AN EXPLORATION OF THE THERAPIST'S

EXPERIENCE OF PSYCHODYNAMIC
PSYCHOTHERAPY WITH PEOPLE
WITH LEARNING DISABILITIES

ii

Declaration

This thesis is submitted in partial fulfilment of the requirements of the Doctorate

in Clinical Psychology at The University of Sheffield.

The author confirms that the work submittedis her own, and that the appropriate
acknowledgementshave beenmadeto the work of otherswhere collaboration
hastaken place.
This work hasnot beensubmittedto any other establishmentor for any other
degree.

iii

Word Counts Page

Thesisformat
The literature review contained in this thesis has been prepared in accordance
in
Intellectual
Applied
Research
for
Journal
the
the
of
author guidelines
with
Disabilities (see Appendix A).
The report section conforms to the requirements of Option B of the guidance for
is
in
The
Clinical
Psychology.
for
Doctorate
the
thesis
report
preparation of
in
Applied
Research
for
Journal
format
the
the
to
therefore written
of
Intellectual Disabilities. The choice of journal was approved by the Research
Tutor (see Appendix A)

Word count
Given below are word countsfor eachof the sectionswithin the thesis. Actual
length
for
is
followed
by
the
the
of eachsection:
criteria
word count

Literature review:

7,894

(5-8,000)

Report Section:

7,989

(5-8,000)

Critical Appraisal:

4,677

(2-5,000)

Thesis Total :
(Without appendices

20,560

(25,000)

and references)
Thesis Total:
(with appendices

and references)

30,411

(35,000)

iv

Abstract

This thesisexploresthe field of psychotherapywith clients with learning

disabilities. The work is organisedinto three sections:
Part One: Literature Review. The review examines the available literature on
psychotherapeutic contact with people with learning disabilities. The emphasis
is on exploring the attitude of the profession towards such clients and charts the
move from exclusion to partial inclusion. The review then explores in greater
depth, the experience of providing therapy to this client group. The review
notes the paucity of information on the topic and concludes that accessto
identity
has
been
by
the
stigmatised
of the group. The spoiled
services
affected
identity associated with learning disabilities appears to be a central focus in the
client-therapist relationship.
Part Two: Research Report

This section describes a qualitative study

exploring therapists' experience of providing therapy to this client group.

Personal accounts were elicited from eleven therapists using a semi structured
interview. Data were analysed using the principles of Interpretative
Phenomenological Analysis (IPA). Super ordinate themes emerged, relating to
the similarities and differences with other client groups, and the experience of
working with stigmatised clients. Themes were identified and theoretical links
made with prior case descriptions.

Part Three: Critical Appraisal. This sectiongives a detailedcritique of the

study's methodology,and exploreslimitations, clinical implications and
directions for future research. A personalaccountthe researchprocessis given,
including learning outcomes.

Acknowledgements

This thesiswould not havebeenpossiblewithout the help of thosemembersof

the Institute of Disability and Psychotherapywho so kindly gave of their time
and experience. To them I owe the largestmeasureof thanks.
I am indebted to many others. These include my supervisors, Professor Nigel
Beail, Professor Paul Gilbert and Dr Gerry Kent. Mr Simon Ratcliffe provided
invaluable input in his role as Service User Consultant and as Chair of the IDP,
Dr Pat Frankish facilitated the progress of the research.

In my workplace, I receivedboundlessemotional and practical supportfrom

Gwyn Fraser,Helen Jamesand TraceyProctor, whoseinput probably savedme
from abandoningthe work when I was sorely temptedto do so.
On the home front, Graham,Debbie and Lesley deserveto be mentionedin
despatchesfor uncomplainingly sitting through the endlessmonotonousdetails
of somebodyelse's research. Di, Sylv and Garry are also awardedmedalsof
honour for actsof valour which were, almost literally, lifesaving!
Finally, I should like to thank my mother for her supportthrough every aspectof
is
for
her.
This
thesis
my academiccareer.

vi

Contents
Page
Part 1: Literature

Review

Abstract
Introduction
Brief history

2
3
7

The role of intelligence

11

Outcome studies
The social context
Transference and counter transference

17
21
24

Spoiled identities and the therapeuticrelationship

Discussion

32
32

Further research

34

Conclusions

37

References

40

Part 2: Research Report

Abstract
Background

Methods

51
52
53

56

Materials
Procedure
Participants
Data collection

56
57
58
59

Data analysis

59

Quality control procedures

60

61

Results
Overview
Super ordinate theme 1.
Master themes (1.1 - 1.5)
Super ordinate theme 2
Master themes (2.1 - 2.3)
Discussion
Relating results to previous research
Methodological limitations
Clinical implications
Further research
References

62
63
63
74
74
87
87
92
93
93
95

vii

Part 3: Critical Appraisal

101

Methodological Limitations
Adequacy of Data
Managing Subjectivity and Reflexivity
Adequacy of Interpretation
Social Validity

102
102
106
108
109

Clinical Implications

110

Further Research

112

Personal Account
Origins of the Project
Implementation
Supervision
Motivation

114
114
115
117
118

Future Work Practise

119

References

121

Appendices

123

AppendixA
i. Letter of approvalof the Journal of Applied Research

123

In Intellectual Disabilities.
ii. Author Guidelines for the Journal of Applied Research
In Intellectual Disabilities.

Appendix B
i. Confirmation of University of Sheffield
Ethical Approval

ii. ResearchGovernanceFramework Agreement.

Notification Letter from DerbyshireMental Health
Services Trust.

124
125

128
129

130

Appendix C

131
132

i. Interview schedule
Appendix D

133
135

i. Letter of introduction
ii. Information for participants.

136
138

AppendixE

140

i. Participant consent form.

Appendix F
i. Demonstrating the analytic process
ii. Field diary excerpt
iii. Example of preliminary analysis
iv. Co-rater comparison.
v. Macro level analysis.

141
142
143
144
145
146
147

vi. Participant validation

149

vii. Participant response

154

vii. Identification of superordinate themes

155

viii. Pen portrait.

158

vi"

Appendix G
i. Initial service user representative consultation
ii. Dissemination consultation.

159
160
163

1X

Figures

Figure 1. Overview of super ordinate and master themes

62

Figure 2. The self as medium: client presentations

67

Figure 3. Malan's triangle of person

70

Figure 4. Continuum model

70

Figure 5. Dominant psychodynamic model

75

Figure 6. Non dominant psychodynamic model

75

Figure 7. Participants' negative counter transference

80

Figure 8. Overview of research process

143

Figure 9. Early model of themes

147

Figure 10. Early model of themes (contd. )

148

Figure 11. Summary of Themes and Evidence:

Super-ordinate theme 1.156
Figure 12. Summary of Themes and Evidence:

Super-ordinatetheme 2.157

Stigma and Psychotherapy:

An exploration of the relationship between psychodynamic
learning
with
and
people
psychotherapists
psychotherapy,
disabilities.

Abstract

Background: Peoplewith learning disabilities have limited accessto psychodynamic

psychotherapy. This review explores factors which may underlie this exclusion.

Method and Materials: An automatedsearchwas conductedusing the Psychinfo and

Web of Sciencedatabases.The library of the Tavistock Clinic was also screened.
Combinationsof key terms including; "learning disabil", "intellectual disabil",
"mental handicap","mental retardation","psychodynamic", "psychotherap",and
"transference"were usedto elicit data. Thesewere then usedas sourcesfor further
references.
Results: Findings showedineligibility due to cognitive limitation hasbeen
challenged. Effectiveness of psychodynamic psychotherapy is not proven by

available research,but findings tentatively supportthe applicability of the method.

Stigma, projection and negative counter transference are all noted in work with this
client group.

Conclusions: The available evidencedoesnot supportthe conclusionthat exclusion

is justified on the groundsof ability, suggestingthe professionmay be respondingto
the stigmatisedidentity of peoplewith learning disabilities.

Introduction

"They represent such an extreme of life that we wonder whether they are
human at all, in any way like us. Our interaction with them seems so
minimal, we wonder what the point of their existence is... we do not know

for
for
they
them,
we
are
or
who
are
us. Is there any mutual identity we
who
between
can establish,any reciprocity
us, and if there is, do we want to
Imow about it? " Ryan and Thomas (1980, p. 13)

In 1993, Bender wrote an article charting what he described as a history of

therapeuticdisdaintowards peoplewith learning disabilities. He identified structural

factors in the developmentof professionsand serviceswhich actedto excludethis
client group. Benderarguedthat the principles underlying the exclusionwere
prejudicial rather than empirical. The aim of this review is to explore the claim by
looking at the rationalesfor exclusion from psychodynamicpsychotherapy,going on
to examinethe social identity of this group, andthe impact this may havehad upon
their inclusion in services. Finally, the review will examinethe available literature on
the therapeuticrelationshipwith peoplewith learning disabilities, with particular
issues
to
transference
reference counter
which are raised.

To explore Bender's (1993) claim, one needsto look at the validity of the rationale
underlying the exclusion. Ineligibility might be arguedfrom two positions;that
specific featuresrelatedto the condition of learning disability renderspeopleunable
to makeuse of psychotherapy;and empirical evidencefrom psychotherapeutic
interventionsthat demonstratesfailure of the techniqueswith this population.

Before addressingthesekey questions,it is useful to explore how contributionsto the

literature emerged. To do so requiresa brief history of psychotherapywith people
with learning disabilities, as in many ways its evolution dictatedthe nature of the
literature which emerged.

In the courseof the review I shall be referring to clients as peoplewith learning

disabilities asthe preferredterm identified by serviceusers. The word "handicap"
will be used in the text as a term relating to specific theories.

Brief History

In Britain, literature on psychotherapywith people with learning disabilities did not

emergeuntil the 1980'swhen Neville Symington was creditedwith writing the first
publisheddescriptionof psychotherapywith a client with learning disabilities
(Symington, 1981). Symington's paper markedthe beginning of significant interest
in this neglectedclient group. He begana workshop for therapistsinterestedin work
with peoplewith learning disabilities at the Tavistock Centrein London. One of the
clinicians influencedby this group was Valerie Sinason.Sinasonwas initially a child
psychotherapistwho, like a number of authorsin the field, moved into working with
peoplewith learning disabilities from a different therapeuticspeciality.

In 1992, Sinasonpublished an influential collection of casestudies. Thesecases

illustrated the clients' emotional intelligence and madea casefor their ability to
engagewith psychodynamicpsychotherapy. Sinason'swriting was hugely influential
(Hodges,2003, Simpson& Miller, 2004). Work in the field was virtually non

5
existent,but Sinason'sanecdotal,narrative style challengedthe views on this client
group's suitability for treatmentin a way that engagedinterest amongstclinicians.
The emphasisfor much of the availablework did appearto be to raisethe profile of
the population and to inspire other clinicians.

Training initiatives by the Tavistock and from clinicians at St Georges Hospital saw

more therapiststaking on clients with learning disabilities. The developmentmay

institutions
by
have
been
1990's
the
the
when
were being
also
assisted
zeitgeist of
closed, with only 3,000 residents in 1999, in comparison to 70,000 in 1970. (Hollins,
2000). Clinicians were faced with needing to offer interventions to people coping
increased
the
the
community
settings,
with
emphasis on choice
with
complexities of
in
inclusion
the government white paper "Valuing People"
and
which culminated
(2001). In addition, there was a growing awareness of the widespread abuse of

demanded
focus
for
learning
disabilities
a
response
and
provided
a
peoplewith
which
early cases (Turk & Brown, 1993).

