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CBT for People with Intellectual Disabilities:
Emerging Evidence, Cognitive Ability and IQ Effects
John L. Taylor
Northumbria University and Northumberland, Tyne and Wear NHS Trust, UK
William R. Lindsay
NHS Tayside, The Sate Hospital, Carstairs and
Univ
ersity of Abertay Dundee, UK
Paul Willner
Bro Morgannwg NHS Trust and University of Wales, Swansea, UK
Behavioural & Cognitive Psychotherapy, 36
, 723
-
733
Reprint requests to John L Taylor, Northumbria University, Coach Lane Campus
-
East,
Benton, Newca
stle upon Tyne NE7 7XA, UK. E
-
mail: john2.taylor@northumbria.ac.uk
Abstract.
Historically people with intellectual disabilities have not been offered or
received cognitive behavioural interventions that have been shown to be effective for
mental health
and emotional problems experienced by those without such disabilities.
This is despite many people with intellectual disabilities having life experiences that
potentially result in them having an increased risk to such problems. This paper discusses
whethe
r such therapeutic disdain is justified based on the evidence that is available and
emerging concerning the application of cognitive behavioural interventions for this
population. Issues concerning access to services, the ability of people with intellectua
l
disabilities to engage in and benefit from the cognitive components of CBT, and the
effect of cognitive abilities and IQ level on treatment effectiveness are explored in
relation to this question.
Keywords: CBT, intellectual disabilities, cognitive abil
ities, IQ
Mental health problems in people with intellectual disabilities
People with intellectual disabilities are likely to experience a range of circumstances and
life events associated with an increased risk of developing mental health problems
(Brow
n, 2000). These include: unemployment, poverty, a lack of meaningful friendships,
intimate relationships and social support networks, stressful family circumstances, and
traumatizing abuse (Deb, Thomas and Bright, 2001; Emerson, Hatton, Felce and Murphy,
2
001; Hastings, Hatton, Taylor and Maddison, 2004). In addition, people with intellectual
disabilities may have fewer psychological resources available to cope effectively with
stressful events, as well as poorer cognitive abilities, including memory, probl
em
-
solving
and planning skills (van den Hout, Arntz and Merckelbach, 2000).
Studies of mental health problems amongst people with intellectual disabilities
report large variations in prevalence depending on the methodology used, such as the use
of case not
e reviews versus clinical evaluation, the nature and type of diagnostic
assessment used, the location of the study sample (e.g. in
-
patient vs. generic community
services), and the inclusion of challenging behaviour as a mental health problem or not
(see Ha
tton, 2002; Kerker, Owens, Zigler and Horwitz, 2004 for brief reviews).
Studies of general populations of people with intellectual disabilities using
screening instruments to identify cases report rates of mental health problems (excluding
challenging beha
viour) ranging between 20% and 39% (Hatton and Taylor, 2005). This
compares with approximate rates of between 16% and 25% for similar mental health
problems in the general population (Goldberg and Huxley, 1980; Meltzer, Gill, Petticrew
and Hinds, 1995). Al
though the overall rates of mental health problems among people
with intellectual disabilities have been shown to be similar to those found in general
populations of people without intellectual disabilities in some studies (e.g. Deb et al.,
2001), the prof
iles for different types of disorders appear to differ. In particular, the
finding that rates for psychosis is higher amongst people with intellectual disabilities is
consistent across studies (Deb et al., 2001; Kerker et al., 2004; Taylor, Hatton, Dixon a
nd
Douglas, 2004a).
Access to effective therapeutic interventions
Identifying the mental health needs of people with intellectual disabilities
Case recognition is a crucial step in meeting the mental health needs of people with
intellectual disabilities
(Moss et al., 1998). However, many people with intellectual
disabilities have mental health problems that are not detected and so remain untreated.
There are a number of reasons for this. First, services for people with intellectual
disabilities and those
for people with mental health problems are often separate and have
distinct cultures leading to gaps in provision for people with intellectual disabilities who
also have mental health problems (Hatton and Taylor, 2005). Second, the assessment
measures ava
ilable to detect mental health problems amongst people with intellectual
disabilities are not well developed and often lack reliability and validity (Deb et al.,
2001). Third, “diagnostic overshadowing” may occur (Reiss, Levitan and Szyszko,
1982), where c
arers and professionals misattribute signs of a mental health problem, such
as social withdrawal, to an aspect of a person’s intellectual disabilities, for example poor
social skills. Finally, staff supporting clients with intellectual disabilities are lik
ely to use
a challenging behaviour rather than a mental health conceptual framework to understand
problematic behaviours (Hatton and Taylor, 2005), and although it is likely that there are
overlaps in terms of causes and maintaining factors, the relationsh
ip between mental
health problems and challenging behaviour in people with intellectual disabilities is
unclear (Emerson, Moss and Kiernan, 1999).
