Delivering effective psychological therapies and interventions to people with intellectual / learning disabilities

Scope and Focus 

Learning disability is defined by the following three criteria: 

• A significantly reduced ability to understand new or complex information, to learn new skills (impaired intelligence); with 

• A reduced ability to cope independently (impaired adaptive and social functioning); and 

• which started before adulthood, with a lasting effect on development. 

In the UK both learning disability and intellectual disability are used to refer to people who meet these three criteria, so both terms are equivalent.  Despite these formal definitions, it is of primary importance to respect the language individuals choose to describe themselves.   

The Essentials of Learning Disabilities module ‘What is a learning disability’ includes more detail on this topic and can be found here.

This guide focusses primarily on people with mild to moderate learning disabilities and psychological therapies and interventions which may be utilised in treating mental health difficulties.  These approaches are most likely to be talking therapies, and much of the available evidence concerns Cognitive Behaviour Therapy (CBT), although this guide is not limited to CBT.  People who have profound and multiple disabilities also experience mental health and emotional difficulties, and it is important to consider approaches which may help to meet their needs.  Talking therapies are generally considered to be inaccessible to this group, but it remains important to consider how their needs are addressed.   

People with learning disabilities experience mental health difficulties across their lives.  Diagnostic overshadowing can mean these often go unrecognised and unaddressed. Psychological interventions and therapies for people with learning disabilities are usually adaptations of interventions and therapies for people without learning disabilities.  The evidence for interventions from studies involving people with learning disabilities is sparse. While more research is needed to examine the effectiveness of interventions for people with learning disabilities across the lifespan, there is promising evidence to suggest people with learning disabilities do benefit from psychological interventions and therapies.  Although the current evidence base is limited, as people with learning disabilities can experience the same mental health difficulties as others, they should have access to the same range of evidence-based interventions. 

This guidance includes evidence and good practice concerning the adaptation of psychological therapies and interventions for people with learning disabilities.  Many of the adaptations outlined in this section will be familiar to clinicians who work in services for people with learning disabilities. Clinicians should consider and provide sensitive and individualised interventions that are flexibly adapted to meet the needs of people with learning disabilities.  Evidence- based interventions in the broader population should be considered, with adaptations for people with learning disabilities (DCP and BPS, 2016).  Service providers can explore ‘goodness of fit’ for their service context using resources available elsewhere in this site [https://www.matrix.nhs.scot/intervention-search/] 

Evidence based adapted manualised interventions are available.  Beat It and Step Up are structured approaches adapted for people with learning disabilities and low mood.  More flexible adjustments can be made to standard therapeutic interventions such as CBT, to accommodate individuals’ cognitive and communication needs, without adhering to a protocol.   

Adaptation of psychological therapies and interventions is both about the skill and confidence of the therapists as well as how services are structured and delivered. ​(1)​ 

Key Considerations  

Wider Context  

People with learning disabilities are more likely to have experiences which increase their risk of psychological difficulties.  Research highlights that having limited social relationships and little purposeful activity make people vulnerable to poor mental wellbeing.  People with learning disabilities can also spend their lives in environments and systems which can be disempowering or don’t encourage autonomy or agency.  Social marginalisation, stigma and discrimination are common experiences, and may make it more challenging for people with learning disabilities to engage with health and social care services and find the help they need.  It’s important that any adaptations to therapies or interventions take account of stigmatising experiences and exclusion. A trauma informed approach is crucial as people with learning disabilities are more likely to experience traumatic events and adversity due to their living environments and social factors. 

Misconceptions about the abilities of people with learning disabilities to benefit from psychological therapy and a lack of support can also be barriers to accessing help for psychological difficulties.  Even if people with learning disabilities receive psychological therapies, people need to have a sense of agency and the necessary support to make positive changes and implement new skills, both within the therapy room and in their daily lives. More about this is included in the Essentials of Learning Disability module Understanding Psychological Difficulties, which can be found here. 