Small pioneer servicesbeganto emerge,where individual practitionershad fostered

an interestin this mannerof working. Neville Symington's workshop blossomedinto
a dedicatedpsychotherapyservicefor peoplewith learning disabilities in 1995
(Hernandez-Halton et al, 2000). Interest was also growing elsewhere, and clinicians
Nigel Beail and Pat Frankish established a similar service in the north of England.

The publications generatedat this time placed emphasisupon describingtherapeutic

approachesand sharingadaptationsto the therapeutictechniquesto accommodatethe
specific difficulties of the client group (Butz et al, 2000). The focus appearedto be

moving from whether the work could be done, to how it might be done.Attempts to
addressthis camein the publication of practical technical handbooks(Conboy-Hill,
1992;Hodges,2003). Although in 2000, Hollins and Sinasonstill judged the
provision of psychotherapyservicesto be inadequate,the use of this therapeutic
approachwas sufficient to allow critical reviews of the practiseto begin appearingin
the literature (Beail, 2003; Willner, 2005; Sturmey, 2005). For the first time there

was starting to emergea literature of psychotherapywith people with learning

disabilities from which to considerthe question,"should it be done?"

The literature included in this review is largely drawn from the referencessupplied
from the searchof the Psychlit and Medline data baseswith additional material being
drawn from searchesof the Tavistock CentreLibrary and local clinical libraries.
Thesesourcesin turn yielded relevant referenceswhich were then pursued. The
available literature is very limited. In particular, the searchyielded no references
disabilities
learning
which explicitly statedreasonswhy peoplewith
were excluded
from psychodynamicpsychotherapy. This may be because,in line with the
marginalisationof this group, the thought of offering therapywas never entertained
so ajustification of exclusion was superfluous. Therefore, literature drawn from the
broaderfield of learning disability researchrelevantto possibleexclusion criteria has
beenincluded.

As the latter half of the review exploresthe exact natureof the individual relationship
information
learning
disabilities,
hasbeendrawn from the few
with clients with
existing casedescriptionswhich included therapists' accountsof their experiences

7
and reactions. The outcomestudiesincluded representthe few systematic
investigationsand reviews available in the literature.

The Role of Intelligence

The Diagnostic and StatisticalManual (fourth edition) defines learning disabilities as:

"Significant subaveragegeneral intellectualfunctioning accompaniedby

significant deficits or impairmentsin adaptivefunctioning with onsetbefore
eighteen. " (p. 28)

The distinguishing factor betweenthis and other conditions which might involve
early onsetor impairmentsin functioning is clearly the cognitive elementof the
definition. The questionof whether intelligence is a required pre-condition for
psychotherapythen becomescentral. Freud (1904) believedthat somedegreeof
intelligence was required for psychotherapeuticgain.

However, Freud's exact referenceto requirementswas, "a certain measureof natural

intelligence" (p. 254). Whilst Freud's definition may have beeninterpretedas
concomitantwith cognitive intelligence, other forms of intelligence have been
identified by clinicians pressingfor inclusion.

Stokes(1987) introducedthe conceptof emotional intelligence to describeclients'

ability to engagewith the emotionaltasks of therapy. Hodgetts(1985) had previously
noted that, evenwhere a learning disability clearly existed,the rangeof competencies
encompassedby intellectual impairment madea unidimensionalmodel inadequate

ill-defined
ineligibility.
for
blanket
This view was supportedby
too
to
and
allow
Hedlund and Sternberg's(2000) review, which identified emotional, social and
practical intelligence as previously unrecognisedaspectsof adaptivefunctioning.

Not only hasthe conceptof intelligence been challenged,but so too hasthe

assumptionof its aetiology. A number of therapistshave questionedthe assumption
that loss of intelligence is solely due to organic causes.Intelligence hasbeendefined
as;

"The capacity of the individual to act purposefully, to think rationally and to

deal effectively with his environment. " (Wecshler, 1944, p. 3)

As such,intelligence hasa self preservativefunction. It hasbeenarguedtherefore if

losing knowledge protectsthe self, presentingas learning disabledcan be a
paradoxically intelligent act (Sinason, 1992).

Symington (1981) exploresthe notion that a personmay perceive intelligence as

threateningand seekto reject this ability and Mannoni (1973) had previously referred
to psychodynamiccausesof learning disabilities. Morelle (1999) describesclients
who withdraw into mutism when demandsare madefor emotionally challenging
less
thus
as
able than they are.
responses,
presenting

Stokes(1987), whilst recognisingthe reality of organic damage,encapsulatesthe

phenomenonas the "exaggerationof handicapas a defence"(p. 2). Sinason(1986)
categorisedthis as one of a rangeof secondaryhandicaps,in which featuresof the
primary, or organic handicapare expandedas a defensivestrategy.The proposalthat

handicapwas exaggeratedas a form of defencewas formulated as a parallel to Bion's

(1967) distinction of psychotic and non-psychoticelementsof the personality. It was
proposedthat there was a distinction betweena more disabledpart of the personality,
and another,more perceptiveand able part which was submergedfor much of the
time. Stokes(1987) describedthis as an attemptto deny the disability by exerting
control over it. By manipulating someaspectsof disability, this reinforcesthe
phantasythat the entire disability is elective, and therefore acts as a defenceagainst
painful impotence.Stokesalso proposedthat this defenceprotectedpeopleagainst
emergentviolent or sexualfeelings, perceivedasthreatening.

Sinasonidentified additional functions of loss of intelligence (Sinason,1986,1992).

Opportunistic handicap was a phrasefirst coinedby Sinason(1986) to cover the use
of a disability to expresshostility and anger.In her 1995paper,"Revengeand
Learning Disability", sheproposedthat a painful awarenessof disability can result in
hatredand attacksupon the self or others. Shedescribeda boy who despoiledhis
school's gamesand toys by pushing his penis into them. In therapy he confessedthat:

"They (meaning his parents) made me come out silly and I am going to give

all the toysDown's syndrome." (p.17)

Opportunistichandicapwould allow the personto disguisesuchaggressiveand

enviousattacksas part of a disability, rather than as intentional acts.

The last subdivision of secondaryhandicapwas that of its use as a defenceagainst

trauma. Sinason(1986) reportedcaseexampleswhere a generalloss of knowledge

10

was usedin this way to lose the awarenessof traumatic eventssuchas previous
sexualabuseand rejection. Hollins and Sinason(2000) have recently expandedthe
definition of traumato include the disability itself.

Thus, rather than being a criteria for exclusion, loss of intelligence might legitimately
have been considered an indicator for the presence of debilitating defences in some
cases, and thus highlighting a need for intervention. This might have been dismissed
as recent knowledge in relation to the debate upon eligibility for psychotherapy, but
the strategy of losing knowledge to protect oneself is actually a central tenet of
Freud's (1920) work, as indeed, was the concept of secondary gain which was
expanded into the concept of secondary handicap.

Support for the validity of the concept of emotional intelligence in the context of

psychotherapyfor peoplewith learning disabilities comeslargely in the form of case

descriptionswith little empirical evidence.This remainsan obvious sourceof
criticism in much of the available literature. Bichard et al (1992) did attempt to
measure outcomes using projective drawings in a creative attempt to capture post
therapeutic psychological adjustment which reflected emotional maturity. Whilst
findings appeared to support the assertions or increased maturity, there remain
inherent difficulties with the reliability of this method of assessment(Lowenthal,
2001)

11

OutcomeStudies
The most striking feature of the literature critically reviewing psychotherapeutic
interventions with people with learning disabilities is that it is almost completely
(1986)
Orlinsky
Howard's
is
in
field
and
usually prolific.
where writing
absent a
descriptions
identified
1100
case
review of mainstream psychotherapy publications
(2006)
25
Whitehouse
five
In
thirty
review
yielded
et
al's
contrast,
over
years.
disabilities.
learning
to
clients with
publications where work related

Oncethe approachbecamemore established,the needfor systematicoutcomestudies

became apparent (Hurley, 1989). The existing literature was either anecdotal case

be
the
might
given,
of
technical
elements
work
accountswhere structural
studiesor
but surprisingly little detail of exactly how the work was done (Frankish, 1989;
Symington, 1981).

Beail addressedthis shortfall in a seriesof outcome studies.In his review of the field
in 1995,Beail noted that there was a dearthof outcomestudiesproviding evidence
for the effectivenessof psychotherapywith the client group. Of reports of work with
twenty three clients, only nine casesincluded outcomedata. He proceededto
differing
investigating
this
ways of assessing
address
with a seriesof studies
(Bead,
for
1998,2000,2001,
such
evaluation
means
outcomes and appropriate
2003).

In a pilot study, Beail and Warden (1996) reported on the outcomes of

disabilities.
Clients
learning
intervention
ten
were
clients
with
with
psychodynamic
including
Pre
the
for
taken
post
measures
were
and
seen a meanof eighteensessions.

12

RosenburgSelf EsteemChecklist (Rosenburg,1965)and the Brief Symptom

Checklist (Derogatis, 1975). These commonly used self report measures were

adaptedfor use as interview schedulesto overcomethe cognitive disadvantagesof the

participants. In this study, the measuresshoweda rise in self esteemand fall in
symptomologyafter the treatment.

Beail was also interestedin investigating other outcomesof psychodynamic

psychotherapy. He noted that interpersonal difficulties were commonplace in the
presentation of people who were referred, but changes in interpersonal difficulties
were not measured. He adapted the Inventory of Interpersonal Problems - 32,
(Barkham, Hardy & Startup, 1996) for use as an interview (Beail & Warden, 1996)
following
it
to
and subsequently used
show changes
psychotherapy (Beail, 2000).

However, a difficulty of applying and adaptingmeasuresfor the learning disabled

population was illustrated by concernsabout the psychometricpropertiesof the
measurein relation to this client group. Kellett, Beail and Newman (2005) addressed
this problem by administeringthe scaleto 255 participantswith learning disabilities.
The scalewas found to be generally psychometrically sound,thus strengthening
earlier conclusions,but the exerciseillustrates how the needto adaptmeasuresfurther
underminesthe limited data on outcomes.

Prior to this, the few outcomeswhich were measuredhad tendedto rely upon
behaviouralobservations(Prout & Nowak-Drabik, 2003). Beail did not discountthe
potential usefulnessof behaviouralmeasures.He observedbehaviourbefore and

13
after short term psychotherapy to chart positive changes in 25 clients with difficulties
with aggression (Beail, 1998).

Newman and Beail (2002,2005) gave evidence for the development of new positive
in
schemas clients during the process of psychotherapy, which accords with the
assimilation model of predicted change. The study used the Assimilation of
Problematic Experiences Scale (APES) that describes a systematic sequence of
changes, identified by the client's statements and behaviours (Barkam et al, 1996).
Interestingly, although significant positive change was recorded, clients with learning
disabilities entered therapy at a lower stage of assimilation, that of avoidance, than
clients without disabilities.

Beail's studiesreportedon different client groups,aswell as using differing outcome

measures,including a dual diagnosisclient group (Beail & Warden, 1996)and a
forensic cohort (Beail, 2001). Both studiesprovided evidencethat psychotherapy
in
could produce significant reductions psychological symptomology and was
associatedwith significantly reducedratesof recidivism for the latter group.

