B R I T I S H J O U R N A L O F P S YC H I AT RY ( 2 0 0 0 ) , 1 7 6 , 3 2 ^ 3 6

Psychotherapy, learning disabilities and trauma: AVAILABILITY OF

PSYCHOLOGICAL THER APIES
new perspectivesy Despite the encouraging rise of creative
therapies (Heal, 1989), group treatment
SHEILA HOLLINS and VALERIE SINASON
(Hollins & Evered, 1990) individual ther-
apy (Sinason, 1992) and family therapy
(Goldberg et al,
al, 1995), treatment for chil-
dren and adults with learning disabilities
who experience emotional problems is still
inadequate. Indeed, in isolating one major
area of concern, namely self-injury, Oliver
Background Psychological therapies An estimated 300 000 children and adults et al (1987) found that of 596 self-injuring
are rarely used in people with learning with severe learning disabilities live in the children and adults, only 12 were receiving
UK, and over 1 000 000 have a mild learn- any psychological treatment, and only one
disabilities.Learning disabilityis often given
ing disability. The majority of the latter live received psychoanalytic psychotherapy.
as an exclusion criterion.There is in relative poverty (Office of Population However, there are promising findings
insufficient published research to conduct Censuses and Surveys, 1989). Many people from outcome studies that psychodynamic
a systematic review.Few outcome studies have coexisting physical disabilities and, treatment reduces emotional problems and
of psychoanalytic or cognitive not surprisingly given the burden they symptoms (Sigman, 1985; Frankish, 1989;
carry, there is an increase in emotional Beail, 1995; Bichard et al,al, 1996).
psychotherapy have been reported.
disturbance in proportion to the severity A review of behavioural interventions
of the learning disability. in learning disability by Scotti et al (1991)
Aims To describe recent advances in
However, there is a tendency to as- found that they were mainly single case stu-
understanding and practice within the cribe the emotional difficulties experienced dies. Cognitive±behavioural therapy (CBT)
learning disability field which have not by the individual to the disability rather has made a significant contribution to the
received wider recognition within than to emotional state or needs. ``My sis- treatment of mental health problems in
mainstream psychotherapy and ter has a tantrum and they say she is cross the general population (such as with trau-
because she doesn't get enough pocket matised groups, in depression, and follow-
psychiatry.
money. I get cross and they phone the psy- ing abuse), and is now being developed in
Method The availability of different chiatrist'', commented a learning disabled practice with people with learning disabil-
young man. ities. Lindsay (1999) discusses data for
psychotherapeutic approaches is
Current definitions of learning disabil- more than 50 people with moderate learn-
discussed.We explore developmental ity point to the importance of holistic ap- ing disabilities; the data show a lasting clin-
issues including the contribution of proaches to understanding individual need ical effect of treatment designed to change
attachmenttheory to our understanding, which look at several aspects of a person's their cognitions. Recently, cognitive±behav-
functioning within the context of their ioural approaches have been developed to
and the effects of trauma on the lives of
own life and relationships (World Health enable parents of disabled children to
people with learning disabilities. Organization, 1992). change unhelpful cognitive attribution pat-
Many people with learning disabilities terns (Turk, 1998) and to adopt more
Results Theoretical and clinical
have personality attributes and other quali- effective coping strategies.
perspectives suggestthat many ties which contribute to a fulfilling life in
therapeutic opportunities exist. spite of their impairments. Many others ex-
perience secondary emotional disabilities
Conclusions Practitioners are which interfere with their adjustment to life
encouraged to extend their therapeutic and their enjoyment of it (Sinason, 1986), DEVELOPMENTAL ISSUES
repertoire, and to report measurable and which may be symptomatic of the trau-
ma of the original impairment. Regardless of the level of learning disability
outcomes.
In this paper we start by reviewing the the following shared psychic organising
Declaration of interest None. availability of different psychotherapeutic principles will have to be dealt with: the ex-
approaches to addressing emotional and istence of the disability itself (including the
mental health problems in people with conscious and unconscious fantasies that
learning disabilities. Key developmental is- accompany it); loss (of the normal self
sues such as attachment formation, sexual- who would have been born); sexuality (in-
ity and mortality are examined in relation ternally distorted by the impact of the dis-
to the experiences of people with learning ability); dependency (not being able to live
disabilities. Then, the experience of trauma autonomously); and fear of death or mur-
by people with learning disabilities, and a der (being part of a group that society
psychotherapeutic approach to its manage- wishes to eliminate). These areas will be
y
See editorial pp. 10^11, this issue. ment are explored. illustrated from clinical perspectives.