Therapeutic disdain for people with intellectual disabilities
Despite the vulnerability of people with inte
llectual disabilities to mental health
problems, historically there has been a general lack of interest in or regard for the needs
of this client group (Stenfert Kroese, 1998). In the past, therapists have been reluctant to
offer individual psychotherapy t
o these clients because this would require them to
develop close working relationships with people perceived to be unattractive because of
their disability (Bender, 1993), which makes the therapeutic endeavour more demanding
and the achievement of quick tr
eatment gains more difficult. In addition, people with
intellectual disabilities may not be considered to have the cognitive abilities required to
understand or benefit from CBT. The suggestion that mature and complete cognitive
capacity is necessary for g
ood outcomes in CBT is however debatable. There is no
evidence in the intellectual disabilities field that deficits in particular cognitive abilities
result in poorer outcomes, and studies involving children show that it is not necessary to
have mature adu
lt cognitive apparatus to benefit from CBT (Durlak, Fuhrman and
Lampman, 1991; Sukhodolsky, Kassinove and Gorman, 2004). On the other hand,
Safran, Segal, Vallis, Shaw and Samstag (1993) suggested a range of cognitive abilities
that should be considered wh
en assessing the suitability of adults without disabilities for
CBT.
There are some indications that the use of cognitive
-
behavioural approaches with
people with intellectual disabilities is becoming more widely accepted. In a survey of the
use of psychot
herapy, around a third of British psychologists who responded reported
using these approaches frequently (Nagel and Leiper, 1999). An edited book on CBT for
people with learning disabilities (Stenfert Kroese, Dagnan and Loumidis, 1997) and a
recent special
issue of the
Journal of Applied Research in Intellectual Disabilities
devoted to CBT (Willner and Hatton, 2006) point to increasing interest in the use of these
therapeutic approaches with clients with intellectual disabilities, in the UK at least.
Howeve
r, a lack of enthusiasm for offering psychological therapies to those with
intellectual disabilities experiencing mental health problems is not confined to history in
some quarters.
Mental Retardation,
a premier US journal, recently published a paper
entit
led “Against psychotherapy for people who have mental retardation” (Sturmey,
2005), which concluded that the evidence is not available to support the use of
psychotherapy, including CBT, with people with intellectual disabilities. Somewhat
surprisingly, St
urmey’s conclusion was based on his critique of Prout and Nowak
-
Drabik’s (2003) meta
-
analysis of studies conducted over a 30
-
year period that found
evidence for the effectiveness and benefit of “behaviourally oriented” psychotherapies
(excluding behaviour
modification) for people with intellectual disabilities (p. 88).
So, given the debate based on what might be conceptual, geographical and
cultural differences in views concerning the practice of psychotherapy with these clients,
what is the evidence to s
upport the use of CBT
-
based interventions for mental health and
emotional problems experienced by people with intellectual disabilities?
A summary of the evidence for CBT for people with intellectual disabilities
In addition to Prout and Nowak
-
Drabik’s (2
003) meta
-
analysis of the effectiveness of
psychotherapy for people with intellectual disabilities that included 92 studies conducted
between 1968 and 1998, there have been several reviews, critiques and commentaries that
have considered the application of
CBT to people with intellectual disabilities who have
mental health and emotional problems in recent years.
Hatton (2002) reviewed psychosocial interventions for adults with intellectual
disabilities and a range of mental health problems. A number of the
studies reviewed
involved CBT interventions. Although the evidence to support the efficacy of these
approaches was found to be severely limited, Hatton concluded that these treatments,
appropriately modified, may be a feasible intervention option for peop
le with mild
intellectual disabilities experiencing a range of mental health problems.
Similarly, Lindsay (1999) showed that although the procedures need to be adapted
and simplified, people with intellectual disabilities and a variety of mental health
pr
oblems can benefit from interventions that retain all the key elements of cognitive
therapy.
In a commentary on the research supporting CBT and psychodynamic
psychotherapy for people with intellectual disabilities, Beail (2003) described a number
of studi
es that support the effectiveness of CBT for people with intellectual disabilities.
Beail pointed out that almost all of the CBT studies were focused on the cognitive skills
deficits associated with mental health and emotional problems. There was virtually
no
evidence available to support the use of interventions involving the modification of
distorted cognitions and schema underpinning the problems experienced by this client
group.