In all, Beail's studiesrepresentprobably the most creativeand systematicwork in the

field of learning disability outcomestudies. However, the numberof participantsare
still small, and adaptationsto measureslargely psychometricallyunsubstantiated.In
his re-review of the field in 2003, Beail concludedthat, measuredby the usual
standardsof empirical evidence,the casefor effectivenesswas weak, but that
conversely,the limited evidenceavailable did provide a positive indicator for
psychotherapy.

14

Willner (2005) agreedwith theseconclusions,citing the lack of randomisedcontrol

trials. In contrast,Sturmey(2005) reviewed evidenceof different interventionsand
publishedhis findings under the headingof "Against therapy". Sturmeyclaimed that
behaviouralapproachesremainedthe preferredoption for peoplewith learning
disabilities.

Sturmey's (2005) paper is particularly relevant, in that exclusion might be justified by

empirical evidenceof ineffectiveness. However, a number of flaws were pointed out

in both conclusions and methodology of Sturmey's (2005) work. Beail (2005) noted

that the review incorporateddatafrom studieswith children and was largely basedon
participantswith severeor profound disabilities in institutional settings. He claimed
that the categoriesusedto define presentingproblemswere ill-defined, and that
mental health topographiesaccountedfor only 1.25% of the data upon which Sturmey
had basedhis conclusions.

Hurley (2005) criticised the inclusion of cognitive techniques such as problem

solving training under the headingof behaviouralinterventions,and noted his

exclusion of additional reports, including clinical casereports. Taylor (2005) pointed
out similar objections.

In all, Sturmey's (2005) conclusionsare not convincing. One difficulty lies in the
definition of psychotherapy. Although Sturmey's (20005) review mentionedone case
of "traditional psychotherapy",it did not distinguish psychodynamictherapy from
other forms, including cognitive behaviouraltherapy. Willner (2005) andBeail
(2003) concludethat it is hard to commentwith any degreeof certainty on the

15
effectiveness of psychotherapy from the available data, and even less possible for the
narrower definition of psychodynamic psychotherapy.

King (2005) condemned the simplistic approach to categorising interventions

underlying Sturmey's (2005) review, and the methodology does indeed appear too
clumsy for the complexities of this client group. Willner (2005) identifies that the
evolution of research in this area reflects the paradigm of "practise -based evidence"
rather than "evidence-based practise" (Barkham & Mellor-Clark, 2000).

The former paradigm is far better suited to the evidence. In this way, the anecdotal
and single case studies that predominate, and are easy to criticise in terms of lack of
outcome measures, can be seen as a valuable component of a meta developmental
process. Salkovski's (1995) hour glass model postulates a process whereby clinicians
identify a problem and begin small scale exploratory investigations. This leads to
"purer" research in line with standards for evidence based practise (Chambless et al,
1998). This then generates the dissemination of information and it's testing in field
conditions.

In all, the stateof researchis perhapsbest summedup by Beail's (2003) observation

that the "absenceof efficacy is not evidenceof ineffectiveness"(p. 471) asthe work
is only just arriving at the stagein which field testing has beengenerated. For the
purposesof this review, effectivenessdoesnot haveto be proven. Rather,there
simply needsto be sufficient evidenceon which to arguefor exclusion. Basedn the
information available,this conclusion doesnot appearto bejustified.

16
Despite this, a recent multi-disciplinary survey by the Royal College of Psychiatrists

(2005), showedthat most respondentsstill believed that individual psychodynamic

psychotherapywas likely to benefit to peoplewith learning disabilities lessthan
cognitive-behaviouraltherapies,family therapy or group work, despitethe lack of
adequatesupportingevidence(Beail, 2005).

It is possiblethat dueto Freud's reservations,practitionerswere still merely over

in
infancy
is
in
It
the
techniques
of
psychotherapeutic
cautious applying
approaches.
interesting to compare people with learning disabilities with other groups previously

included
from
(1993)
Bender
that
therapy.
thosewith
notes
groups
excluded
excluded
psychosisdespitethe Freud having not ruled out appropriateadaptationsin
techniquesovercoming his original reservations.Bender proposedthat the
psychotherapeuticinstitutions set up rules of exclusion for disfavouredgroups. It is
thus possible that people with learning disabilities were caught up in the exclusory

rules by accident,asthe prospectof any therapy would have beeninconceivableat

that time.

However, Bender observed that the rules for some groups have changed. British
Psychoanalytic Society, until 1986, excluded patients over 40 years of age. However,
it would seem highly unlikely that any therapist would nowadays claim the principles
were not applicable for this group, or claim they lacked the skills required to work
with these clients. Yet Nagel and Leiper (1999) suggested that 59% of psychologists
felt they lacked the competency to work psychoanalytically with this client group.

17

Why then, shouldtherapistscontinueto avoid offering servicesto this group basedon

apparentlyinsufficient evidence,and questionskills which might be adjustedto suit
other categoriesof adult serviceusers?There appearsto be a needto explore reasons
other than the suitability and effectivenessof the techniqueto accountfor the
"unoffered chair"

The Social Context

" Disability is somethingwhich can only exist in relation to something

else,or someoneelseand therefore it is not only a problem for oneperson
or another, but also a problem of discourse. In other words, the location of
the disability could be said to be betweenpeople rather than in people."
(Bungener & McCormack, 1994, p. 365-366)

Bungenerand McCormack (1994) identify herethe key notion that learning

disabilities are not intrapersonal,but interpersonal. Thus this group is actually
defined by their social identity, and needto be consideredin this context. The
authorsassertthat the "adhesiveidentification" (p. 371) we useto makelinks with
others,is facedwith overwhelming "differentness" in individuals with learning
disabilities, leadingto the building of stereotypes.

Goffman (1963) exploredthe conceptof stigma, a "spoiled identity", or global

attribution of the self as failing to reachthe individual's cultural standards.Lewis
(1998) described stigma thus:

18

"The whole self becomesdefined by the stigma. Theexpressions"the

Down's child", the mentally retardedperson, " or "thefat lady" all reflect
defining
feature
"
inescapable
is
that
the
the
the
an
realization
stigma
of
self.
(p. 128)

Wolfensberger's(1972) famoustreatiseidentified that thosewith learning disabilities

are characterisedas "man as other", becauseof their level of perceiveddifference.
The negative impact of this stigmatising collective identity can be seen throughout the
history of people with learning disabilities, from the Eugenics movement, through
Nazi extermination policies and the setting up of Asylums (Ryan & Thomas, 1980).

This doessuggestthat in addition to any theoreticalrationale aboutthe inability to

identifies
therapy
there
perhaps
make use of
must run a parallel social process,which
this group as neitherworthy of such input, nor sufficiently "human" asto experience
a similar psychologicallife to others(Ryan & Thomas, 1980).

Hardly surprising,then, that this stigmatisedidentity has had an impact upon the way
that servicesand clinicians approachedthe group. Wolfensberger(1972) highlighted
the exclusionof this group from mainstreamsociety, including health services.
Hughes(1945) describedhaving a learning disability as a "master status"which
supersededall other social identities. Phillips (1966) notedthat signsof
psychologicaldistresswere often misdiagnosedas corollariesto learning disability
ratherthan seenas a separateissue,and thereforewent untreated.

19

The term "diagnostic overshadowing"was coined by Reisset al (1982), whose

studiesshowedthat being identified as having a learning disability reducedthe
likelihood of being given another,mental health related diagnosis(Reiss& Szysko,
1983).Bender (1992) arguedthat the developmentof specialisedservicestacitly
institutionalisedovershadowing. He claimed that the evidenceshowedhow being
part of a stigmatisedgroup hasa major impact upon the servicesoffered to that
particular cohort. This begsthe questionof how social identity might affect the
decisionsof individual clinicians, faced with the treatmentof stigmatisedindividuals.

Goffman (1963) described"courtesy stigma" by which those associatedwith a

stigmatisedindividual might be infected. Studieshave shownthat having a learning
disabledchild stigmatisesthe parents(Rimmerman,& Portowitz, 1987)and Schelles
(1999) describessimilar distressin siblings.

Ogle's (1963) commentssuggestthat it may also apply to professionals,speakingof

"group embarrassment"in relation to working therapeuticallywith peoplewith
learning disabilities. Limited referenceto this phenomenoncan be found in the
literature of the field. Mitchell (2000) exploresa stigmatisingprocessfor nurses
working with thosewith learning disabilities which parallelsthe experiencesof their
clients.

In the recentreport from the Royal College of Psychiatrists(2005), whilst the lack of
input was blamed mostly on resources,prejudice and unhelpful perceptionsabout
peoplewith learning disabilities were cited as barriersto serviceprovision. The
report doesnot identify whose prejudicesthesemight be (or indeedto whom they

20
learning
had
directed)
be
shown
although an earlier survey of psychiatrists
may
disabilities to be the least preferred speciality (Hook, 1973). Hollins (2000) reported a
survey indicating that most junior doctors chose alternative specialities. Those that
did
in
field
learning
disabilities
to
the
so only after experiencing a
of
chose work

learning
disability.
because
had
family
they
a
a
memberwith
positive placement,or

Professionalavoidanceis not confined to psychodynamicpractitioners.Sternfoert

Kroese (1997) reportsfrom the field of cognitive-behaviourtherapy that:

"

box'
Skinnerian
`black
to cognitive
the
approach
pure
although
...

learning
disabilities
by
been
has
most
people
with
rejected
and
processes
(be
it verbal or non-verbal), cognitive thought
with
now
credited
are
behaviour therapists have so far failed to show any great interest in
"
(p.
6)
into
their
these
clinical practises.
clients
welcoming

The neglect of this client group has been perpetuated by educational structures. Only
in the last three decades have psychotherapy trainees been able to have clients with
learning disabilities as training cases, following the lead of Joan Symington (Sinason,
1992).

Simpson (2004) offered an explanation suggesting that:

"There can be an unconsciousaversion amongstpeople training as

learning
taking
to
patients
with
counsellors
on
psychotherapistsand
disabilities. This can be basedon afear that is, in part, socially
"
(p.
xxiii)
conditioned.

21

Evidence suggests that factors of social identity may be impacting on professionals'

decision making processes. Retzinger (1998) proposed a concept of ideological
counter transference which may link social influences with the therapist's response to
his or her clients. However, before exploring this further, it may be useful to define
the meaning of counter transference.

Transference and Counter Transference

Freud (1910) first describedthe processesof transferenceand countertransferencein

the therapeuticrelationship. Transferenceis seenas consciousand unconscious
responsesfrom a client towards an other. LaPlanche(1988) definestransferenceas;

"... a process of actualisation of unconscious wishes. Transference uses

specific objects and operates in theframework of a specific relationship
(p.
455)
these
established with
objects.

LaPlanche notes that by some definitions, transference connotes all the phenomena
which constitute the client's relationship with the therapist. Complimentarily, counter
transference is the term for the equivalent feelings evoked in the therapist by the
client:

"The whole of the analyst's unconsciousreactions to the individual

anlysand- especiallyto the analysand's own transference." (LaPlanche,
1988,p. 92)

22

In classicpsychoanalysis,countertransferencewas interpretedfrom an
epiphenomenalisticstandpoint,as a negativeside-effectof therapywhich reflected
the therapists' own unresolvedpersonalconflicts. In most researchstudies,the
interpersonalrelationship betweenclient and therapist,necessarilyincorporating the
factor
in
deciding
has
been
be
key
transference,
to
shown
a
conceptof counter
outcome, regardless of model (Henry, 1998; Orlinsky & Howard, 1986).

