Perceived barriers and facilitators to positive therapeutic change for people with intellectual disabilities: client, carer and clinical psychologist perspectives
Over the past 15 years psychological therapy for people with Intellectual Disabilities (ID) has been increasingly advocated (e.g., Linington, 2002) and successful treatment outcomes of psychological therapies for this population have been highlighted in a number of studies (e.g., Beail, 1998). However, the processes underlying these successful treatments are uncertain and some authors argue that success could be attributed to person-centred counselling rather than the specific approach adopted (e.g., Beail, 1998). Current literature highlights a substantial gap and an increasing need for research that identifies conditions under which the effects of therapy are optimised for people with ID through the exploration of barriers and facilitators to positive therapeutic change.
This thesis explored the experiences of Clinical Psychologists (CPs), their clients with an ID and the client’s carers, with regards to the perceived barriers and facilitators to positive therapeutic change. Furthermore, this research aimed to develop a cohesive understanding from the multiple perspectives of the topic area. A triadic case design was utilised in which two triads of the CP, clients with ID and carers were nested by one CP. Therefore one ‘case’ constituted one CP, two of their clients (with ID) and two carers. Three of these cases were recruited and therefore this study had 15 participants and as the CPs were interviewed twice (once regarding each client separately) 18 interviews were completed. Thematic analysis was deemed to be an appropriate methodology to address the gap in qualitative research with people with ID. This methodology allowed the exploration of participant’s accounts whilst enabling the flexibility that is required to accommodate the varied abilities of people with ID. From the analysis of the transcripts of the 18 semi-structured interviews, five super-ordinate themes and one central theme were identified based on their frequency and salience from participants across all three participant groups.
The first super-ordinate theme, ‘what the client brings’ encapsulated a number of factors related to the client that participants perceive to be initial barriers within therapy, namely, the ID itself (e.g., communication skills, memory) and the client’s engagement in therapy. A second super-ordinate theme that the client also brings to therapy is their ‘wider system’. This theme encompasses the facilitating role that a wider support network can play and also the barriers that the wider system can bring with regards to the negative influence of others on the client. A third super-ordinate theme related to ‘therapy factors’ that are generally perceived to be facilitators to overcome the barriers that clients bring to therapy. This included therapy adaptations and the therapeutic relationship. The fourth super-ordinate theme, namely ‘the mental health GP’ encompasses the concept that psychologists are required to coordinate the often extensive wider system of people with ID and this is because participants felt that in order to benefit from individual therapy, all of the client’s needs must be met, including physical health needs and ensuring that the client lives in an appropriate environment. Given the four super-ordinate themes noted above, all of these concepts foster the fifth super-ordinate theme ‘systemic dependency’.
The mere presence of an ID means that naturally people are more dependent on others. As a result, therapy factors including the therapeutic relationship and adaptations to therapy (e.g., increased longevity of therapy) can foster strong attachments which can facilitate an unhelpful level of dependency. Additionally, the client’s wider system can also become dependent on services to help them facilitate care and coordinate the numerous services involved. All of these super-ordinate themes maintain the concept of the ‘revolving door’ into services. Additional subthemes noted in the extended paper are examples of barriers and facilitators to therapeutic change that are considered to have an important impact on therapy but were only noted by one group of participants (e.g., clients) and thus did not contribute to cohesive understanding of multiple perspectives aimed for within the journal paper. For example, clients reported confidentiality to be a barrier and CPs reported attachment difficulties of clients to be a barrier.
The results of this study offer the first explorations of conditions under which therapy can be optimised for people with an ID through the awareness of barriers and facilitators to positive therapeutic outcomes. CPs are shown to be skilled at overcoming barriers within therapy; however there appeared to be a process of facilitators creating more barriers within therapy and the phenomenon of the revolving door needs to be fully considered. Given the potential impact of funding constraints on the role of CPs and access to psychological therapies for people with ID, this has important implications for the way psychologists working within this population market themselves and further evidence their work