The Royal College of Psychiatrists (2004) carried out a limited review of
the
evidence for the effectiveness of psychological treatments with people with intellectual
disabilities. It was suggested that the lack of good quality research evidence to support
the use of psychological therapies with this population is, in part, due
to intellectual
disability having been used routinely as an exclusion criterion from efficacy research.
The report concluded that the available, albeit limited, evidence for the effectiveness of
psychotherapeutic approaches, including CBT, with these clien
ts is promising.
Sturmey (2004) selectively reviewed and critiqued cognitive therapy for people
with intellectual disabilities with anger, depression and sex offending problems. Sturmey
concluded that the evidence to support CBT approaches is weak when co
mpared to the
extensive evidence base for behavioural interventions based on an applied behavioural
analysis paradigm.
In a critical review of psychotherapeutic interventions for people with intellectual
disabilities, Willner (2005) found that CBT interve
ntions utilising cognitive skills
training (e.g. self
-
management, self
-
monitoring, self instructional
-
training) show
promise. However, approaches focusing on cognitive distortions were considered to have
only a very limited evidence base. Willner concluded
that there is some evidence that
psychological therapies (chiefly CBT) can benefit people with intellectual disabilities
with emotional problems for which there is no realistic alternative.
In summary, the evidence for the effectiveness of CBT for peopl
e with
intellectual disabilities remains sparse, with a reasonable number of case studies and case
series reports indicating that these approaches show promise in the effective treatment of
mental health problems experienced by people in this population. M
ore recently the
evidence base has been augmented with the publication of eight studies describing
controlled trials comparing CBT for anger control problems with wait
-
list control
conditions (see Willner, 2007 for a review). All of these studies reported
significant
improvements on outcome measures for those in treatment conditions that were
maintained at 3 to 12
-
month follow
-
up. With the exception of one controlled study of
CBT for depression that yielded very positive outcomes (McCabe, McGillivray and
Ne
wton, 2006) anger research provides the strongest evidence that CBT can be effective
with people with intellectual disabilities. In clinical terms this is important because of the
prevalence of anger and its close association with aggression in this popula
tion, as well as
its consequences for people in terms of institutionalization and (over) prescription of
behaviour control drugs (Taylor and Novaco, 2005). In research terms these
developments are also important to our understanding of the application of C
BT to
people with intellectuals disabilities, as attentional biases and cognitive distortions
associated with threat perception, as well as memory biases for distressing experiences,
are intrinsic to anger problems and thus to their effective treatment (Ta
ylor, Novaco,
Gillmer and Robertson, 2004b).
Cognitive ability and IQ effects
It has been suggested that “readiness” for treatment is an important issue in the
effectiveness of CBT (e.g. Howells and Day, 2003). Willner (2006) discussed in detail
the facto
rs that can affect the willingness of clients with intellectual disabilities to engage
effectively in CBT. These include the client’s motivation to participate, which might be
associated with a range of issues, including their confidence in doing emotional
ly and
intellectually challenging psychological work; their sense of self
-
efficacy and self
-
determination; the extent to which a referral for CBT is voluntary or coerced; the skills
and attitudes of the therapist in adapting the therapy to make it more acc
essible; and the
level of support or hindrance provided by the person’s carers and support systems. These
factors can affect any clients’ willingness to engage in CBT, as can a person’s ability in
terms of the skills and understanding that is required for
this form of therapy. However,
given that people with intellectual disabilities are more likely than those without
disabilities to have cognitive impairments that might hinder their ability to engage in and
benefit from CBT, the linked issues of cognitive
ability and level of intellectual
functioning are explored in more depth in the following sections.
Cognitive ability and CBT
In relation to cognitive therapy, Kendall (1985) distinguished between a
cognitive
distortion
model as the basis of traditional C
BT (e.g. Beck, 1976), which aims to identify
and correct distortions in the content of thoughts, assumptions and beliefs; and a
cognitive deficit
model as the basis of self
-
management interventions (e.g. self
-
instructional training; Meichenbaum, 1977) that
focus on deficiencies in the processes by
which information is acquired and processed.