In modernpsychoanalysis,countertransferenceis now considereda valuable process

by
in
information
approaches,
providing
a
means
which
psychodynamic
of
gathering
the client's experiencesmay be understood.

Retzinger's (1998) ideological counter transference relates to a "third party" in the

therapeutic relationship, and may take the form of theoretical perspectives, belief
systems or clinical positions. It acts to interfere with the direct reciprocal relationship
in
locate
it
"problem"
In
the
the
the
therapist
to
the
particular,
allows
client.
with
client, which Retzinger believed leads to discrimination or projection.

Ideological countertransferencewould thus encompassboth the belief that clients

with learning disabilities are cognitively unableto makeuse of therapy,but also
beliefs basedon the roles and stereotypesthat Goffman (1963) andWolfensberger
(1972) describe.Of course,prescribedroles are not exclusiveto peoplewith learning
disabilities. Orlinsky (1986) describesconsiderableresearchinto role investmentin
mainstreamtherapy. However, the roles assignedto peoplewith learning disabilities
are particularly negative.

23

Wolfensberger(1972) proposesthat peoplewith learning disabilities, too, are aware

ideological
has
been
therefore
that
them
the
onto
and
may
perpetuate
of
role
projected
countertransferencethrough their actions:

"When a person is perceived as a deviant, he is cast into a role that carries

with it powerful expectancies.Strangely enoughtheseexpectanciesnot only
take hold of the mind of the perceiver, but of the perceived person as well. "

(p. 15)

The belief that peoplewith learning disabilities have an awarenessof the roles
in
handicap
is
inherent
described
the
them
onto
concept
of
secondary
projected
earlier. Caseexamplesare given of where clients presentthemselvesin accordance
(1972)
"menace",
"object of unspeakable
Wolfensberger's
stereotypes
of,
with
dread", "eternal child", "diseased organism", (p20-23) and more (Sinason, 1992;
Stokes, 1987; Symington, 1981; Korfe-Sausse, 1999; Parsons & Upton, 1986).

Empirical evidenceof role adoption doesnot appearto havebeenexplored,but

awarenessof a stigmatisedidentity is supportedin the literature. Szivos-Bach's
(1993) findings showedthat young peoplewho perceivedthemselvesto be most
stigmatisedhad the lowest self esteemand felt least likely to fulfil their aspirations.
Jahoda's(1988) study found similar awareness.

24

Spoiled Identities and the Therapeutic Relationship

Thus the awarenessof the social context may impact on both the therapist and client.
One can ask whether other elementsspecific to individual therapeuticrelationships
with peoplewith learning disabilities may be challengingto the professional.

Lopez (1974) highlights the unpopularity of engagingtherapeuticallywith children

with impaired intelligence. As he says:

"Therapeuticefforts in which a prolonged and intimate relationship betweenchild

and therapist is central, are, to judge from the literature, extremely rare... " (p.
278)

Sternfert-Kroese (1997) noted that, regardless of therapeutic speciality, true working

alliances were rare and difficult.

There is some evidence to suggest that carers and

professionals may avoid emotional identification with such clients. One study asked
both clients and their attendant carers and professionals about the clients' responsesto
bereavement (Harper & Wadsworth, 1993). Results showed that clients spoke
primarily in terms of emotions whilst professionals and carers predominantly
described behaviours.

Symington (1981) musesabout the responsesevokedby peoplewith learning

disabilities. He relatesthis to the proffering of psychotherapeuticservices:

"I think there may be another reason that deters usfrom treating people
who are subnormal. It is that we are all retarded in someareas of our

25
mental functioning.

One of us says, "I am absolutely useless at maths,

"
7
philosophy,
and another,
another says, can never understanda word of
"I can never understanda word of economics," and so on. Whenwe treat a
subnormalpatient we are reminded only too poignantly of our own mental
be
It
is
to
too
that
understandable
we
prefer
not
so
only
retardation.
(p.
"
199)
reminded

Hodges (2003) summarisesthe processof projection to which Symington alludes.She

insecurity
feelings
inadequacy,
disability,
that
and
of
ugliness
claims
society projects
into peoplewith learning disabilities. What Goffman (1963) describesas a social
defences.
into
is
translated
personalexperiencesand
process,

Somewriters have clearly postulatedthat learning disabledclients may evoke

(Alvarez
&
&
Ryan
Reid,
1999,
therapists
transference
within
counter
uncomfortable
Thomas, 1984). Negative transferencedescribesthe situation whereby unpleasant
feelings such as hostility and rejection are evokedwithin a relationship. Whilst
addressingthesefeelings is an expectedand necessarypart of the therapeuticwork,
Storr (1979) points out the destructivepotential of failing so to do.

`In caseswhere negative transferencecannot be resolved,therapy will cometo an

(The
be
less
break
because
it
in
true
the
the
off.
same
may
common
patient
will
end
reversecase,in which the therapist has a negativecounter-transferencetoward the
be
"
(p.
73)
cannot
resolved).
patient which

26
The available literature suggests that this may not in fact, be less common where
clients with learning disabilities are concerned. Mannoni (1973) describes similar
instances where therapy with clients with learning disabilities is terminated through
what she considers to be unresolved negative transference. It was reported that the
psychiatrists who did not favour work with people with learning disabilities (Hook,
1972) identified transference and counter transference as the most important elements
in their experience of training, begging the question of whether negative transferences
are anticipated.

It is unclear whether prospectivetherapistsmight be concernedabout encountering

the "real" (Schneider,1999) issuesthat peoplewith learning disabilities face. Sinason
(1992) emphasisesthe traumatic natureof working with this process,as shesays;

"Wheredeath, damage,torture, decay, chromosomalabnormality and organic

malfunction are alive in the sessionthe therapist has the task offacing the real
hurt... " (p.81)

Hollins and Sinason (2000) have recently equated the trauma of learning disabilities
to the definition given by the American Psychiatric Association (1994). There are
difficulties with the parallel, in that the definition requires "suddenness" as an
expected part of trauma. This might apply to the shock of diagnosis of learning
disability or the traumatic experiences a person might be prone to as a result of their
learning disability.

Whilst the identification is not complete, this opens up parallels

for the therapist to the experience of "vicarious trauma" (Pearlman & Saakvitne,
1995).

27

In what might be describedas "chronic" trauma,Hollins and Grimer (1988) described

three "secrets" which characterisework with people with learning disabilities. They
proposedthat thesewere the disability itself, sexuality and death.

With regard to the disability itself, the authors identify the grief associated with the
loss of the perfect child or self, which the family and individual experiences. This
grief is remarked on by most writers in the field and can continue over a lifetime
(Bicknell, 1983, Sinason, 1992). Hollins (1992) makes reference to the impact this
may have upon the therapist claiming it is appropriate for the therapist to be able to
share the reality of the disability: to be able to feel the hopelessnessof the situation
and a sense of disappointment or even panic. This sense of distress in addressing
disability has been described in other cases (Hodges &Sheppard, 2004; Jones &
Bonnar, 1996)

Mannoni (1973) illustrated one way in which primary handicap impacted upon the
therapist. She noted the very real dependence issues for her clients, that meant
parents often could not be kept separate from the therapeutic process. She
recognised the need to listen to the parents' viewpoints as an aid to formulation.
Mannoni theorised that the consequence of this was that therapists were pushed
towards identifying with the issues of the mother, rather than of the client. Jones and
Bonnar (1996) endorsed this by reporting marked maternal counter transference in
their experience of running group therapy.

28
Mannoni (1973) believed that maternal counter transferences with clients with
learning disabilities would not be comfortable for the therapist. She postulated that
murderous feelings are present in the relationship of mother and the child with a
disability, even if those feelings are disguised or denied.

This accordswith Hollins and Grimer's (1988) assertionthat the secretof "death" is
inextricably linked with parentalrelationships.This is claimed to be both a fear of
losing parentsupon whom they are dependent,but also fear of individual's own
mortality, in recognition of the parents' murderousfeeling towards their imperfect
offspring. Sinason(1992) describedcaseswhere clients' demonstratedtheir
emotional awarenessof the destructivewishes of otherstowards them becauseof
their disabilities.

Mannoni believedthat thesepowerful emotionswould play out in the transference.

Sheobservedthat the apparentlack of cognitive ability on behalf of the client resulted
in the "complete non-satisfaction"or "boredom" (p52) of the therapist. Shenoted
that therapy was often terminated by the therapist who felt nothing more could be
achieved. Other theorists (Sinason, 1992, Reyes-Simpson, 2004, Hodges, 2003) have
noticed overwhelming lethargy, or the slow passage of time during therapeutic
sessions. Mannoni framed these phenomena as unrecognised counter transference.
The termination of therapy might then be interpreted as a symbolic expression of this
imperfect
for
the
and "unsatisfying" client to be therapeutically dead.
wish

The last of Hollins and Grimer's (1988) secretsis that of sex; the taboo of sexuality
and peoplewith learning disabilities. The prevalenceof sexualabusein this client

29
group (Turk & Brown, 1992) means that therapists have a strong chance of being
faced with the impact of sexuality and abuse in their contact. Disclosures or
therapists' concerns about abuse are frequently reported in case studies (Sinason,
1992; Emmanuel, 2004). Corbett et al (1996) describe the traumatic effect
acknowledging the abuse histories of clients can have on workers.

The expression of sexuality in clients is often described in the literature as shocking.

Sinason (1992) described that in fourteen years of working as a therapist, only two
women were able to speak about, or symbolically represent their body's sexuality.
The others acted out issues by presenting them physically. Hodges (2003) also
described caseswhereby clients displayed their vagina or masturbated in the sessions.

As is apparent from the examples above, not only were specific, powerful
transferences and key issues likely to arise with this client group, but the therapist
was also faced with completely atypical ways of communicating meaning. Parsons
and Upton (1986), in their survey on experiences of therapists from the Tavistock
clinic, noted that without exception, clients presented with behaviours not routinely

seenfrom mainstreamattendees.

Therapists were faced with behaviours that broke the conventions of therapy. These
included; intense questioning, inappropriate demands, arriving early or late for
appointments (Parsons & Upton, 1986). Other authors confirm similar experiences of
clients' domination of the sessions (Symington, 1981). Kakogianni (2004) described
how one client who would climb on the windowsill in the therapy room.

30
In contrast, reports also include extreme passivity or non-engagement with the
therapeutic process. Clients were described who did not seem to engage in genuine
contact with the therapist (Kauffe-Sausse, 1999) or presented with submissive
behaviours which impeded the process (Sinason, 1992). Sinason identified what she
described as the "handicapped smile", intended to placate a more powerful other.

Presentation often took the form of "acting out" (Perry, 1990). Perry defined acting
out as an episode whereby:

"The individual deals with emotional conflicts, or internal or external stressors, by

acting without reflection or apparent regard for negative consequences. Acting out
involves the expression of feelings, wishes or impulses in uncontrolled behaviour with
apparent disregard for personal or social consequences. It usually occurs in
response to interpersonal events with significant people in the subject's life, such as
parents, authority figures, friends or lovers. "

Examples of acting out experienced in sessions included behaviour as extreme as

setting fires (Parsons & Upton, 1986). Physical or verbal assaults on therapists were
described (Baikie, 2004; Ruth, 1999; Hodges & Sheppard, 2004). Self harm such as
scratching, eye gouging, spitting and smearing has been observed (Hodges, 2003,
Slnason, 1992).

