Psychotherapy with Young People in Care: Lost and Found
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Therapists working with people with learning disabilities have described some of the differences in therapy and some of the issues that are related to the person's experience of having a disability, which are not necessarily related to its severity. General therapeutic issues These issues are commonly encountered and, if not acknowledged or adequately addressed, can lead to a lack of accessibility of therapy. The past failure of therapists to adapt their practice or understanding can be projected onto patients, who are thus labelled as 'unsuitable' for therapy:.
Referral and consent : individuals rarely exercise their own choice and refer themselves for therapy. Some may express a wish to talk to someone about their problems or it may be suggested to them by carers or other professionals. More usually a health professional with experience, knowledge or training will identify a 'need' for therapy from aspects of the person's mood, behaviour or personal history.
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While referrals in the general population tend to indicate the person's wishes about therapy and its outcome, for people with learning disabilities it is the expectations or dissatisfactions of carers or the aspirations of the referrer that are highlighted, without a clear indication of whether these have been discussed with the person being referred. The initial assessment will need to clarify consent and explore the meaning of therapy.
What Your Therapist Doesn’t Know
The therapist may need to focus on the patient's understanding of why they are there and what they expect or wish to happen. Because people with learning disabilities tend to try to please others this can place them in a vulnerable position in relation to therapy and the therapist. This has significant implications for the regulation of training and supervision for therapists working with this patient group. Confidentiality : maintaining the therapeutic process relies on a greater degree of communication and support from carers and fellow professionals than in the general population.
Too rigid an approach to confidentiality can undermine the process and value of therapy, yet the patient needs to be able to trust the therapist.
Psychotherapy With Young People in Care: Lost and Found
It is essential to make the therapeutic boundaries clear from the outset for the patient, carers and others. Good communication can be ensured by the joint formulation between therapist and patient, and between therapist and carer of letters, and by telephone calls and agreed meetings to discuss general progress and mutual concerns.
Accessibility : people with learning disabilities do not usually travel independently and have to rely on others to take them to appointments. Regular attendance over a long period requires considerable commitment of carers' time and resources and special arrangements for cover in staff teams. The progress of therapy can be easily jeopardized by anything that threatens the reliability of necessary support and escort, such as financial constraints, staff shortages or failure of communication.
Carers who have to make a regular commitment to supporting an individual's attendance for therapy may experience feelings of impatience or envy with the process and may also wish to know what is happening in the therapy. If these issues are not addressed, then therapy can be undermined. A second professional or key-worker who can provide liaison, support and communication is helpful. The therapeutic relationship : the fundamental importance and efficacy of the therapeutic relationship is common to all psychological therapies. It is characterized by attentiveness, empathy, consistency, warmth and non-intrusive concern.
People with learning disabilities whose early relationship experiences have been of rejection or lack of intimacy, and who expect to be devalued or disliked, may find it difficult to form a trusting treatment alliance. If the therapist takes the concept of 'analytic neutrality' too literally, they may be perceived as cold, rejecting or lacking in concern. A greater degree of warmth and friendliness, combined with a more flexible approach to the timing of sessions and the use of physical touch, can help to establish a more positive and trusting relationship, although this may be at the expense of the patient's ability to express and process negative emotions in therapy.
Communication : it can take time to establish an effective communication style in therapy. Non-verbal communication and the use of adjunctive methods such as drawings, doll figures and picture books are emphasized; art, music, play and drama therapies are particularly prominent. If difficulties in communication are experienced, it is important that silence can be both tolerated and used therapeutically. Particular therapeutic approaches Psychodynamic therapies : adapting traditional psychoanalytic methods has enabled considerable progress to be made, and a variety of related approaches are being developed.
Sinason has written extensively in this area, with vivid illustrations of case material. She emphasized the significance of secondary handicap as a defence against the trauma of disability. Together with Hollins, she described issues that commonly arise with this patient group, which are too painful to address in everyday life, and thus assume the nature of taboo subjects or 'secrets' Figure 3.
Beail demonstrated the effectiveness of out-patient-based therapy using a Kleinian model for a group of individuals with challenging and offending behaviour, and Frankish described positive outcomes in an emotional-developmental framework derived from the work of Margaret Mahler. Cognitive-behavioural therapies: cognitive processes are now seen as more significant in behaviour modification, and specific treatments for anxiety and depression are also used.
People with learning disabilities find it difficult to recognize and accurately label emotional states in themselves and others, but this has been successfully addressed by approaches to anger management in groups and with individuals. Treatment should be modified to suit the individual's level of functioning, using non-verbal materials, visual aids such as drawings, symbols, photographs and dolls, and role play.
Concepts of 'loss' may need to be worked through at various stages of the family life-cycle, such as loss of the 'normal' child or sibling, or loss of aspirations for the individual's future development. The roles assigned to members of families are often the source of difficulty or dysfunction.
A person with learning disabilities may be expected to be inept or incapable in all circumstances; or they may be seen as 'special' or a family 'pet'. They may fulfil a role that keeps family or parental relationships intact or provides a focus for dysfunction. Assessing the effectiveness of therapy There have been few studies of the effectiveness of psychotherapy for people with learning disabilities, and the lack of access of such people to therapy generally has led to their being excluded from mainstream research.
The therapist reminds the person when their behavior is unhealthy or disruptive—when boundaries are overstepped—and then teaches the skills needed to better deal with future similar situations. Often times DBT involves both individual and group therapy. It looks at conscious, outward action, and social adjustment. It does not try to change the personality, but rather to teach new skills that can lessen symptoms.
Therapy is meant to help support system and family members find more effective ways to resolve those difficulties. FFT also focuses on the stress family members and support systems feel when they care for someone with a mental health condition.
Child and Adolescent Mental Health Services. (CAMHS) - West London NHS Trust
While talk therapy is the most common, there are many other forms of therapy that people find helpful. Often times the therapist may begin by encouraging the person revisit the trauma in their mind and share what they experienced. This often helps the person better process the trauma that occurred. Additionally, the therapist may assign homework where they request the person to confront a situation or thing that would cause them distress, beginning with something that likely will only cause minor distress and working up to things that will cause a lot of distress.
This stepping process helps the person increase their tolerance and decreases the anxiety associated with each event or experience. In addition to eye movement, clinicians also sometimes use tapping on the left side and then the right side of the body or headphones that produce sound in the left ear only, followed by the right ear.
Light therapy is often used for the treatment of Seasonal Affective disorder where a person experiences depression in the months of the year when there is a minimal amount of sunlight, but may also be used to treat other types of depression. During a light therapy session the person in treatment would sit near a light box that gives off a bright light, similar to natural sunlight.
The amount of time people spend near their light box each day varies but often falls in the minute range. Participating in art activities has been shown to help people reduce their stress levels and better address problems in their life.
For some, the positive effects can come from self-directed participation in any form of art, but in true art therapy, a trained art therapist would select specific materials and assignments that are chosen to target the exact needs of the participant. Animal assisted therapy occurs when the owner and the animal are trained in a specific way to help people.
In contrast, animal assisted activity is often less structured and may focus more on the presence of the animal rather than a specific job they are performing.
Psychotherapy with Young People in Care: Lost and Found
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