It is important to keep in mind that someone with a learning disability can also be a member of one or several other disadvantaged groups. Formulation should always be used to try and make sense of the range of potential factors that might contribute to the difficulties they are facing.  This should be completed jointly and be accessible for the person.   

Involvement of supporters 

Involvement of supporters in therapy is likely to bring benefits. Supporters can attend therapy sessions with the person and support their communication with the therapist. The supporter can also assist with homework tasks and help to make and maintain changes in the person’s life.  However, the involvement of supporters can also bring challenges and needs some thought ​(2)​. For example, there is a risk that supporters might dominate therapy sessions and emphasise their own concerns.  Consequently, clinicians should be mindful that the priorities of the person with learning disabilities must remain at the centre of the work. Clarifying the supporter’s role in therapy, including the need for confidentiality, is essential at the start of therapy and this can be reviewed as the work progresses. An agreement or contract can give a helpful structure for these discussions.  Where supporters are included in sessions, planned time alone with the clinician each session can ensure openness. It can be difficult for support organisations to ensure the continuity in support staff, to accompany people to their appointments. The consistency of support should also be addressed at the outset of any therapeutic work. 

Supporters are well-positioned to understand the person’s environment and system, and consider barriers which may impact the progress of therapy. This might include an understanding of the person’s financial constraints. Therefore, the involvement of supporters can help set realistic and achievable goals for therapy.   

Informed Consent 

As with all psychological interventions and therapies, wherever possible informed consent should always be sought from the person.  People with learning disabilities are often sent for psychological help without understanding the reason for their referral, or what is involved in therapy (see adaptation table for more information).  There is always a ‘presumption of capacity’ as a starting point (Adults with Incapacity Act Scotland, 2000), however, where it is suspected or established that someone does not have capacity to consent, appropriate processes should be followed.  Even in the absence of capacity, it is vitally important to provide the person with accessible information about therapy using a format and approach that is most accessible for them. This information should ensure, to the best of their ability, that they understand why they have been referred for psychological help and what will happen in the psychological intervention or therapy ​(2)​.        

Confidentiality, responding to risk  

Explicit planning around confidentiality should be undertaken at the start of the therapeutic work.  Some people with a learning disability will know that their personal information has been widely shared among professionals and support staff. So, talking with them about their preferences around confidentiality may be a new experience and care should be undertaken in supporting them to consider this.  The usual limits to confidentiality relating to risk should always be explained in a way that is accessible. 

Central to all child and adult protection and safeguarding policy is the statutory responsibility of all clinicians to keep people safe from harm, even if not working with them directly.  It is essential that clinicians have a good understanding of their roles and responsibilities with regards to child and adult protection and safeguarding, and links to core training are below.  Individual organisations may also have their own specific training or resources.    

Adult protection level 1 https://learn.nes.nhs.scot/64321/public-protection/adult-support-and-protection-practice-level-1-informed 

Adult protection level 2 https://learn.nes.nhs.scot/64322/public-protection/adult-support-and-protection-practice-level-2-skilled  

Child Protection level 1 https://learn.nes.nhs.scot/64323/public-protection/child-protection-practice-level-1-informed 

Child protection level 2 https://learn.nes.nhs.scot/64324/public-protection/child-protection-practice-level-2-skilled  

 

Taking intellectual and developmental skills into account 

Each person with a learning disability has their own unique profile of abilities and it is important to adapt the intervention to fit with that profile in a person-centred way ​(1)​. In general, having a learning disability can impact on a person’s ability to make sense of and remember large amounts of new information.  Planning, organisation and problem solving can be more difficult for people with learning disabilities. Some developmental skills such as recognising and managing emotions and being able to take the perspective of others can vary across the whole population but may be more difficult for people with learning disabilities.  These factors should not be viewed as a barrier to engaging in psychological therapies and interventions but should be considered as part of a person-centred approach to adapting therapy.  Additional multidisciplinary input such as speech and language therapy assessment is helpful to inform an individualised approach. 