Theseatypical behaviourspresentedmajor challengesto therapistsworking with this

client group. Stokes(1989) and others identified the difficulty inherent in separating
organic damagewhich genuinely affects an individual's capacity from the

31

psychologicallimitations later imposed,i. e. determiningwhether a client's

presentation is due to primary (organic) limitations, or due to secondary

(psychological)handicapping.(Simpson,2004; Lee & Nashat,2004). In addition, the

therapist still hasto respondto a situationwhich is outsidethe boundariesof usual
social interactions.

In particular, the phenomenon of opportunistic handicap promises to evoke difficult

(1994)
in
Bonnar
Jones
the
therapist.
noted that social awareness was
and
emotions
shown by the members of their therapeutic group who doubted their acceptability to
others, and expressed envy of others' relationships. Envious attacks towards
therapists are noted in the literature. Stokes (1987) described how one client would
habitually ask unanswerable questions that made the therapist feel as if they were the
"stupid" one, a counter transference frequently described in the literature (Sinason,
1992; Hodges, 2003; Hodges & Sheppard, 2004)

As Stokesdescribes:

`In my view he was doing this to reverse the tables, to have me as the one who was

helplessand could not understandthings. But in addition I felt it also had an

he
is
that
of
capacities
which
was implicitly
envious
quality,
envious
my
aggressive,
mocking. " (p.4)

Stokeswent on to reflect that there may be a significant degreeof fear of the level of
envy that could be directed at a non-disabledtherapist and identified the additional
uncomfortablefeeling of guilt which could be evoked in response.

32
Discussion

A review of the literature on the topic of the natureof psychotherapeuticrelationships

basedon psychodynamicprinciples with peoplewith learning disabilities facesa
information
due
is
little
difficulties.
Firstly,
to the
there
available
numberof
very
application of the approachbeing in its infancy. What information there is proved
difficult to access. Searchesof major psychological data basesrevealedno results
handicap",
disabil",
key
"mental
"learning
associatedwith
words of
"psychotherapist"and "transference". The limited referenceswhich emergedfrom
interventions.
included
"psychotherapy"
a
range
of
covered wide
searcheswhich

There are generic difficulties in empirical data relating to people with learning
disabilities. Difficulties in categorisation are apparent in the attempts to review the
literature from different interventions. Sturmey's (2005) review demonstrated how
in
be.
There
label
"psychotherapy"
the
are particular problems
can
amorphous
of
identifying or reconstructing categories of presenting problem for this client group.
The observations made by Hughes (1945) and Phillips (1966) also seem relevant
(2005)
level
Sturmey
instance,
for
literature;
the
the
at
criticisms
when considering
for failure to distinguish mental health categories adequately may reflect the master
identity of learning disabilities through which psychological distress is missed. Beail
(2005) notes how outcomes can then be misinterpreted according to how the
first
instance.
in
behaviour
the
the
researcher constructs

The difficulties in categorisationalso apply to the client group themselves. The

in
is
distinguished
disabilities
learning
somereviews. When
not
severity of
for
literature
to
support
peoplewith multiple and profound
on
attempting review

33

disabilities, Nakken and Vlaskamp (2002) found twelve different descriptions

pertaining to the group out of the thirty five articles.

There is a problem here in that peoplewith learning disabilities are treated as a

homogenousgroup for the purposesof providing servicesand research.However, this
categorisationis basedon functioning, rather than any unifying theory. Even using a
biomedical model, this group is not homogenous.

However, despitediffering orientations,clinicians seemagreedthat organic

disabilities do exist. If undifferentiated,the conclusionsdrawn about therapeutic
approachesmay be basedon unrecogniseduncontrolled variables relating to the
individual's abilities. Yet evenwhere this differentiation is made,the difficulty of
distinguishingbetweenprimary and secondaryhandicapshas beennoted and
psychogeniclearning disabilities proposed.

The limited amount of information on this topic meansthat much of the information
from studieswith adults is compoundedwith that of children. This difficulty is not
confined to outcomereviews. Much of the casestudy material relatesto therapy
undertaken with children (Sinason, 1992; Kaggianni, 2004; Emmanuel, 2004). It is

dangerousthen to extrapolatethis to work with adults. Featuresdescribedas

in
the therapy, such as boundary breaking may be due to developmental
significant

immaturity rather than the learning disability.

Whilst the contributions from the small number of authorspublishing anecdotalcase

studieshave beenimmenselyuseful as a valuable part of the practise-based evidence

34

paradigm,the field tendsto suffer from what might be describedas "epistemological

incest". Almost all material is drawn from the work of those associatedwith a
handful of key theorists and clinicians. For instance,one of the two collections of
casestudies,which representsthe riches pool of recent evidenceis generatedby
clinicians from the Tavistock Centre(Simpson& Miller, 2004), whilst the other,
editedby De Groef, featuresa chapterby Sinason(1999). Thus new work tendsto
use the sameframe of referenceand significant challengesto theoriesare absentfrom
the literature.

Challenges are not made to the specific psychotherapeutic theory itself, in relation to
people with learning disabilities. Information and research from other conceptual
frameworks relating to people with learning disabilities are not triangulated with the
interpretations. For instance, the research on "theory of mind" (Frith & Happe, 1999)
suggests limitations as to insight of others' perceptions. This would appear be
important with regard to Sinason's (1992) assertions of clients' awareness of the
disabilities.
impulses
those
towards
with
negative
of others

Further Research

Clearly further researchis required. Given the significant role played by individual
practitionersin determiningwhether people are offered psychotherapy(Royal
College of Psychiatry,2005), an appropriatefocus of attention may be the attitudesof
therapiststowards this client group. An exploration of whether therapistshold
expectationsof specific negativetransferencewould be particularly valuable.

35

A major areaof lack is that of information regardingthe therapeuticprocess. The

perspective of therapists working with this client group is almost wholly unexplored.

Information is only available inferentially, as no direct work hasbeendone on the

therapist's experienceof therapy. Investigation into the natureof this work would be
valuable in exploring the impact of this client group on the therapist, andthe ways in
which negativetransferencesare experiencedand managed.

It would be valuableto explore outcomeoptions for casedescriptionswhich have

previously relied upon clinicians' judgementsas to outcomes. It would be interesting
to explore whetherprojective tests could be combinedwith other outcomemeasures
to provide reliability andsvalidity checksto determinethe value of pursuethis form
of measure.

With regardto the effectivenessof psychotherapy,larger scaleoutcomestudieswould

be more valuablethan attemptingto collate information from different studies. In an
attempt to produce a stronger evidence base, Willner (2005) recommends the use of

randomisedcontrol trials. However, there are argumentsregardingboth the

appropriateness and practical applicability of this form of enquiry.

Firstly, one could argue that the field is insufficiently advanced for this type of
enquiry to be useful, that it is still in the "practise-based evidence" phase of
Salkovski's (1995) model. Others, such as McLeod (2000) would argue that
qualitative methodology is much better suited to the subtleties of research into

psychotherapy.

36
The pragmatic difficulties would be significant. The evidence cited previously notes
the complexity of the learning disability categorisation. Concepts such as emotional
intelligence would make matching difficult, as equivalent IQ scores could not be
assumed to indicate similar levels of ability with regard to insight or psychological
mindedness. Psychogenic learning disabilities may be indistinguishable from organic
limitations but may be hugely influential on outcomes. Even where organic causes are
clearly present, Arvio and Sillanpaa (2003) found 61 different syndromes, with
varying impact of the individuals' functioning, within a population of 461.

One difficulty with the RCT methodologyis the complexity of contextual elementsof
peoples' lives. Simplistic distinctions such as institutional versuscommunity settings
may not capturesignificant variables. The standardisationof the treatmentpackage
to be evaluatedis equally problematic. The precedingliterature cites how
psychodynamicprinciples needto be adaptedto the individual, with resulting in
potentially larger variations in medium, setting and boundariesthan one would find in
an equivalentmainstreamstudy.

Finally, Gatesand Atherton (2001) note that effectivenessis not the only factor that
shouldapply to interventionsin health and social care. They statethat for people
with learning disabilities, equity, appropriatenessand accessibility are important
factors, a position which placesthe scientific within the context of the social, echoing
the dual strandsof this review.

37

Conclusions
In considering Bender's (1993) proposition that the reasons for excluding people with
learning disabilities from psychotherapy are prejudicial rather than empirical, the
literature does offer support for his assertion. Rather than having to prove the case
for inclusion, surely the onus should be providing sufficient grounds to justify
excluding part of the population.

The theoreticalbasisfor exclusion due to intelligence can clearly be questioned.

There is researchto arguethat intelligence is not a unidimensional concept. The
conceptof loss of intelligence as a defenceis illustrated in casestudiesand
acknowledgedby Freud (1920) himself. The concernsregardingintelligence are,
however,conceptualobjections. Even if there were no evidenceto the contrary,
exclusion could not be logically justified until the proposalwas empirically proven.

The empirical evidenceavailable is agreedto be an insufficient for conclusionsto be

drawn as to the effectivenessof the approachfor this population. Early indications are
that the approachcan be effective, but again,proof of effectivenessis not requiredto
questionthe validity of exclusion.

What information exists doesnot necessarilyaddressthe issuesof the therapeutic

relationship. Rather, emphasisis often on techniqueor outcomedue to the needsof
the emergingfield.

Bender's (1993) suggestionof exclusion being prejudicial appearswell founded.

There is evidenceto suggestthat the social identity of peoplewith learning

38

disabilities impactson clinicians' decisions. At a collective level, the "spoiled

identity" of learning disabilities may have encouragedthe belief that the approach
be
would not suitable.

Retzinger's (1998) concept of ideological counter transference offers a bridge

betweenthe collective, social processesdescribedby Goffman (1963) and

Wolfensberger(1972) and the individual's experiencesand defences.For this counter
transferenceto be significant in the decisionto avoid offering therapy, it would need
to have an anticipatory component. Whilst this is not mentionedspecifically, the
natureof the phenomenonshedescribesclearly incorporatesbeliefs and emotions
externalto the immediatetherapeuticsituation.

The actual experienceof psychotherapywith clients with learning disabilities is only

derived through extrapolation from case accounts. However, it appears engagement

brings
issues
learning
disabled
for
the
the
serious
clients
challenges
with
real
of
therapist. The traumatic nature of the disability may well have an impact upon the
therapist, as working with other traumatised groups is known to do. (Pearlman &
Saakvitne, 1995). The therapist may have to cope with atypical behaviours. In
particular, the dynamic of able therapist and dis- abled client may leave the therapist
open to envious attack, feeling helpless and inadequate, the very experiences
Symington (1981) proposes we wish to avoid.

It is significant that Hollins (2000) describeshow junior doctors are drawn into the
field only after experiencewith the client group. This perhapssuggeststhat, difficult
though theseissuesare, peoplefind it is possibleto work with the negative

39
transference. It is perhaps ultimately an expectation of negative transference which

may inhibit individual clinicians from offering services.