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 P S YC HOT H E R A P Y, L E A R NIN G D I S A B I L I T I E S A N D T R AU M A

Diagnosis of learning disability ^ Dependence and disability death are acquired later than usual in
the family's response in adulthood people with learning disabilities (Harper
At the birth of a disabled child many par- The extra needs of some disabled teenagers & Wadsworth, 1993). These concepts are
ents experience something akin to grief for make it more difficult for them to take the not made easier to acquire by exclusion
the perfect child who was expected. Recent first steps towards adult life. Many parents from the more concrete aspects of death
studies of the effects on attachment of an also experience difficulty in letting go of and death rituals.
early diagnosis of learning disability suggest their disabled adult son or daughter, per-
that attachment is more likely to be inse- haps because of the distorting effect on par-
Clinical vignette
cure (Esterhuyzen & Hollins, 1997). The ental psychopathology of caring for a child
long-term consequences for people with with different needs (Hubert, 1991). Three years after her husband's death, a
learning disabilities of insecure maternal Both CBT and psychodynamic therapy widow was still telling her daughter that
attachment probably bear similarities to can help people to look at the internal± Daddy had gone to work. Her daughter had
those (such as separation difficulties) external dimension in their lives, and try had respite care during the funeral rituals
described by attachment researchers (De to reconcile their inner world with the and had not shared in the family grieving.
Zulueta, 1993; Main, 1996; Sausse, 1996), external reality which other people see. A Later, there were no rituals or grieving visi-
but may also include challenging behaviour pilot repertory grid study was conducted tors that could help her daughter to under-
and pathological grief following significant by one author (S.H.) with young adults stand or to express her feelings of loss. Her
losses (Hollins & Esterhuyzen, 1997). with learning disabilities in group therapy. repetitive questioning, `where is Dad?',
The pre-treatment grids showed a larger could easily have been misperceived as
than expected difference between ratings echolalia, and considered inappropriate.
for real self and ideal self. In the first year The mother hoped to protect her daughter
of treatment, this gap widened for some from the reality of her loss and assumed
members as they confronted the reality of that she would not be deeply affected by
Attachment something which is so difficult to explain.
their learning disabilities. Most of them
Childhood attachment is a prerequisite of succeeded in closing the gap as treatment
safety. Attachment to an adult or adults progressed (Hollins & Evered, 1990).
protects children from danger while they Psychopathology of grief
develop the maturational skills to care for In a study of parentally bereaved adults with
themselves. Where a parent is unable to Sexuality learning disabilities, only about half were
screen a child from danger, or is part of a Sexual development occurs over the same known to have attended the funeral of a
dangerous experience for a child, the child's period of time in everyone, but people with deceased parent (Hollins & Esterhuyzen,
perception of safety and of adult protective- learning disabilities may receive contradic- 1997). As a group the bereaved subjects
ness can be altered or destroyed (Pynoos et tory messages about certain basic sexual demonstrated more psychopathology and
al,
al, 1995). matters, and also about the appropriateness behavioural disturbance, including irritabil-
Spitz (1983) found that in an orpha- or inappropriateness of their behaviour. ity, anxiety, adjustment difficulties and
nage where hygiene was impeccable, tod- Developing their sexual identity, and depression, than the controls. Nearly three-
dlers who had no attachment figures were achieving the transitions from childhood quarters of their carers did not attribute
more susceptible to illness and had higher to adolescence and from adolescence to any behavioural change to the bereavement.
mortality rates. The infants started becom- adulthood, are more difficult than for those Most of us need time, perhaps many
ing `retarded' at three months, when wean- without learning disability (Sigman, 1985). months, to grieve after a death; follow-up
ing occurred and the `modest human Little help is available to prepare the young of the above subjects after five years
contacts' they had were stopped. Some person with learning disability to have an (Bonell-Pascual et al,
al, 1999) pointed to the
were given a better environment in their intimate relationship or to plan to get mar- likelihood of delayed and/or prolonged grief
second year of life but ``notwithstanding ried. This is an area of ambiguity for staff in many people with learning disabilities,
this improvement in environmental condi- and, even more, for their clients. particularly those who had not had a
tions, the process of deterioration proved However, we know that sexual abuse of bereavement-related intervention.
to be progressive''. Spitz (1983) described children and adults with learning disabil-
how children faced with a long period of ities is more common than it is in the rest
deprivation ``offer pictures reminiscent of The fear of annihilation
of the population (Turk & Brown, 1993),
brain-damaged individuals, of severely re- and that some of the `victims' later become The unconscious fear of annihilation is exa-
tarded or downright imbecile children''. perpetrators of abuse. If spoken language cerbated in people with learning disabilities
We raise the question of whether this skills are limited, it may be difficult to com- as a result of their facing societal and perso-
infantile depression also accounts for the vi- municate the emotional feelings of emer- nal death-wishes (Sinason, 1992). For exam-
sual appearance of some learning disabled ging sexuality or those associated with ple, the casual mention of amniocentesis or
children. Moreover, we consider that where sexual experience or sexual abuse. abortion on television or radio may have a
there is disruption to bonding as a result of traumatic impact, because it may awaken
the disability, the disability itself is experi- in the disabled person the awareness that
enced as a trauma, both at the time it is Mortality he or she might have been `discarded' as a re-
diagnosed for the parents and at the time There is evidence that concepts of the uni- sult of these procedures. Compliance, exces-
the child becomes cognitively aware of it. versality, inevitability and irreversibility of sive `smiling' of a false kind, violence, and