As highlighted by Beail (2003) and Willner (2005) amongst others, in the
intellectual disability field little attention has been given to the effectiveness of cognitiv
e
distortion based interventions that aim to elicit negative automatic thoughts, identify
themes in such thoughts, and help clients to modify thinking related to dysfunctional
attitudes and beliefs. This is despite the evidence that such approaches can be
highly
effective for a range of mental health problems experienced by those without intellectual
disabilities. Given that more than 80% of people with intellectual disabilities have
mild
intellectual disability (American Psychiatric Association, 1994), it
is unclear why the
evidence pertaining to those without intellectual disabilities might not apply also to the
majority of those with intellectual disabilities. This is potentially important as one
proposed advantage of cognitive therapy based on Beck’s (19
76) approach, which aims
to modify distorted evaluative beliefs, is that it promotes portable internalized control that
facilitates generalizability across settings and situations (Taylor, 2005). Cognitive deficit
based self
-
management approaches (e.g. sel
f
-
monitoring, self
-
instructional training) to
ameliorating cognitive deficits are the most common type of cognitive interventions used
with people with intellectual disabilities, but these approaches have been criticized for
their lack generalizability acr
oss skills and settings, and their dependence on external
cues (e.g. Willner, 2005).
One reason for the limited evidence to support the effectiveness of interventions
aimed at identifying and modifying cognitive distortions is that many interventions for
people with intellectual disabilities labelled as CBT have failed to incorporate these
treatment components, and have instead focused on cognitive deficit based approaches to
developing clients’ skills in self
-
monitoring and self
-
instruction (Taylor, 2002;
Beail,
2003). However, this picture is changing slowly. Lindsay (1999) reported on successful
outcomes of CBT interventions for people referred for a range of clinical problems
including anxiety, depression and anger that explicitly incorporated work on t
he content
of cognitions underpinning and maintaining their emotional difficulties. Using imagery
rehearsal therapy, a technique that deals with dream imagery in the same way as
cognitive distortions, Willner (2004) and Stenfert Kroese and Thomas (2006)
su
ccessfully treated a man and two women respectively who were experiencing post
-
abuse nightmares. Haddock, Lobban, Hatton and Carson (2004) reported a case series of
five people with mild intellectual disabilities and psychosis who improved on measures
of p
sychotic symptoms and behaviour following a cognitive
-
behavioural intervention
adapted from an established therapy that included a cognitive restructuring component.
In addition to these case study and case series reports that did not involve control
cond
itions, there have now been a number of controlled studies of cognitive behavioural
anger interventions that have explicitly incorporated cognitive content and restructuring
treatment components. A group anger management intervention resulted in significan
t
improvements over the control condition in a community setting (Willner, Jones, Tams
and Green, 2002); and significant improvements relative to control groups on reliable
anger measures following individual cognitive
-
behavioural treatment were described
in a
series of concatenated studies involving detained men with mild
-
borderline intellectual
disabilities and significant histories of aggression (Taylor, Novaco, Gillmer and Thorne,
2002; Taylor, Novaco, Guinan and Street, 2004c; Taylor, Novaco, Gillmer,
Robertson
and Thorne, 2005).
Another reason for the limited evidence for interventions for people with
intellectual disabilities aimed at modifying cognitive distortions is the complexity of
these techniques and the presumed difficulties that these client
s have in understanding,
assimilating, recalling and using these approaches (Whitaker, 2001). However, Novaco
and Taylor (2006) and Taylor et al. (2004b) have provided detailed clinical case study
material showing that people with mild and borderline intel
lectual disabilities can
successfully engage in the exploration of maladaptive automatic thoughts and can
generate and weigh the value of more helpful alternatives in the context of individual
cognitive
-
behavioural anger treatment. Further, experimental ev
idence has been provided
to demonstrate that people with mild intellectual disabilities can recognize emotions
(Joyce, Globe and Moody, 2006; Oathamshaw and Haddock, 2006; Sams, Collins and
Reynolds, 2006), label emotions (Joyce et al., 2006), discriminate
between thoughts,
feelings and behaviours (Sams et al., 2006), and link events and emotions (Dagnan,
Chadwick and Proudlove, 2000; Joyce et al., 2006; Oathamshaw and Haddock, 2006).
However, in three studies all using the same experimental procedure it wa
s found that the
majority of study participants were unable to successfully complete an experimental test
of their ability to understand the mediating role of cognitions, particularly when the
complexity of the task was increased (Dagnan et al., 2000; Joyc
e et al., 2006;
Oathamshaw and Haddock, 2006). A general finding across all the studies investigating
the cognitive skills of people with intellectual disabilities was that performance on the
experimental cognitive tasks was positively associated with rece
ptive vocabulary.
