Cognitive Therapies

Adapted versions of the cognitive therapies are being used increasingly with people with ID. It had been considered by earlier writers that methods for cognitive therapy would have to be adapted considerably in order to be understood clearly by individuals with mild ID (Kroese, 1997). However, more recent research suggests that with minor adaptations, simplification and so on, assessment and treatment are extremely similar to those seen in mainstream therapy. Dagnan & Sandhu (1999) used an adapted version of the Rosenberg Self-esteem Scale (Rosenberg, Schooler & Scoenbach, 1989) and the Gilbert & Allen (1994) Social Comparison Scale in a study of the impact of social comparison and self-esteem on depression in people with mild intellectual disabilities. Psychometric analysis of these scales indicated a factor structure that is consistent with the factor structure of the original scales when used in the mainstream population and a good level of internal and test/re-test reliability. Kellett et al. (2004) conducted a similar investigation using the Brief Symptom Inventory with 335 participants. Again they found a factor structure with a high degree of overlap with the original factor solution presented by the developers of the scale. Powell (2003) demonstrated a similar finding with the Beck Depression Inventory and the Zung Self-Rating Depression Scale. Given that these assessments show similar internal consistency, factor structure and so on when used with participants with ID, it suggests that assessment and treatment methods may not have to change substantially when used with this client group. Lindsay (1999) reviewed the existing published clinical material and noted that the essential structure of cognitive therapy remained the same with some simplification and adaptation. Therefore the major characteristics of assessment and form of cognitive therapy structures remain very similar with this client group.

At the outset it should be noted that people with intellectual disabilities form approximately the lowest 1 % of the population in terms of measured IQ. Below an IQ of approximately 65, represents less than the lowest 1 % of the population. Even within this relatively small group, there is an heterogeneity of ability ranging from individuals who can function normally in the community, perhaps with a little support, to profoundly handicapped individuals who will have no expressive language, have difficulty in feeding or dressing themselves and may be doubly incontinent. Cognitive therapies rely on verbal skills, ability to accurately report thoughts and feelings to weigh evidence and to engage in a variety of quite abstract verbal skills, such as Socratic reasoning. People with ID are specifically handicapped in these areas. Problems that require combinations of memory and verbal skills are likely to be specifically impaired. Sturmey (2004) has identified deficits in a range of cognitive, problem-solving, planning and memory strategies that may present difficulties for the implementation of cognitive therapy in this client group. He also notes that interviewing people with ID presents problems in relation to the reliability and validity of information obtained. Finlay & Lyons (2001) and Dagnan & Lindsay (2004) have elucidated a range of difficulties in interviewing including how interviewers ask questions, how they deal with acquiescence and nay saying, item content, response media and formats all of which may affect the information obtained from interviews. However, these authors also suggest simple modifications and solutions to overcome any difficulties.

Using these frameworks, Dagnan, Chadwick & Proudlove (2000) evaluated the cognitive/emotional skills of 19 men and 21 women with mild ID. They used cognitive emotional skills tests of recognising emotions from pictures with faces, describing the emotional state of participants and stories and identifying the emotional antecedents, beliefs and the subsequent behavioural consequences. They found that 75 % of participants could link beliefs, emotions and behaviours. However, only 10% could do better than chance on choosing an emotion to match a situation and belief and only 25 % scored better than chance when choosing a belief given an emotion and a situation. The authors concluded that although people with mild ID have some prerequisite skills to engage in cognitive therapy, they would require preparatory training to learn many skills needed to participate, including understanding the idea of cognitive mediation. Sturmey (2004) notes that 'At this time we do not know what degree of competency of skill is needed in such tasks in order to achieve levels of competence that would permit effective participation in cognitive therapy.' This statement seems as true for mainstream populations as for populations with ID. In his review, Sturmey (2004) also notes that therapies based on applied behaviour analysis have been evaluated in the hundreds of big data based studies and three significant meta analyses (already mentioned) have endorsed their effectiveness.

The field in general suffers from a paucity of controlled investigations and there are few randomised controlled trials. In general, the field is developed with a large number of uncontrolled case investigations with weak experimental designs (for example, Lindsay et al., 1998). Therefore there are a significant number of case series reports on anxiety and depression. None of these achieve scientific respectability in relation to the Cochrane collaboration or EBP.

The one area that does now contain five controlled studies is that of anger and aggression. The cognitive therapy tested is that based on Novaco's analysis of anger and aggression, which emphasises the misinterpretation of internal and external cues, which leads to the individual perceiving threat in a situation which may be ambiguous or neutral. Novaco's (1975) model of anger expression and anger management has led to a three-phase anger treatment consisting of education about anger and understanding the relationship between anger and other emotions (phase one), perception of situations and emotional arousal in order to manage anger in general anger-provoking situations (phase two), and treatment involving specific, individual anger-provoking situations (phase three). An early controlled trial (Benson, Johnson Rice & Miranti, 1986) compared anger management treatment with other relaxation-based procedures both separately and in co-ordination. They found that four different treatment groups all improved in terms of anger management but that there was no differences between the groups. This study suffered for lack of a control group.

More recently there have been five further controlled studies all employing waiting list controls and all demonstrating the superiority of anger treatment (Lindsay et al., 2004; Rose, West & Clifford, 2000; Taylor et al., 2002; Taylor, Novaco, Guinan & Street, 2004; Willner et al., 2002). The Lindsay et al. study in particular has larger numbers with 33 participants receiving anger treatment and 14 waiting list controls and, in addition, subjects are followed up for up to four years both in terms of proximal measures of anger such as an anger provocation inventory and in terms of aggressive incidents both prosecuted and reported to the authors. Therefore, in the one area where there is more scientifically sound evidence, there are clear indications for the effectiveness of the cognitive treatment.

However, even in this area with the greatest scientific integrity, Sturmey (2004) has pointed out several serious shortcomings. Anger programmes include a number of non-cognitive procedures such as relaxation training, staff education and skill rehearsal. There are problems with treatment integrity, reliable independent variables, the design of case series, and social validity. He notes that there is a promising series of case studies using cognitive therapy for sex offenders but that included in their treatment are multi-component packages of relaxation, social, vocational and staff training alongside cognitive therapy (for example, Lindsay et al., 2002). Therefore the cognitive therapies are confounded with other interventions. In terms of EBP, the work on cognitive therapy can only form a basis for future systematic better designed evaluations.

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