40

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51

Part Two: Research Report

Therapists' Experience of Learning Disabled Clients

Key words:

Learning disabilities, psychodynamic psychotherapy, IPA

52

Abstract

Background: Little is known about the experienceof the therapeuticrelationship

with clients with learning disabilities. This study aimed to explore individual
practitioners' experiences,including those of transferenceand counter transference
with this client group.
Materials and Method: A semi structuredinterview was usedto elicit personal
accountsfrom eleventherapistsworking psychodynamicallywith clients with
learning disabilities. Data were analysedusing the principles of Interpretative
PhenomenologicalAnalysis (IPA) to producerelevantthemes.
Results: Two super-ordinatethemesemerged,one identifying similarities and
differencesfrom work with other client groups,the other noting the issuesimpacting
on the therapistfrom working with the "spoiled identity" of a learning disability.
Conclusions: The findings accordedwith previous clinical reports. Theoretical links
were madewith the fields of psychodynamicpsychotherapyand shameresearch.
Implication for clinical settingsand future researchwere discussed.

53
Background
The offering of psychotherapy to people with learning disabilities

is a recent

phenomenon, after a long history of therapeutic disdain (Bender, 1993). As yet, little
is known about what the experience of therapy is like for those clinicians who take an
inclusive stance. Of necessity, the early literature in the field initially

focussed on

demonstrating the ability of cognitively impaired clients to engage with therapy

(Symington, 1981; Frankish, 1982; Sinason, 1986,1992).

As access to therapy

services began to be extended, research emerged on adapting and disseminating

therapeutic techniques (Hodges, 2003; Conboy-Hill, 1992) and investigating these
techniques' effectiveness with this population, through systematic outcome studies
(Beail, 1995,1998,2001,2003,2004;

Beail & Warden, 1996; Beal; Newman & Beail,

2005).

However, despite the recognised importance of the therapeutic relationship in the

outcome of therapy, and numerous studies on the issue with

clients without

disabilities (Orlinsky et al, 1994) little is known about the nature of the therapeutic
relationship with learning disabled clients.
distinct from that with clients without

Mannoni (1973) described the work as

disabilities. Hollins

and Grimer (1988)

postulated that therapists would be faced with specific issues with this client group,
describing three defining "secrets" including; the disability itself, sex and death.
Frankish (1989) explored the impact of the primary disability on the personality and
Stokes (1987) and Sinason (1986) introduced the concept of secondary handicap to
explain how limitations were exaggerated as a defence against trauma and used
opportunistically to express anger and envy.

54

The meansby which these meaningsare communicatedare atypical of non-disabled

clients. Clients might direct aggressiontowards others or themselves(Ruth, 1999;
Hodges & Sheppard,2004; Hodges,2003). Dominance,passivity, boundary breaking
and sexualisedbehaviour have all been noted (Korf-Sausse, 1999; Symington, 1981,
Sinason, 1992).

Modern psychodynamicpsychotherapydescribestransferenceas a primary meansby

which the therapist experiences their client.

Negative transference, where

is
feelings
a
uncomfortable
are evokedwithin relationship, describedas rare by Storr
(1979), but is frequently described in the literature for people with learning
disabilities

(Alvarez

&Reid,

1999, Ryan &

Thomas, 1984). Specific counter

transferencesreported as part of case descriptions include feelings of stupidity,

interpreted as envious attacks from clients (Stokes, 1987). Shock and disgust were
describedby Sinason(1988) as responsesto her clients' traumatic presentation.

Although a flavour of the experienceof working with this client group can be
extrapolatedfrom casedescriptions,systematicresearchinto therapists' experiences
is missing from the literature. Thus, this appearedto be a valuable areato begin
exploring in this study.

Qualitative methodologywas selectedasbeing best suitedto providing rich data on

this subject,aswell fulfilling a heuristic role of generatingquestionswhich might be
addressedusing quantitative methodology.

55
McLeod (2000) reviewed the contribution of qualitative research to the evidence base

for psychotherapyand concludedthat qualitative researchcould be very valuable in

contributing to an increasedunderstandingof psychotherapy. McKenna and Todd's
(1997) study, in which clients describeddifferent kinds of therapeuticexperiences,
noted that the subtletiesof the processwould not havebeenidentified by quantitative
methodology.Qualitative methodologyis held to be valuable where exploration of a
field of interest hasonly just begun,and a broad rather than narrow focus for
investigation is required (Marshall & Rossman, 1995). Smith (1995) claimed that

semi-structuredinterviews and qualitative analysiswere especiallysuitablewhere one

is particularly interestedin complexity or process,or where an issueis controversial
or personal.

Within the qualitative approaches, a number of possible methodologies exist. In depth

comparisonsare beyondthe scopeof this report but the applicability of the different
modelsto the current study is considered. Discourse,conversationaland narrative
is
(Rennie,
focus
have
been
for
1999).
The
their
relativistic slant
analysis
criticised
placedon deconstructingthe narrative as behaviour,which is not the primary interest
of this study. Groundedtheory (Glaser& Strauss,1967) aims to constructa
theoreticalmodel from participants' data. However, the current study is intendedto
cover the unexploredprimary issuesand experienceof individuals working with
peoplewith learning disabilities. Therefore,groundedtheory methodologymight
most usefully be employedat the next stageof exploration.

Interpretive PhenomenologicalAnalysis or IPA, (Smith, 1995)was selectedasthe

most appropriatemethodologyfor this study due to the focus on the participants'

r --- - ,

56
inner world. IPA is designedto attemptto explore peoples' lived experiences,and
the sensethey make of theseexperiences.The approachaims to investigatethe
meaningof eventsor statesrather than claim to define theseeventsor states
objectively. This approach,in particular, seemedcongruentwith the subject matter
with it's emphasison the interpretativeAs with other qualitative methodologies,IPA
incorporatesthematic analysisbut aims for further depth, of analysingthe meaningof
themesrather than simply placing text into descriptivecategories.The interpretative
elementalso explicitly acknowledgesthe "double hermeneutic" statusof this kind of
inquiry. It recognisesand utilises the questioneras part of the process.

Method

Eleven professionalswho offer psychodynamicpsychotherapyto clients with

learning disabilities were invited to give personalaccountsof their work. Following
ethical approval,a semi-structuredinterview, constructedusing the principles
identified by Smith and Osborn (2003), was undertakenwith the participants. A
descriptivethematic analysis(IPA) was then applied to the transcripts.

Materials

The interview schedulewas developedthrough Smith and Osborn's (2003) process

outline of four stages,which were usedto generatethe interview questions. The
broad rangeof topics relatedto therapists' experienceswere identified and arranged
in a logical sequence.Open,non-leadingquestionswere then identified and
secondaryprompt questionsgenerated. The appropriatenessof the scheduleand
researchprotocol was then checkedin consultationwith a serviceuser representative.

57

Procedure
Potential participants were recruited from the membership lists of the Institute of
Psychotherapy and Disability (IPD). The IPD is an organisation which fosters the
learning
in,
clients
with
psychotherapy
with
psychodynamic
practise of, and research
disabilities. This source was chosen as eligibility for membership met stringent
academic and experiential criteria, ensuring appropriate purposive sampling.

Membershiprequiredthat:
" Participantshad a post graduatedegreein psychotherapy,or an equivalent
professionalqualification.
in
had
Participants
two
a
"
a minimum of
years experience of working

psychodynamicmodel with peoplewith learning disabilities.

including
had
Participants
two caseswith
ten
clients,
minimum
of
"
worked with a
therapy extendedover a minimum of one year.

A letter of introduction was sentto the Chairpersonof the IDP asking permissionto
contactmembers. When this was received,all membersof the IDP were sent
information regardingthe project. Twenty membersrespondedand eachwas then
contactedby the researcherto discussparticipation. Of those who responded,eight
were not interviewed due to geographicallocation, non-dynamictherapeutic
for
full
having
the
criteria
membershipof the IPD. A
orientation and not yet
reached
further participant was unableto be interviewed within the data collection period.
The remaining participantswere given information which included an explanationof
the interview process,data collection and storage.Anonymity was guaranteedfor
both them and any clients described. Limits of confidentiality were also described,
including the needto act on any malpracticedisclosed. Consentwas obtainedat this

58

stage,and checkedagain prior to interview. Participantschosewhen and where the

interviews were to take place.

Participants were asked if they would be willing to be part of a sample contacted by

telephone or email after their interviews had been analysed, in order to check the fit
between the researcher's emergent themes, and the participant's experience.

Participantswere also offered the opportunity to receive feedbackon the completed

study.

Participants
The purposive sample consisted of eleven participants, six women and five men.
Participants' ages ranged from 36 to 58 years. All participants were White. All were
learning
involved
in
therapeutically
clients
with
with
actively
working
currently
disabilities. The settings in which participants worked included educational
establishments, social, forensic and health care services, and voluntary institutions.

The agesof clients rangedfrom those in secondaryeducationto older adults. The

sample'sprofessionalbackgroundsencompassedsocial work, teaching,medicine,
creativetherapy and psychology.

Data Collection
Interviews took placein venueschosenfor convenienceby the participant. Sites
included day services,university offices and participants' homes. Where interviews
in
held
set
off campus,safetyprocedureswere
place.
were

59
The interviews ranged from between forty to one hundred and twenty minutes long.
Interviews were recorded using audio tape for later transcription. The interviews were
conducted in accordance with Smith and Osborn's (2003) recommendations, using
the prepared schedule to elicit experiences but attending to establishing rapport, using
minimal prompts, being flexible as to the structure of the questioning and monitoring
the effect of the interview upon the respondent. Immediately after the interview, the
researcher recorded her impressions and thoughts on the process in a field diary for
cross referencing with the data produced by the participant.

Data Analysis
Interviews were transcribedverbatim and the data analysedusing the method
identified by Smith et al (1995):

1.The first transcript was read through twice, and read again in conjunction with the
tape recording to check for textual inaccuracies and to pick up additional elements of
inflection or meaning. On reading through, the researcher's initial observations were
recorded line by line in the right hand margin. Observations included summaries of
comments, questions and preliminary themes (See Appendix F. ii).

2. Next, emergentthemescharacterisingeachsectionof text were identified and

noted in the left hand margin. Clustersof themeswere then collected into master
themes that reflected the participant's experience (See Appendix F. iv. ). This was
repeated for each transcript. A summary table of master and sub themes (with their
references) was then produced (See Appendix F., Figs. 10. & 11.)

3. Each individual's themeswere then comparedwith the othersto producea

summarydiagram of super-ordinatethemeswhich characterisedthe collective

60

experiencesof participants. To aid this process,transcriptswere colour codedand

text visually displayedin thematic groupingsto show significanceacrosscasesand
keep conceptsgroundedin text (SeeAppendix F.vii. ).
4.New data emergingwith later transcriptswere comparedwith previously identified
themes.
5.Analysis continueduntil all major, relevantthemeshad beenidentified.