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 HOL L IN
I N S & S IN A S ON

withdrawal may be different responses to and physiological responses to triggers of things have happened for both of you ^ things
this fear. the event. Avoidance and numbing of gen- other people did to you and things you did. For
eral responsiveness are prevalent, as are example, Mr B., sometimes the police came and
it was fair, and sometimes you did not think it
memory distortions, omissions or dissocia-
Clinical vignette was fair ^ and perhaps, most frighteningly of all,
tive reactions. Symptoms of increased sometimes the police came and there was
A 40-year-old woman with autism lost arousal include hypervigilance, startle re- evidence but you had no memory of doing it.
three stone in weight, and seemed to have actions, sleep disturbance and inability to Mr B.
lost the will to live. Her mother's brother concentrate. The presence of past trauma
Yes.That's
Yes.That's right.
had died two years earlier, and her elderly in the present can be understood by Freud's
parents were in poor health. They would (1893) concept that the psychical trauma, V.S.
not make any plans for her future as, in or rather the memory of it, is a ``foreign Andinthose cases the police did know more than
common with some other older parents, you.
body which long after its entry must con-
they were hoping that she would die before tinue to be regarded as an agent that is still Mr B.
them. Family therapy sessions were effec- at work''. You
You mean ^ I am not paranoid because some-
tive in reaching a new family view of her times the police do know more than me?
life opportunities and the importance to Mr A.
Clinical vignette to illustrate
her of concrete plans being made for her I am going to miss my mum at Xmas. Really miss
the impact of trauma
future. her.
This vignette is drawn from a weekly psy-
S.H.
choanalytic group run by the authors for
TR
TRAUMA
AUMA The magic has really gone out of Xmas, hasn't it?
men with moderate learning disabilities
(IQ 45±65) who show inappropriate sexual Mr D.
A separate category for psychological trau- behaviour. This extract is from a session Yes.
Yes. No champagne or rides in a Rolls-Royce to
ma was first added to the Diagnostic and three years after treatment began and three group therapy.
Statistical Manual of Mental Disorders in weeks before a Christmas break. Patient de- Mr E.
1980 for adults and in 1987 for children tails have been changed to avoid recogni- My mum won't have any beer at Xmas because
(American Psychiatric Association, 1980, tion. Group members gave verbal consent of fighting.
1987). To have experienced a trauma, ``a to the reporting of a session. V.S.
person must have experienced an event that Mr A. And Mr C. hasn't got a mum to see ^ he hasn't
is outside the range of usual human experi- (wringing his hands, very physically agitated) I am seen her since he was really little and he has no
ence and that would be markedly distres- upset I am. Very upset. It happened last night. I idea where she is; and Mr A. doesn't see his
sing to almost anyone, such as a serious wet myself. I could not help it. She rubbed my mum; and Mr B.'s mum doesn't wantto be woken
threat or harm to one's life or physical nose in the urine. She hit me. She did. She hit me. up at 1. a.m. when he is anxious; and S.H. and I
integrity'' (DSM±III; American Psychiatric She rubbed my nose in it. (His despair and agita- are bad mothers not looking after you all at
tion built up.We were both aware that this had Xmas. And perhaps, Mr B. you are worried that
Association, 1980).
been a regular occurrence in his past but did not if you move nearer your mum she won't manage
In addition to definitions of trauma that
take place in his current placement.) to help you.
include destruction of one's home or com-
V.S. Mr A.
munity, or witnessing violence, we suggest
I wonder if, because Mr A. is so miserable with I am not going to my mother's.I used to run away
that some components apply to the experi-
Xmas coming, he is remembering something to get to her. I used to run away to find her. My
ence of disability.
from the past that used to happen, but he feels it mother can decide if I stay with her ^ no-one
The current criteria for a traumatic is happening now. (Mr A. stopped wringing his else. (He gets agitated again.)
event in DSM±IV (American Psychiatric hands and sat still, listening.)
S.H.
Association, 1994) add that ``the person's S.H. I think you are frightened, Mr A. that when your
response involves intense fear, helplessness, Did you understand that, Mr A.? V.S. says that hospital closes down you might have to be with
or horror. In children this may be expressed when you think about what your mum used to your mum, who did not look after you? But that
instead by disorganised or agitated behav- do, it feels as if it is happening now. won't happen. Y You
ou will be in another safe place.
iour''. Suddenness is an intrinsic component Mr A. (A sigh of relief passed around the group.)
of a traumatic incident. The discovery of a I know.Yes.
know.Yes. Mr B.
baby's impairment, whether by amnio- We don't have magic about Xmas any more.
Mr B.
centesis, a scan or indeed at birth, has that
I phoned my mum at 1 a.m. She was cross about V.S.
characteristic of suddenness.
it.I rang because I was paranoid. You
You are pleased there will be ward parties, but
S.H. also you are sad, and when you're sad, or sad
Post-traumatic stress disorder and angry, all the bad memories come back.
What does paranoid mean?
Central to the experience of post-traumatic Mr B. Mr A.
stress disorder for both children and adults Yes.
Yes.
I thought people knew more about me than they
is the re-experiencing of the trauma did ^ like the police might come and ask about We consider that traumatic symptoms are
through flashbacks, recurrent intrusive dis- something and I hadn't done it. significantly under-recognised in people
tressing recollections, traumatic play, V.S. with learning disabilities. This short ex-
dreams and nightmares of the event, behav- You and Mr A. have got something in common tract shows how earlier trauma was
ioural re-enactments, and psychological that helps the whole group. In the past, bad expressed through flashbacks for one