Effect of IQ on treatment effectiveness
An issue closely associated with the question of the cognitive ability and skills of people
with intellectual disabilities to successfully engage in treatment aimed at modifying
maladaptive cogni
tions is the impact of general intellectual functioning (IQ) on treatment
effectiveness. Willner et al. (2002) found in a small study of cognitive
-
behavioural anger
treatment involving community participants with mild intellectual disabilities that
improve
ments on a composite measure of client and carer ratings were significantly and
positively associated with verbal IQ. Linear regression analysis indicated that participants
(
n
= 7) with a verbal IQ of 50 or lower would show no improvements following therap
y.
In a larger study, Rose, Loftus, Flint and Carey (2005) investigated factors associated
with the efficacy of cognitive
-
behavioural group intervention for anger with 50 people
with intellectual disabilities in community settings. In a regression analysis
they found
that participants with greater verbal ability, as measured on a test of receptive vocabulary,
tended to show greater improvements on an anger inventory immediately following
completion of treatment. However, this effect was not maintained at 3
to 6
-
month follow
-
up.
In a study of individual cognitive
-
behavioural anger treatment involving men with
mild
-
borderline IQ and forensic histories, Taylor et al. (2005) examined the relationship
between IQ and treatment responsiveness. Treatment completers
were partitioned by
median split of 69 on full scale IQ. Pre
-
to post
-
treatment anger change (improvement)
scores were not significantly different for those in the higher and lower IQ groups. From
pre
-
treatment to 4
-
month follow
-
up there was a significant
difference on a measure of
anger reactivity, with a greater improvement occurring in the lower IQ group. Means for
other anger change scores also showed greater improvement in the lower IQ group, but
these were not significant.
The same pattern of change s
core differences was found by Taylor (2007) in an
evaluation of 50 men and women with forensic histories who had received cognitive
-
behavioural anger treatment as part of a clinical programme delivered in routine clinical
practice. That is, those in the lo
wer IQ group (median split at full scale IQ = 70) did not
differ significantly from those in the higher IQ group on pre
-
to post
-
treatment anger
change scores, but they showed greater improvement from pre
-
treatment to follow
-
up.
The inconsistency in the Wi
llner et al. (2002) and Rose et al. (2005) study
findings that low verbal IQ is associated with poorer treatment outcome, and the results
obtained by Taylor et al. (2005) and Taylor (2007) that did not find this relationship, may
reflect the more intensive
(twice weekly sessions) and individual nature of the treatment
provided in the latter two studies. This treatment format may have been better able to
overcome the intellectual limitations of the patients than the group delivered weekly
therapy sessions pr
ovided in the former studies. It is possible also that the Taylor et al.
(2005) and Taylor (2007) studies involved more intellectually able participants than the
other studies, which could explain the different findings concerning verbal ability and
treatm
ent outcome. Whatever the reasons, it would seem that verbal ability or IQ on their
own cannot be used to predict individual clients’ responses to CBT in a reliable way.
Clients’ level of intellectual functioning, along with their specific cognitive abilit
ies and
skills deficits, need to be assessed carefully along with their levels of motivation,
confidence and support, to formulate what is required of the therapist in modifying the
intervention to make it reflexive to the individual needs and learning sty
le of each client
(Lynch, 2004; Willner, 2006).
Conclusions
People with intellectual disabilities experiencing mental health and emotional problems
have in the past been excluded from research programmes looking at the effectiveness
and efficacy of cognit
ive and behavioural psychotherapies, national service frameworks
and evidence based guidelines. Is this historical exclusion, along with the therapeutic
disdain on the part of therapists for these clients
–
Bender’s so called “unoffered chair”
(1993, p.7)
–
still justified? Probably not; at least not for people in the mild
-
borderline
ranges of intellectual functioning.
There are some encouraging signs that practitioners are beginning to offer CBT
interventions routinely to people with intellectual disabi
lities who are experiencing
emotional problems. And, while the evidence base is small, it is building slowly and it
suggests that the majority of people with intellectual disabilities (that is, those in the mild
range) have the ability to engage in and ben
efit from cognitive behavioural interventions,
particularly self
-
management approaches based on a cognitive deficit model, for a range
of emotional problems. Larger and better
-
designed clinical trials using more ecologically
valid outcome measures are requ
ired to investigate whether the results obtained to date
are robust, can be maintained over time, and are generalizable across settings.
Clients with mild intellectual disabilities have been shown to have the skills
considered necessary for the cognitive c
omponent of CBT, including emotional labelling
and recognition and, to a significantly lesser extent, understanding of the mediating role
of cognitions. These skills appear to decline as verbal ability (receptive vocabulary)
decreases, but it is not clear
whether this is real phenomenon or a function of the
complexity of the experimental tasks presented to study participants. There is a danger in
extrapolating from failure on experimental cognitive tasks to an inability to engage with
cognitive components o
f CBT in a therapeutic context. For example, clinical research on
anger control problems has indicated that clients’ responsiveness to CBT that includes
cognitive appraisal and restructuring components is not related to clients’ IQ level in a
linear way. W
illner and Goodey (2006) describe how CBT can be modified in practice
for a client with a range of significant cognitive skills deficits so that it is still effective in
targeting the cognitive distortions that are central to her presenting problem.
