Psychodynamic psychotherapy in severe and profound intellectual disability
| DOI | https://doi.org/10.1108/AMHID-11-2019-0037 |
| Date | 01 April 2020 |
| Pages | 45-60 |
| Published date | 01 April 2020 |
| Author | Julian Himmerich |
| Subject Matter | Health & social care,Learning & intellectual disabilities |
Psychodynamic psychotherapy in severe
and profound intellectual disability
Julian Himmerich
Abstract
Purpose –Psychodynamic psychotherapy is increasingly adapted and used with individuals with
intellectual disability (ID) and mental health difficulties. However, the evidence base is still small and
largely based on casestudies and small trials whose participants mainlyhave mild to moderate ID. This
paper aims to review and critique the literature in regards to the adaptations; and the effectiveness of
psychodynamicpsychotherapy for those with severeand profound ID.
Design/methodology/approach –A systematic literature search of PsycINFO, Social Policy and
Practice, Medline, Cumulative Index to nursing and allied health literature and applied social sciences
index and abstractswas conducted. Six studies met inclusioncriteria and underwent a qualityevaluation
and criticalreview.
Findings –Six papers (all case studies) met inclusion criteria and underwent a quality evaluation and
criticalreview. Some adaptations to therapy were reported,such as a more flexible therapeutic frameand
increased use of the physical environment as a therapeutic tool. Due to significant methodological
weaknesses of the included studies, it is yet unclear whether psychodynamic psychotherapy is an
effectiveintervention for individuals with severeand profound ID.
Research limitations/implications –Only a small number of case studies met the inclusion criteria.
Further research should use more robust outcome measures, larger samples and compare
psychodynamicpsychotherapy to alternativeinterventions.
Originality/value –This paper is the first to review the psychodynamic psychotherapy literature with
regard to its effectiveness as a treatment specifically for individuals with severe and profound ID and
mentalhealth difficulties.
Keywords Effectiveness, Mental health, Learning disability, Intellectual disability, Adaptations,
Psychodynamic psychotherapy
Paper type Literature review
Introduction
Current clinical practice guidelines(National Institute for Health and Care Excellence, 2016)
assert that individuals with intellectual disability (ID) should be offered the full range of
psychological therapies with adaptations for individual needs and levels of disability.
Increasing evidence is emerging for a range of approaches (British Psychological Society,
2016) and there is some preliminary evidence that psychodynamic psychotherapies may
be effective for those who have ID (British Psychological Society, 2016;James and Stacey,
2013;Shepherd and Beail, 2017;Willner, 2005). However, most participants in
effectiveness studies were described to have had mild to moderate ID and there is very
limited research includingthose with severe and profound ID as participants.
Intellectual disabilities
An ID is a condition marked by “intellectual and adaptive functioning deficits” in a range of
domains whose onset must be during the developmental period (American Psychiatric
Association, 2013). Categorisation into mild, moderate, severe and profound level of
Julian Himmerich is based
at East London NHS
Foundation Trust, London,
UK.
Received 20 November 2019
Revised 2 February 2020
Accepted 3 March 2020
The work was initially written as
part of a university
coursework, hence the solo
authorship and no funding.
DOI 10.1108/AMHID-11-2019-0037 VOL. 14 NO. 3 2020, pp. 45-60, ©Emerald Publishing Limited, ISSN 2044-1282 jADVANCES IN MENTAL HEALTH AND INTELLECTUAL DISABILITIES jPAGE 45
disability is conventional and guided by the Diagnostic and Statistical Manual of Mental
Disorders (DSM-5) (American Psychiatric Association, 2013). Severe and profound ID are
characterised by significant global developmental delay, very limited communication ability
and often accompanied by physical and congenital abnormalities. Individuals with this level
of disability likely require constant and close support and supervision in all areas of
everyday functioning. Just over two per cent of adults in the UK are estimated to have ID
(Public Health England, 2016). There is no separate estimate of those with severe and
profound ID but other studies have estimated a third to a fifth of those who have ID to meet
criteria for a severe and profound level of ID (Arvio and Sillanpa
¨a
¨, 2003;Strømme and
Valvatne, 1998).
Emergence of psychodynamic approaches for people who have intellectual
disability
People who have ID experience poorer physical and mental health than the general
population regardless of severity of the ID but have not always beenoffered the same range
of treatments available to the general population (Emerson and Baines, 2011). Within the
domain of psychological therapies, for example, behavioural approaches were often the
preferred choice of treatment, whereas relational approaches, such as psychodynamic
psychotherapy, were rarely used (Greenhill, 2011). It has been argued that this imbalance
in offered treatments reflected a general, historical, bias that the emotional inner lives and
abilities to form attachments by people who have ID were limited and that any therapeutic
work on a relational basis would be ineffective (Greenhill, 2011). However, there is much
evidence that individuals who have ID do have rich inner emotional lives, form attachments
much the same as those without ID and use defence mechanisms to cope with
psychological distress (British Psychological Society, 2017;Newman and Beail, 2010;
Schuengel et al., 2010;Sinason, 1999). In fact, some have argued that the extent of
emotional developmental problems and disturbance in the ID population are higher than in
the general population (Arthur, 2003). Much of the seminal work towards a more
psychodynamic understanding of people who have ID has been summarised by Jackson
and Beail (2013). For example, Sinason (1992,1999) argued that the ID is often
compounded by a secondary disability that serves as a defence against the pain and
trauma of the ID but that this defence could be addressed by psychotherapy. Frankish
(1989,2013a,2013b) posited that the development of attachment styles and a sense of the
self as a separate entity will bedelayed in those with a disability but that they can be helped
in this process through psychotherapy –an approach that became known as disability
psychotherapy (Frankish,2018).
Evidence for psychodynamic approaches for people who have intellectual disability
Psychodynamic psychotherapy has been defined as an exploration of “those aspects of
self that are not fully known, especially as they are manifested and potentially influenced in
the therapy relationship” (Shedler,2010, p. 2). A number of terms including psychodynamic
psychotherapy, psychoanalytic psychotherapy and psychoanalysis are used with subtle
differences in meaning (Shepherd and Beail, 2017), but the term psychodynamic
psychotherapy will be used as an umbrella term henceforth. There are many forms of
psychodynamic psychotherapy, but most commonly clients attend for individual therapy
either once or several times aweek at the same time and place. Sessions are traditionally of
50 min length. It is not uncommon for psychodynamicpsychotherapy to continue for several
years although shorter, more intensive approaches exist. It is generally thought that the
client’s current difficulties are rooted in the way the client relates to their environment
including other people. The client is thought to have developed these ways of relating
based on their early experiences and past relationships with caregivers. These
interpersonal difficulties are expected to also play out in the relationship between therapist
PAGE 46 jADVANCES IN MENTAL HEALTH AND INTELLECTUAL DISABILITIES jVOL. 14 NO. 3 2020
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