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 P S YC HOT H E R A P Y, L E A R NIN G D I S A B I L I T I E S A N D T R AU M A

man, and through an incomplete memory

for another.
CLINICAL IMPLICATIONS

& Ongoing clinical audit using standard outcome measures should be part of learning
DISCUSSION
disability psychotherapy service protocols.
Understanding the mental health
& Psychotherapy training and supervision should be made available to health and
needs of people with learning
disabilities social care practitioners in the learning disability field.

Historically, there has been a profound in- & Clinicians should be alert to the possible role of past trauma in shaping current

ability to consider that the individual with interpersonal behaviour.

learning disabilities has any emotional skills
with which to consider his or her predica- LIMITATIONS

ment. We consider that the existence of

& Limited quantitative research evidence is available.
learning disability evokes primitive fears
and fantasies societally concerning damage, & This review is too short to do justice to the available literature on patient and
guilt and loss. Some of the guilt may be due therapist experience.
to societal disadvantages.
Emotional distress or mental illness may & We focused mainly on psychoanalytic theoretical and clinical issues, rather than

be disguised or expressed in ways rather dif- the full range of therapeutic approaches.
ferent from the norm, typically behaviour-
ally. In order to make connections between
feelings and behaviour, experience and skill
are required to put into words what someone
cannot say for themselves, along with a will- SHEILA HOLLINS, FRCPsych,VALERIE SINASON, BPAS, Department of Psychiatry of Disability, St George's
ingness to see whether the person can under- Hospital Medical School, London
stand more than they can communicate in
words. In particular, the important role of Correspondence: Professor Sheila Hollins, St George's Hospital Medical School, Department of
Psychiatry of Disability, Jenner Wing,CranmerTerrace, London SW17 0RE.Tel: 020 8725 5501; Fax: 020
past trauma in shaping a person's interperso-
8672 1070; e-mail: s.hollins@
s.hollins @sghms.ac.uk
nal behaviour has been highlighted in this pa-
per. We should remember that the existence (First received 12 July 1999, final revision 20 September 1999, accepted 21 September 1999)
of disability at birth impacts on the relation-
ship of the individual with their family and
community.
However, therapy is likely to remain a rare opportunities need to be developed in
provision for the foreseeable future. order to make psychoanalytic psycho-
The clinician's role therapy available to people with learning
Psychiatrists and other mental health pro- disabilities.
fessionals have a role in understanding the Training
continuum between social care and health Future research
care, and in promoting healthy lifestyles Education for health and social care Clinical audit using standard outcome mea-
which support good mental health. Mental professionals about the emotional needs sures should be part of learning disability
health assessments and interventions must of people with learning disabilities should psychotherapy service protocols.
focus not just on the individual, but also be made widely available, and psychiatrists Research is needed to look at predictors
on the context within which an individual should inform this agenda. Professionals in of outcome in terms of patient characteris-
lives his or her life. the multi-disciplinary team would be tics, and to help practitioners focus their
enriched by understanding and applying therapeutic effort as effectively as possible.
the core concepts of CBT (Kroese et al, al, However, process research will also be
Service developments 1997). The need for parental counselling valuable in helping us to understand more
More specialist psychological therapy ser- as part of early intervention following about the impact of learning disabilities
vices for people with learning disabilities diagnosis of learning disability is rein- on individuals and families.
including CBT, family therapy and psycho- forced by recent attachment research; such
dynamic therapies, are being developed in counselling could be part of the repertoire
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