Thus,
more clinical research and research
-
based practice is needed before we can
justify denying potentially helpful treatments based on the cognitive distortion model to
people with intellectual disabilities on the basis of poor declarative knowledge in
artific
ial test situations that might not translate into procedural knowledge in the therapy
situation. This is particularly important in relation to the treatment of internalizing
disorders experienced by these clients (e.g. anxiety, depression, anger) in which
perceptual schemas, attentional biases and entrenched beliefs are central.
References
American Psychiatric Association
(1994).
Diagnostic and Statistical Manual of Mental
Disorders
(4
th
ed.). Washington, DC: Author.
Beail, N.
(2003). What works for people
with mental retardation? Critical commentary
on cognitive
-
behavioural and psychodynamic psychotherapy research.
Mental
Retardation, 41
, 468
-
472.
Beck, A.T.
(1976).
Cognitive Therapy and the Emotional Disorders
. New York:
International Universities Press.
B
ender, M.
(1993). The unoffered chair: the history of therapeutic disdain towards
people with a learning difficulty.
Clinical Psychology Forum, 54,
7
-
12.
Brown, G.W.
(2000). Medical sociology and issues of aetiology. In M.G. Gelder, J.L.
Lopez
-
Ibor Jr. and
N.C. Andreasen (Eds.),
New Oxford Textbook of Psychiatry
.
Oxford: Oxford University Press.
Dagnan, D., Chadwick, P. and Proudlove, J.
(2000). Towards and assessment of
suitability of people with mental retardation for cognitive therapy.
Cognitive
Therapy
and Research, 24
, 627
-
636.
Deb, S., Thomas, M. and Bright, C.
(2001). Mental disorder in adults with intellectual
disability. I: prevalence of functional psychiatric illness among a community
-
based population aged between 16 and 64 years.
Journal of Intel
lectual Disability
Research, 45
, 495
-
505.
Durlak, J., Fuhrman, T. and Lampman, C.
(1991). Effectiveness of cognitive
-
behavior
therapy for maladapting children.
Psychological Bulletin, 110
, 204
-
214.
Emerson, E., Hatton, C., Felce, D. and Murphy, G.
(2001).
Learning Disabilities: the
fundamental facts
. London: Foundation for People with Learning Disabilities.
Emerson, E., Moss, S. and Kiernan, C.
(1999). The relationship between challenging
behaviour and psychiatric disorders in people with severe developm
ental
disabilities. In N. Bouras (Ed.),
Psychiatric and Behavioural Disorders in
Developmental Disabilities and Mental Retardation
(pp. 38
-
48). Cambridge:
Cambridge University Press.
Goldberg, D. and Huxley, P.
(1980).
Mental Illness in the Community: the
pathway to
psychiatric care
. London: Tavistock.
Haddock, G., Lobban, F. Hatton, C. and Carson, R.
(2004). Cognitive
-
behaviour
therapy for people with psychosis and mild intellectual disabilities: a case series.
Clinical Psychology and Psychotherapy
,
11
,
282
-
298.
Hatton, C.
(2002). Psychosocial interventions for adults with intellectual disabilities and
mental health problems.
Journal of Mental Health, 11
, 357
-
373.
Hatton, C. and Taylor, J.L.
(2005). Promoting healthy lifestyles: mental health and
illness
. In G. Grant, P. Goward, M. Richardson and P. Ramcharan (Eds.),
Learning Disability: a life cycle approach to valuing people
(pp. 559
-
603).
Maidenhead: Open University Press.
Hastings
, R.P., Hatton, C., Taylor, J.L. and Maddison, C.
(2004).
Life events a
nd
psychiatric symptoms in adults with intellectual disabilities.
Journal of
Intellectual Disability Research, 48
, 42
-
46.
Howells, K. and Day, A.
(2003). Readiness for anger management: clinical and
theoretical issues.
Clinical Psychology Review, 23
, 319
-
3
37.
Joyce, T., Globe, A. and Moody, C.
(2006). Assessment of the component skills for
cognitive therapy in adults with intellectual disabilities.
Journal of Applied
Research in Intellectual Disabilities, 19
,17
-
23.
Kendall, P.C.