The human rights of people with learning disabilities can often be undermined. Therefore, it’s vital to get beyond people’s limitations in therapy and to consider their strengths, emphasising the abilities and autonomy that they have. A strengths-based approach aims to empower people and can lead to positive and personalised interventions and outcomes.  

Therapy relationship 

The therapeutic relationship is a key factor in psychological interventions and therapies across all populations.  People with learning disabilities may lack close personal relationships in their lives. Therefore, the supportive nature of the therapeutic relationship can be even more significant ​(3)​. There are specific considerations when working with people with learning disabilities relating to power, stigma and agency.  While power is always a consideration in therapy, the impact of this is likely to be amplified by the nature of previous relationships people with learning disabilities have had with professionals and others in supportive roles. The idea of working in a collaborative way with a therapist is something that may be new to them. Therefore, when adapting therapies and interventions for people with learning disabilities, care needs to be taken to create opportunities for collaboration, shared agency and celebrating success, thereby facilitating the creation of an effective therapy relationship.   

While being mindful of power differences, therapists can offer scaffolding to the person, bringing views and suggestions about new strategies or changes that the person may not be able to think about independently.  However, any scaffolding needs to start with a genuine curiosity and seeking to understand the person’s interests and passions ​(2)​. The idea that a person learns better when working in partnership with others can be a helpful guiding principle ​(4)​.  Therapists are encouraged to reflect on their own biases to support development of genuinely collaborative relationships.    

Making psychological interventions and therapies accessible  

The practical strategies needed to adapt psychological interventions and therapies for people with learning disabilities are described in detail here (link to pop out table).  Considering the individual and their unique presentation, strengths and needs are key to selecting the adaptations which will be most appropriate and useful.  Where people with learning disabilities are also autistic or otherwise neurodivergent, additional information about adaptations is available here. 

The ways in which systems and services are designed and delivered can also be a barrier to accessing psychological therapies and interventions.  These barriers might include the availability of services or approaches, and the willingness to adapt processes and systems to ensure that services are inclusive for people with learning disabilities.  The ways services can exclude people with learning disabilities includes process for accessing help, including being expected to opt-in by telephone following receipt of a letter.  Involving people with lived experience in designing and reviewing services is an essential step towards ensuring the accessibility of services. 

Training and supervision are also key to ensuring that therapists have the skills and confidence to successfully adapt their approach.      

Measuring change remains an important element of therapeutic interventions and robust measures have been developed for people with learning disabilities: e.g. CORE-LD, Glasgow Anxiety Scale, Glasgow Depression Scale, Impact of Events Scale – Intellectual Disabilities. 

 

Table: Suggested considerations in adaptation of psychological interventions and therapies for people with learning disabilities. 