Quality Control Procedures

Morrow (2005) identified the need to adequately manage the subjectivity inherent in
qualitative approaches. A number of quality control measures were adopted to
address key areas. These included;

"

Dependability: this was addressedby making the processas explicit and repeatable
being
in
data
Appendix F.
each
given
as possible,with examplesof
at
stage

"

Appropriate Representation of Participants' Data: checks were undertaken with

two participants. These participants were provided with the initial analysis of their
interviews and invited to comment. Both reported the analyses to be reasonable
representations. Data from their additional comments were incorporated into the
body of the report (See Appendix F.v). As an additional check, the first transcript
by
for
M.
).
(See
Appendix
F.
co-rated
a
second
analyst
representational
was
validity

"

Rigorous Subjectivity: One of the key features of IPA is the recognition that the

researchexerciseis a dynamic process(Smith et al, 1999).There is an explicit

expectationthat the researcherneedsto be a self-awarecontributor to the process.
Thereforethe researcherkept ongoing noteswere in a reflective field diary (See
Appendix F.i). The needto make explicit the researcher'sown views and biasesis
addressedin the position statementincluded here.

61
Researcher

The researcherwas a forty five year old white woman. A clinical psychologistby
profession,shehad worked for sixteenyearsin servicesfor adultswith learning
disabilities. An interestin psychotherapywith this client group was generatedby
clinical experienceand pursuedwith further training on psychodynamicapproaches
interest
in
learning
disabilities.
A
researchon shamewas
particular
with peoplewith
generatedfrom previous academicpursuits.

Results
The findings of the data collection and analysis process are described in this results

illustrative
interviews.
following
from
The
transcript
the
quotes
sectionwith
conventionsare used:
...
_

[]

Pause.
Emphasis given by interviewee.

Indicatesthe removal of irrelevant text or the descriptionof textual

content to ensure anonymity.

Participantsare referredto by pseudonymsand other namesin the text havebeen

changedexceptwhere referencesare madeto a contributor to the field. Referencesto
text include the participant's nameor initial, plus the line reference.Whilst the term
"learning disability" is used in referenceto clients, "handicap" is used where this is
relevant to relate to pre-existing theoretical and linguistic frameworks.

62
Overview
Following the analytic process, eight master themes emerged from the data. These
themes were then grouped into two super-ordinate themes which appeared to reflect
commonalities (See Fig. 1.). The Super-ordinate theme of "Similarities and
Differences" collected comparative observations from participants, whereby their
experiences of therapy with this group were interpreted in the light of their experience
of therapy with clients without learning disabilities. "Working with Spoiled
Identities" was identified as a second theme. Whilst this clearly related to the
previous theme, the emphasis here was on the impact on the therapists themselves in
dealing with the issues raised within sessions, and the broader context of being a
therapist who worked with people with learning disabilities.

Figure 1. Overview of Super-Ordinate and Master Themes

SUPER-ORDINATE

SIMILARITIES

AN DIFFERENCES

THEMES

WORKING

WITH SPOILED IDENTITIES

Master Themes
1.1 Common Ground

2.1

Evolution as Therapist

1.2 Specific Issues

2.2

Impact on Therapist

1.3 Self as Medium

2.3

Courtesy Stigma

1.4 Adaptations to Therapy

1.5 Primary, Secondary and Tertiary
Handicap

63

Super-Ordinate Theme 1: Similarities and Differences

The categorywas madeup of five masterthemesdescribedbelow;

Common Ground (Theme 1.1): Participantsdescribedsimilarities in working with

peoplewith learning disabilities and those without disabilities. At a conceptuallevel,
participantsidentified a continuum model which highlighted the artificiality of segregating
issues
learning
disabilities.
Similar
arosefor client and therapist:
peoplewith

Louise:

There was two, if you like, two extremes of the spectrum IQ but it

hadjust seemedthe samestuff, there was abuse,trauma and self harm and
eating disorders, depression. (L. 468)

Denny: It wasn't any different to myfirst client I'd seenin mainstream

adolescentunit []just

the anxietiesabout getting it wrong, would 1

remembereverythingthey'd told me, would I be able to think in the room.

(D. 91)

Accounts highlighted alternativeforms of intelligence, which equalledthose of

clients without disabilities:

Alistair: Weall know that people who have limited intellectual abilities
have sometimesincredibly you know, erm, ermpowerful [] emotional
intelligence. (A. 315)

Participantsreflected that the principles of therapywere universal:

64

Paul: I think that all sorts of modelsfrom learning disability are equally
applicable to any client disorder (P. 378)
Louise: In a way we are all working in afield of disability because we are
all trying to bring a sort of understanding to somebody else's experience so

its not that different and yes, it's a different degreebut actually it's what
we're all doing. (L. 238)

Issues Specific to People with Learning Disabilities (Theme 1.2):

Despitethesecommonalities,most responsesemphasiseddifferences. This group

issues
heightened,
by
learning
the
therapist
to,
their
presented
with
or
unique

disability. The disability itself was inescapable:

Candace: Not one client I work with you don't have to, sort of, the issueof
disability itself, that's going to come up even if they've been referred for
something else (C. 519)
Denny: I think the work that I've done focuses on the pain of what it means
bring the elephant into the room, talk about
to have a learning disability
...
it, you know. (D. 137)

Clients struggledwith their disabledidentity, with "otherness". Belinda described

one client's fear and Jamesspokeof a woman whose pain was devastating:

Belinda: His flat mate was calling him Frankenstein[] but I could seefor
[him] it was more than namecalling, it was somethinghe was living. []

65
What I felt was coming out of him was strong messagesabout being
something other than" normal everyday", but what this something else was,
was extremely frightening erm, and it was like monstrous, Frankenstein. (B.
570)
James: [I said] "Even though I'm a doctor, I can 't fix your disability. [J
For the first time ever, she stopped all the screaming and she slumped down
until she was on thefloor holding onto my legs and sobbing, sobbing and
sobbing. (J. 422)

This grief people had for the loss of their ideal self was a common feature. The
spoiled identity led to an awareness of being shamefully different, with the attendant
anger:

Denny : Whenthey arrive at my door they are mortified that they have been
labelledpublicly and shamedpublicly [ J the bullying, the namecalling,
...
the terror of being "Other'. you know, it heightenstheir awarenessof the
shame,the guilt that theyare not the child their parent wanted,and they can
never be the child their parent wanted Theanger that they are not the,
[sic] they want,you know, they want to be. (D. 335).

With the negativesocial implications of learning disabilities, therapistswere often

faced with their clients' experiencesand expectationof rejection. Disrupted
attachmentsand relationshipswere an expectedcorollary to having a learning
disability. A history of abandonmentand abusewas almost universal. There was a
recognition that social factors would shapewhat was brought into therapy:

66

Graham: Thecontext in which people are living is different you know the
social narratives, the cultural narratives [... J that impacts on the individual
(G.
347)
is
into
the
therapeutic
with
you.
who coming
relationship

The Self as Medium (Theme 1.3): The ways in which people communicated their

issueswere often very different to mainstreamclients. Characteristically,clients used

the "self', through their roles, actions or their bodies asthe meansby which meaning
was communicated. Participantsgave examplesof the different presentationsthey
faced (see Fig. 2). As Kieran explained:

Kieran:

You know this is not conventional work, the person lying down

talking about their childhood, erm,you know they may be very, very
how
banging
for
to makesenseof
the
twenty
on
side
minutes
and
repetitively
that or what to do about that, it's a challenge.(K 211)

Specific challengesthe participantscopedwith included literal acting out of feelings.

Issuesidentified (theme 1.2) as particularly resonant,suchas abandonment,often
provoked strong reactionsin parallel situationsin therapy. Louise describedone
client tearing up her letter about holiday dates:

Louise: I think it's all concretelyre-enacted,erm, rather than saying that, I

think, you might befeeling angry with me, so it's tearing things up because

theyfeel so abandoned.(L. 145)

67
This was an experience shared by most participants:
Alastair:

I've been shouted at, spat at, fists waved at me. (A. 232)

Denny: One little kid actually head butted me. (D. 255)

Learning disabled clients went beyond this physical expression, as therapists had to
deal with communication being "embodied" by the client.

Belinda: He picks his plaster away and gouging, gouging away at his cut.
(B. 743)
James: She would also harm herself, she would scratch herself, cut herself,
her arms were full of scratches and sores. (J. 402)
Louise: Mere have been other therapists where there's been soiling that
happened in the session. (L. 184)

Figure 2. The Self as Medium: Client Presentations

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68

Need to Adapt Therapeutic Process(Theme 1.4): Due to the identified

differences,and an acknowledgementof limitations from the primary learning
disability, every participant remarkedon the needto adaptthe therapeuticprocessin
some way:

Candace:I think it is hard to get across to someonewho's a

psychotherapist,erm, and is usedto a client coming in for 50 minutesand
then going again, just how different it is to have tofit in with a person.
(G537)

The adaptationsidentified included simplifying language,slowing the paceof

sessions, using and attending to non-verbal communication, using alternative

beyond
being
to
try
those learnt from standard
mediumsand
approaches
willing
training. Jamessummedup the flavour of the participants' responseswhen he said it
was about:

James: Always trying tofind a way of getting in touch with the real person
that's in there and also by whatevermeansit takes.(J. 168)

All participantsemphasisedthe increasedvalue of using transferenceand counter

transferencein understandingtheir clients' communications. Most describedthis as a
critical therapeutictool for this client group.

Kieran: You can't work without the counter transferenceand you knowyou
need to be alwayspaying attention to it thinking about it. (K 229)

69

Overall, the participantsdescribeda model in which the theory regardingthe person

in therapy remained constant, but the clients represented an extreme end of the
continuum which was greatly impacted upon by organic limitations, life experiences

and presentationrelatedto secondaryhandicaps.To use and extenda formulation of

the factors addressedin psychotherapy,suchasMalan's (1979) triangle (seeFig. 3),
the conceptualrelations within therapy remainedconstant,but the shape(or
experience)of the therapywas dictated by the planesof the continuum. (SeeFig. 4)

Primary, Secondary and Tertiary Handicap (Theme 1.5): The need to adapt

therapy seguedinto a significant theme for almost every participant, regardingthe

definition of their role. The tensionwas generatedby the difficulties in identifying
the "real" in therapy, distinguishing between primary and secondary handicaps:

Candace: She had thesepseudo seizures and when I first started working
with her it was absolutely terrifying [I. I only started to work out that it was
a pseudo seizure when she would start to have them 10 minutes before the
(C.
384)
end of every session.

Not only did participants struggle with clarifying primary and secondary handicaps,

they noted the difficulties in distinguishing betweentheseand tertiary, or social

handicapsimposed(seeFig.4), often due to dependency.

70

Figure 3. Malan's Triangle of Person

PRESENT

TF

PAST

..

NS

R.E.NC'E

Figure 4. Continuum Model

:P1:Mt RYits: oic Tr.

DEGREE OF DISABIL.
SECONDARI
HANDICAP
PRA EN TATION

TERTIARY HANDICAPTRAUMATIC EXPERIENCES

S FROM SPOILED IDENTITY
:ISSU_E.

71
Belinda: I'm never really sure
[J sometimes they can have a bit of a moaning
...

sessionabout their workers, and that's an interesting thing, becauseI, I'm never
sure whether it's the clients. (B. 478)

Candace: You know, if they werefive minuteslate you can't necessarilymakean

interpretation of it becausethey had to rely on a carer to get them there. (C. 539)

Individuals set different boundariesas to whether changingthe techniquesinvolved in

delivering therapy extendedto altering the traditional role of the therapist.
Differenceswere apparentbetweenparticipants as someissuesthat were identified as
primary handicapsrequiring adaptationswere also cited as interpersonalprocesses
with intentionality that could be overcomeif boundarieswere held.