(1985). Toward a cognitive
-
b
ehavioral model of child psychopathology
and a critique of related interventions.
Journal of Abnormal and Child
Psychology, 13
, 357
-
372.
Kerker, B.D, Owens, P.L., Zigler, E. and Horwitz, S.M.
(2004). Mental health
disorders among individuals with mental re
tardation: challenges to accurate
prevalence estimates.
Public Health Reports, 119
, 409
-
417.
Lindsay, W.R.
(1999). Cognitive therapy.
The Psychologist, 12
, 238
-
241.
Lynch, C.
(2004). Psychotherapy for persons with mental retardation.
Mental
Retardation,
42
, 399
-
405.
McCabe, M.P., McGillivray, J.A. and Newton, D.C.
(2006). Effectiveness of treatment
programmes for depression among adults with mild/moderate intellectual
disability.
Journal of Intellectual Disability Research, 50,
239
-
247.
Meichenbaum, D.
(
1977).
Cognitive Behaviour Modification: an integrative account.
New York: Plenum.
Meltzer, H., Gill, B., Petticrew, M. and Hinds, K.
(1995).
The Prevalence of
Psychiatric Morbidity among Adults Living in Private Households: OPCS survey
of psychiatric mor
bidity in Great Britain, report 1
. London: HMSO.
Moss, S., Prosser, H., Costello, H., Simpson, N., Patel, P., Rowe, S., Turner, S. and
Hatton, C.
(1998). Reliability and validity of the PAS
-
ADD Checklist for
detecting psychiatric disorders in adults with
intellectual disability.
Journal of
Intellectual Disability Research
,
42,
173
-
183.
Nagel, B. and Leiper, R.
(1999). A national survey of psychotherapy with people with
learning disabilities.
Clinical Psychology Forum, 129
, 14
-
18.
Novaco, R.W. and Taylor,
J.L.
(2006). Cognitive
-
behavioural anger treatment. In M.
McNulty and A. Carr (Eds.),
Handbook of Adult Clinical Psychology: an evidence
based practice approach
(pp. 978
-
1009). London: Routledge.
Oathamshaw, S. and Haddock, G.
(2006). Do people with intel
lectual disabilities and
psychosis have the cognitive skills required to undertake cognitive behavioural
therapy?
Journal of Applied Research in Intellectual Disabilities, 19
, 35
-
46.
Prout, R. and Nowak
-
Drabik, K.M.
(2003). Psychotherapy with persons who
have
mental retardation: an evaluation of effectiveness.
American Journal on Mental
Retardation, 108
, 82
-
93.
Reiss, S., Levitan, G. and Szyszko, J.
(1982). Emotional disturbance and mental
retardation: diagnostic overshadowing.
American Journal of Mental
Deficiency
,
86
, 567
-
574.
Rose, J., Loftus, M., Flint, B. and Carey, L.
(2005). Factors associated with the
efficacy of a group intervention for anger in people with intellectual disabilities.
British Journal of Clinical Psychology, 44
, 305
-
317.
Royal Colle
ge of Psychiatrists
(2004).
Psychotherapy and Learning Disability
. Council
Report CR116. London: Royal College of Psychiatrists.
Safran, J.D., Segal, Z.V., Vallis, T.M., Shaw, B.F. and Samstag, L.W.
(1993).
Assessing patient suitability for short
-
term cogn
itive therapy with an interpersonal
focus.
Cognitive Therapy and Research, 17
, 23
-
28.
Sams, K., Collins, S. and Reynolds, S.
(2006). Cognitive therapy abilities in people with
learning disabilities.
Journal of Applied Research in Intellectual Disabilities,
19
,
25
-
33.
Sukhodolsky, D.G., Kassinove, H. and Gorman, B.S.
(2004). Cognitive
-
behavioral
therapy for anger in children and adolescents: a meta
-
analysis.
Aggression and
Violent Behavior
,
9
, 247
-
269.
Stenfert Kroese, B.
(1998). Cognitive
-
behavioural thera
py for people with learning
disabilities.
Behavioural and Cognitive Psychotherapy, 26
, 315
-
322.
Stenfert Kroese, B., Dagnan, D. and Loumidis, K.
(Eds.) (1997).
Cognitive
-
Behaviour
Therapy for People with Learning Disabilities
. London: Routledge.
Stenfert K
roese, B. and Thomas, G.
(2006). Treating chronic nightmares of sexual
assault survivors with an intellectual disability: two descriptive case studies.
Journal of Applied Research in Intellectual Disabilities, 19
, 75
-
80.
Sturmey, P.