Type of Adaptation
Before the first appointment		People with learning disabilities may not know that they have been referred to a service, or why.  This can lead to confusion and distress for people, as well as changes to their routines.  It may also lead to appointments being offered to people where psychological intervention or treatment is not indicated.  Empowering people to ask questions about their referral is suggested, as well as trying to ensure that wherever possible the timing and venue of the session suits them.    Accessible, easy read information may be helpful to the person and their carers. This should include information about the service and about attending appointments, including who they will meet.  Short videos can be created which enable the person to learn about the place they will be visiting, as well as where they should report to and where they will wait.
Assessment and early stages of therapy	Language and communication	It is important to take account of the individual’s communication ability and preferences.  Where the person has a communication assessment, this can help guide adapted communication. For example, people may have expressive and receptive language abilities which are commensurate with each other, or they could have a particular strength or weakness in one area.  Be aware that there may be times when people with learning disabilities may be more acquiescent or suggestible.  Assess which kind of questions are most useful for the person.  Open-ended questions can be helpful, but they can also feel anxiety provoking for some people.  Using closed questions or multiple or fixed choice ones can help the person in session if they are lacking confidence to talk more openly, especially in initial sessions when they haven’t formed a relationship with the therapist.   Use the person’s own preferred terms to describe things.     Don’t assume a shared understanding of common words like anxiety, stress etc.  Take time to check in with the person and understand what they mean when they use particular terms.  It is fine to let someone know you haven’t understood their communication.  Find ways with the person, or with their supporter if they have one, to achieve a better understanding of what they are saying.
	Adapting assessment	Reading and writing abilities can vary across this population.  It is essential to check with the person in a non-stigmatising way about their level of literacy and use this information and their preferences to tailor the work to their needs.  Recording audio can be a helpful support here.  Adapted standardised assessment measures are available, including the CORE-LD, Glasgow Depression Scale, Glasgow Anxiety Scale, Impact of Events Scale-ID.  Even when keeping self-monitoring systems and diaries simple, using visuals where appropriate, care needs to be taken to ensure that the person understands what is being asked of them.
	Understanding emotions	People with learning disabilities can have difficulties in recognising, understanding, and talking about emotions.  A key task in therapy includes assessing this and establishing a shared vocabulary. One task of therapy may include developing these skills with the person or finding ways of scaffolding their understanding.
	Practical adaptations during sessions	The pace of assessment and intervention should be considered.  Take time to determine what session length is best.  Some people do best with shorter, more frequent sessions, and others find longer sessions easier.  It may be helpful to have a short break in the session.  People may find it harder to recall past events or report on their history in a coherent way.  Using concrete examples and developing a visual timeline can be helpful.  It may take longer to gather information, and this should be adapted to individual needs.  Frequent sessions are beneficial to ensure continuity and keep people engaged in the journey of therapy.  Where possible, meeting weekly is recommended to avoid long gaps between sessions.  People can benefit from being invited to modify the room to make it more comfortable, for example where someone may be bothered by harsh lighting, and it can help them to know they can ask for it to be turned off.
	Adapting formulation	Developing a formulation collaboratively is a key aspect and should include the wider context of the person’s life.  It is important this is shared in a way which is meaningful for the person, including visual aids and audio recordings, keeping it concrete and related to the person’s experience.  The formulation should link clearly to a plan for therapy, and realistic, achievable goals.    Simple formulations which focus on the here and now, incorporate strengths and focus on coping strategies are recommended.  It can be helpful to share the formulation with carers, if appropriate and with the person’s consent.
During therapy	Language and communication	Chunk information down into smaller parts to support processing.    Keep language concrete and use real life examples to aid understanding where possible.  Try not to include too many information carrying words in one sentence.  Use of visual supports such as photographs or symbols is recommended, take care to ensure these are meaningful and appropriate.      Interactions which might otherwise be verbal could be accomplished in other ways, for example activities such as sorting tasks, role play, demonstration.      Continue to actively check understanding
	Supporting specific aspects of cognitive ability	It’s important to normalise some of the challenges that people with learning disabilities may experience, for example difficulties with remembering, planning, attention.  This may prevent people becoming discouraged.    Individuals with learning disabilities may process new information at a slower pace. Consequently, make sure they have enough time to process questions and think about how to respond.  Along with other adaptations, this can support difficulties with memory, processing speed and attention. Some key adaptations include:   Visuals – personalised materials which are appropriate for the person.  It can be useful to ask them what kind of style they like – some people find colourful materials useful, where others prefer materials presented in written black and white format.  Support the person to be actively involved in session, for example writing the agenda, ticking off items as they are covered. Check in with the person to assess understanding and whether material needs to be adapted in other ways.  It can also be useful to check if people need a short break or if the session should be ended.  Repetition throughout session – recapping, checking in and ensuring the person understands.  It may be helpful to build this into the agenda so there are formal ‘checking in’ times.  Provide a folder to keep key therapy information, like handouts, homework activities, session summaries and formulation.    Some people may find it helpful to record audio prompts or reminders.  Setting up reminders on smart devices can also be useful to prompt people to carry out tasks.       It can be useful to provide links to specific helpful online materials e.g. YouTube videos, relaxation scripts.  Use memory prompts, e.g. sticker on fridge for homework activities  Work with the person to find ways to accommodate difficulties with planning and organisation.   For example, planning when and how a homework activity may be done by linking to the person’s routine, e.g. after dinner may be a good time for someone, or during supported time for another.
	Directive approaches	If the person has a clear idea about what is happening in therapy, it can foster a greater sense of ownership and promote collaboration. Paradoxically, this means that it can be helpful for the therapist to be more directive at times, offering a clear structure (joint agenda setting), being more directive and asking concrete questions.    Don’t assume the person will infer understanding, it is important to use concrete language and be clear about expectations both within and between sessions.
Flexibility	Therapy components	When offering psychological interventions and therapies to people with learning disabilities, it is important to be flexible and adjust techniques according to the person’s needs.    For some people, there may be aspects of therapy which may be more challenging, such as identifying and working with thoughts.  Therapists may need to be creative and draw on a full understanding of the person’s life to make these aspects meaningful, interesting and engaging for the individual.  For example, using someone’s favourite film or TV character to explore feelings, thoughts and behaviours.     In some instances, practical, skills-based activities and behavioural approaches may be helpful to emphasise, such as progressive muscle relaxation, role play and behavioural experiments.
	Involvement of others	Involvement of others is a key aspect in supporting people with learning disabilities to access and benefit from psychological therapies and interventions and requires careful consideration.  See above section.
	Including interests	Allocating time to talk about the person’s areas of interests can be a useful way to support development of the relationship and ensure attention during the session.  Some people benefit from a few minutes at the start and / or end of the session for this kind of discussion.   Incorporating the person’s areas of interest in session can also support attention, processing and memory.
Ending therapy		Provide a summary of what the person has worked on and the approaches and strategies that have been useful in an accessible format.  Highlight the progress made towards the specific identified goals and provide a roadmap for the person to continue to progress.  Using visuals and concrete, real life examples can be helpful.  Ending a supportive relationship may be particularly difficult for people with learning disabilities, who may have few such relationships in their life. It may be helpful to provide reminders, over the course of therapy, of the number of sessions remaining. A gradual ending, with increasing space between appointments, may reduce the sense of a sudden loss and help the person to recognise their ability to maintain progress.

