paper are very limited. For me, the most useful parts were the many direct quotes from respondents, several of whom seemed to want their service to be accessible to people with learning disabilities, but felt the system in which they work is not flexible enough for this to happen.

I also feel that parts of this paper provide a glimpse as to how far we have to go before IAPT services meet their statutory duty to provide services accessible to people with a learning disability. 15% of those who responded to the question ‘can therapy be provided within a mainstream service?’ said ‘no’. The authors put a positive spin on this, but I find it alarming that, if this figure is in anyway representative, then someone with a learning disability referred to IAPT has roughly a 1 in 7.5 chance of seeing a clinician who doesn’t think they can provide a helpful service to this population. This is not good enough, and reminds me of the experience I hear commonly reported in learning disability services that people with a learning disability tend to be ‘batted back’ when they are referred to IAPT, even when the referral has been for individuals with a ‘mild’ disability whose needs could be met with some minor reasonable adjustments.

Given recent coverage of systemic discrimination against people with learning disabilities in the NHS (Mazars, 2015), it seems that IAPT may be another area where the rights of people with learning disabilities to the same quality healthcare as the rest of the population are not upheld.

Further research in this area, answering properly defined questions with appropriate research designs, is badly needed so we have better quality evidence about where IAPT fails people with learning disabilities, which can be brought to the attention of senior managers and policy makers.

Is IAPT another area where the rights of people with a learning disability to good quality healthcare are not being upheld?

Links

Primary paper

Shankland J, Dagnan D. (2015) IAPT practitioners’ experiences of providing therapy to people with intellectual disabilities. Advances in Mental Health and Learning Disabilities, 9(4), 206-214. [Abstract]

Other references

Chinn D, Abraham E, Burke C, Davies J. (2014) IAPT and Learning Disabilities (PDF). Research Report, Kings College, London. Last accessed 29 March 2016.

Cooper SA, Smiley E, Finlayson J, Jackson A, Allan L, Williamson A, Mantry D, Morrison J. (2007) The prevalence, incidence, and factors predictive of mental ill-health in adults with profound intellectual disabilities. Journal of Applied Research in Intellectual Disabilities, 20(6), 493-501. [Abstract]

Department of Health (2011). No health without mental health: a cross-government mental health outcomes strategy for people of all ages. Last accessed 29 March 2016.

Mazars (2015) Independent review of deaths of people with a Learning Disability or Mental Health problem in contact with Southern Health NHS Foundation Trust April 2011 to March 2015 (PDF). Last accessed 29 March 2016.

Taylor J, Lindsey WR, Hastings R, Hatton C. (Eds.) (2013) Psychotherapy for People with Intellectual Disabilities. Routledge, London. [Publisher page]