(2004). Cognitive thera
py with people with intellectual disabilities: a
selective review and critique.
Clinical Psychology and Psychotherapy, 11
, 222
-
232.
Sturmey, P.
(2005). Against psychotherapy with people who have mental retardation.
Mental Retardation, 43
, 55
-
57.
Taylor, J.
L.
(2002). A review of assessment and treatment of anger and aggression in
offenders with intellectual disability.
Journal of Intellectual Disability Research
,
46
(Suppl. 1), 57
-
73.
Taylor, J.L.
(2005). In support of psychotherapy for people who have menta
l retardation.
Mental Retardation, 43
, 450
-
453.
Taylor, J.L.
(2007).
Cognitive Ability, Skills and Remediation in CBT for People with
Intellectual Disabilities
. Paper presented at the BABCP 35
th
Annual Conference,
Sussex University, Brighton, September.
Ta
ylor, J.L., Hatton, C., Dixon, L. and Douglas, C.
(2004a). Screening for psychiatric
symptoms: PAS
-
ADD checklist norms for adults with intellectual disabilities.
Journal of Intellectual Disability Research, 48
, 37
-
41.
Taylor, J.L. and Novaco, R.W.
(2005).
Anger Treatment for People with Developmental
Disabilities: a theory, evidence and manual based approach
. Chichester: Wiley.
Taylor, J.L., Novaco, R.W., Gillmer, B.G. and Robertson, A.
(2004b). Treatment of
anger and aggression. In W.R. Lindsay, J.L. Taylo
r and P. Sturmey (Eds.),
Offenders with Developmental Disabilities
(pp. 201
-
219). Chichester: Wiley.
Taylor, J.L., Novaco, R.W., Gillmer, B.T., Robertson, A. and Thorne, I.
(2005).
Individual cognitive
-
behavioural anger treatment for people with mild
-
borde
rline
intellectual disabilities and histories of aggression: a controlled trial.
British
Journal of Clinical Psychology, 44
, 367
-
382.
Taylor, J.L., Novaco, R.W., Gillmer, B. and Thorne, I.
(2002). Cognitive
-
behavioural
treatment of anger intensity among of
fenders with intellectual disabilities.
Journal
of Applied Research in Intellectual Disabilities, 15
, 151
-
165.
Taylor, J.L., Novaco, R.W., Guinan, C. and Street, N.
(2004c). Development of an
imaginal provocation test to evaluate treatment for anger proble
ms in people with
intellectual disabilities.
Clinical Psychology and Psychotherapy, 11
, 233
-
246.
van den Hout, M., Arntz, A. and Merckelbach, H.
(2000). Contributions of
psychology to the understanding of psychiatric disorders. In M.G. Gelder, J.L.
Lopez
-
Ibor Jr. and N.C. Andreasen (Eds.),
New Oxford Textbook of Psychiatry
(pp. 277
-
292). Oxford: Oxford University Press.
Willner, P.
(2004). Brief cognitive therapy of nightmares and post
-
traumatic ruminations
in a man with learning disabilities.
British J
ournal of Clinical Psychology, 43
,
459
-
464.
Willner, P.
(2005). Readiness for cognitive therapy in people with intellectual
disabilities.
Journal of Applied Research in Intellectual Disabilities, 19
, 5
-
16.
Willner, P.
(2006). The effectiveness of psychoth
erapeutic interventions for people with
learning disabilities: a critical overview.
Journal of Intellectual Disability
Research, 49
, 73
-
85.
Willner, P.
(2007). Cognitive behaviour therapy for people with learning disabilities:
focus on anger.
Advances in M
ental Health and Learning Disabilities, 1
, 14
-
21.
Willner, P. and Goodey, R.
(2006). Interaction of cognitive distortions and cognitive
deficits in the formulation and treatment of obsessive
-
compulsive behaviours in a
woman with an intellectual disability.
Journal of Applied Research in Intellectual
Disabilities, 19
, 67
-
73.
Willner, P. and Hatton, C.
(Eds.) (2006). Special issue: cognitive behavioural therapy.
Journal of Applied Research in Intellectual Disabilities, 19,
1
-
129.
Willner, P., Jones, J., Tams,
R. and Green, G.
(2002). A randomised controlled trial of
the efficacy of a cognitive
-
behavioural anger management group for clients with
learning disabilities.
Journal of Applied Research in Intellectual Disabilities, 15
,
224
-
235.
Whitaker, S.
(2001). An
ger control for people with learning disabilities: a critical
review.
Behavioural and Cognitive Psychotherapy, 29
, 277
-
293.