Links to resources 

Talking Therapies for Depression: Beat it https://learn.nes.nhs.scot/15092   

Talking Therapies for Depression: Step Up https://learn.nes.nhs.scot/15095   

Essentials of Learning Disabilities https://learn.nes.nhs.scot/75162 

Division of Clinical Psychology & The British Psychological Society (2016). Psychological therapies and people who have intellectual disabilities.  DOI: https://doi.org/10.53841/bpsrep.2016.rep106 

References

​​1.Dagnan D, Taylor L, Burke C. Adapting cognitive behaviour therapy for people with intellectual disabilities: an overview for therapist working in mainstream or specialist services. the Cognitive Behaviour Therapist 2023 /01;16:e3. 

​2.Jahoda A, Kroese BS, Pert C. Cognitive behaviour therapy for people with intellectual disabilities: Thinking creatively. (2017).Cognitive behaviour therapy for people with intellectual disabilities: Thinking creatively.xii, 271 pp New York, NY: Palgrave Macmillan/Springer Nature. 

​3.Pert C, Jahoda A, Stenfert Kroese B, Trower P, Dagnan D, Selkirk M. Cognitive behavioural therapy from the perspective of clients with mild intellectual disabilities: a qualitative investigation of process issues. J Intellect Disabil Res 2013 -04;57(4):359–369. 

​4.Chadwick P. Person-based cognitive therapy for distressing psychosis. Chichester: John Wiley & Sons Ltd; 2006.​