Kieran: Our standard model, therapeuticmodel, 50 minutes,same,same

room, same space you know everybody who's worked in this way have found
that, that, that can be worked with, erm, even people with more severe
learning disabilities. (K 275)
Graham: Is it appropriate to have a one hour, 50 minute session with a
client who's got a learning disability when it might be more punitive to sit
there when nothing's happening? (G. 329)

Therewas similar confusion at a systemiclevel. For instance,there was recognition

that this client group was at real risk of being damagedby the serviceson which they
were dependent:

72
Alistair: The therapy endedabruptly becausea psychiatrist had decided
that he neededto movesomewhereelseand he would, they had a therapist
there so he didn't need to seeme any more. (A. 113)
Belinda:

[Of a client regularly taken by her carers to watch planes taking

did
felt
knew
They
at
they take
the
why
and
so
she
abandoned
airport]
off
her to a place where she and to watch people going off... there was
(B.
415)
felt
I
the
thing.
whole
about
quite perverse
something

All the participants made either implicit or explicit reference to the social and
in
political system which people were embedded, recognising a need to work
forced
dilemma
However,
to
this
a
and
most
participants
were
created
systemically.

beyond
had
to
the confines of the
they
act
a
responsibility
considerwhether
therapeuticsessionand how this shouldbe done:

Paul: How much, you know, am I willing and able to get embroiled in
those kind of messy dynamics for society to work out... the ambivalence and
the uncertainty about the role and the responsibilities that go with that sort
learning
broader
involved
in
if
that
clinically
role,
stays with you you stay
of
disabilities. (P. 239)

A number of practitionersreportedworking systemicallywith psychodynamic

interface
in
the
to
with
principles, or working conjunction with others control
services,but for some,this broader responsibility necessarilyalteredthe natureof
their role.

73
Denny: There will be so many different agencies involved in their lives and
you're part of a cog, you're a cog in a big wheel and sometimes I'm an
advocate. (D. 369)

Ela: I care what happens,and I try to put themfirst. Beyonda kind of,
beyond perhaps what I should have. (E. 452)

Graham: I think it works to do that kind of work, slightly more educational.

(G. 318)

Overall, the "purity" of participants' therapeuticroles varied accordingto the degree

to which they felt their psychodynamicmodel was an overarchingconceptthat could
usefully apply to the myriad aspectsof their clients' lives (seeFig. 5) i. e. where the
be
interpret
direct
to
transference
and
could
used
reactions
action. Where
conceptof
alternateorganic or socialtheoriesappearedto be part of the "real", people struggled
to integrate these into their working practice in their clients' best interests (see Fig. 6).

Whilst all participantsdecidedtheir own boundaries,Belinda reflected the integrative

in
itself
the
therapy
that
and
maintaining
structure
of
position
providing a service

impactedon broader social context:

Belinda: Weare actually opposedto erm somethingthat is society's death

wish and this idea generally that people that aren't perfect don't have a
place in the world and we are working with people showing the world that
actually people do have a place in the world (B. 989)

74
Super-Ordinate Theme 2: Working With Spoiled Identities

This theme of grappling with the internal and externalworlds of peoplewith learning
disabilities formed a bridge to the secondsuperordinate theme,that of working with
peoplewith a spoiled identity (seeFig. 1).

Evolution as Therapists (Theme 2.1): The participants described very similar

experiences which contributed to their working in the field of learning disabilities.
With the exception of the two who shared a medical background, all participants had
had experience of people with learning disabilities in other roles, prior to marrying
this up with psychodynamic psychotherapy. For some, contact was limited, but many
reported it as forming part of a narrative in their lives:

Denny: I supposemyfirst contactsgo back to childhood becausemy mother

was er working as a [professional] in a school []for

young people with all

sorts of disabilities. (D. 103)

Despite this, participantsalmost universally describedtheir speciality as having been

unplanned:

Suzzanne: I fell into it really. (S. 10)

Candace: I kind of endedup in learning disabilities by not really choosing
it (C. 27)

75
Figure 5. Dominant Psychodynamic Model

'MEIZAPLST ROLE

PSYCHOD"AMIC
MODEL
i
e

ORGANIC
COUNIMVE
4,

MODEL

Figure 6. Non-Dominant Psychodynamic Model

TH}: R. ,#'IS'f
F [;* 1t_ATOR
ORQANIC
COGNITIVE
MODEL

DYNAN k
MODE(.
!

`'CC ]AL,
MODEL

ADVOCATE

-i,..

76

The common experienceinvolved an additional two setting conditions; an

environmentsupportiveof psychodynamicthinking; and intellectual curiosity about
the inner world of peoplewith learning disabilities. Most describeda catalyst, in the
form of contactwith an inspirational "mentor". As illustrated by:

Louise: I happenedto be in a teamwhere, as it turned out, everybodyhad

done this alongside counselling qualifications, so very sort of attuned to the
needfor counselling. (L. 16)
Graham: I realised that there was more tojust doing music than playing
the tambourinesand playing thepiano. It was more about the
beginning
happen
betweenme
to
which
was
relationship
psychotherapeutic
(G.
15)
the
clients.
some
of
and
Alistair:

I[]

got the director of [an organisation offering psychotherapy to

learning
disabilities]
do
to
come
and
a workshop there, and I
people with
sat in on it, it'was very interesting, I thought this was a really interesting
"Phew,
I
in
interesting
thinking,
could I do that work too? " (A.
area. was
49)

Someparticipantsexplicitly acknowledgedthat there must be internal factors which

drew them to work with the client group. A few intervieweesmentioneda wish to
addresssocial injustice and almost all participantsreportedbeing attractedby the
challengingnatureof the work. Mainstreamclients were not seenas offering the
samemental exerciseand excitement:

77
Ela: I found our patients completely mind rotting really. (E. 74)
James: With people with learning disability its much more, much more
for
hack.
(J.
bucking
bronco
185)
than
going
a
gentle
riding a

Sometimespeople reportedthe challengesof working with learning disabledclients

input:
their
the
them
value of
made
question

Candace: [I] can't get any feedbackfrom her about whetherwhat we are
doing is helpful to her or not really, that's what theproblem is umyou know
it feels like you're working, working,floundering around a bit in the dark.
(C. 416)

Self doubtswere a commonpart of participants' narrative, but despitethese,people

seemedable to find examplesof the value to their work. They explain:

Kieran: I'm a sort of passionatebeliever in this, as a model, erm, and as a

but
I
helps
[I
life.
(K
in,
in,
it
in,
wouldn't
say
curative
with
sort of, erm,
153)
James: Explaining learning disability psychotherapyto other people
how
if
its
about
all
awful disability is, erm, well
soundsrather gloomy, as
there is that but there is, it can be uplifting as well, it can be quitepoignant.
(J. 440)

78
Denny: I was never sure what the kids were leaving with, and it's the kids
that, who come back to visit to say "Hi '; to show me their children, which is
My God! You know?... say what I mean to them so, and, I do believe that
...
it's been very profoundly moving and worthwhile. (D. 212)

Impact on Therapists (3.2): Despite the enjoyment of the challengepresentedby

cientswith learning disabilities, all of the participants madereferenceto the wearing
natureof the work. Although a few participants madereferenceto positive counter
transferences,it was the negativecounter transferencesevokedby their clients' issues
and presentationwhich dominatedaccounts(seeFig. 7). Feelingsof sleepinessand
angerwere strongly represented.

James: I think some of the strongest things are things having difficulty
keeping awake. (J. 280)

Ela: I didn 'tjust not like him, I felt like slapping him. (E. 482)
Suzzanne: I've never spoken about my murderous feelings towards people
[] it would be terribly difficult to talk about my own counter transference.
(S. 24)

The self doubts noted in the previoustheme were placedin the context of counter
transference,as feelings of inadequacyand incompetencewere reflected almost
universally.

Denny: I just feel devastatedat the end of the sessionI feel absolutely
useless,pathetic. (D. 280)

79
Alistair: I think the work can be affected in a very negativeway if you were
just trying to keephold of all thesethings and thinking you know, `I should
be above this ", you know, and "This shouldn'tflap

me" and it does, it does.

(A. 285)

A senseof shamefor lack of competencewas apparentfrom a number of accounts.

Where participantsidentified with their clients, there was guilt for the therapist's non
disabledposition:

Eta: Every time we have to have a discussionabout endingyou know I find

it terribly traumatic. And I've got somebodyat home to talk to you know,
I'm not in theposition that has nofriends and mostpeople dislike. (E. 694)
Graham: That was a real harsh onefor me,you know that could have been
me. (G. 217)

The otherness,previously recognisedby clients, was also uncomfortably presentfor

the participants.This, along with the embodiedcommunicationnoted earlier,
dealing
in
to
the
therapist
appeared challenge
with countertransferencesof dislike
and disgust.

Alistair: Its like being with the kind of, the, the kind of sexmonsterkind of
fantasy that people might have of, of, of especiallywith someonewith a
learning disability. (A. 272)

80

Figure 7. Participants' Negative Counter Transferences

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81

Louise: Thisperson actually launchedherself at me in this excited/angry

dug
her
sort
actually
claws in me. I said claws... (Sounded
state and
of
embarrassedand corrected)fingernails. (L. 81)
Suzanne: I had the sensethat he was often testing me as to how much I
could, how, how much I could tolerate him, how much he disgustedme.

(S.55)

Participants were placed in the position of able, powerful "other" (most often parents)

in the transference. Most frequently, transferenceinvolved abusive,critical or

abandoningfigures.

Candace:It's more commonthat they makeyou into an abandoningand

inadequate sort of parent. (C. 470)

Kieran: A harshpunishingfather. (K. 177)

Whilst all the intervieweesusedthe framework of countertransferenceto reflect on

their experiences in sessions, Louise and Alistair made the point that the impact of

thesepowerful dynamicswent beyondthe professionalrole:

Alistair: Its difficult to talk about becauseit is, it's, you know verypersonal
talking about counter transference,talking about myself. (A. 264)
Louise: I think there's an impact on you as a person, not as a therapist but
as a person doing this, it really can't be overestimated (L. 255)

82

Just as clients used embodimentto expressissues,a similar processappearedto be

occurring with the therapists. Physical symptomswere commonly reported:

Paul: Wehad somevery strange biological sensations.(P. 365)

Alistair: He's another exampleoffeeling quite sick sometimes.(A. 287)
Belinda: I did actually leave the sessionswith a terrible headache.(B. 904)

Participantswrestled with the interpretation of physical sensations,but the consensus

appearedto be that the processof acting as a containerfor painful emotionscould
have a physical, aswell as emotional impact on the therapist.

James: Sometimesyou have to pay attention to whether or not you have

simplypicked up the latest bug or whether in fact your body and immune
systemare being assaultedby unconsciousthings that are beingprojected
onto us. (J. 353)

All participants madereferenceto the needfor good supervisionand / or personal

therapyto help with the considerablestrainsof the job.

Kieran: Youknowyou can get more helpfrom colleaguesin supervision.

(K. 242)

Louise: I think it's really vital to have a good teamsupport and good
supervision. (L. 257)

83

Overall, the participantsalmost universally describedthe work as hard, due to the

themesidentified as differencesfrom mainstreamwork. The traumatic issuesand
extremesof presentation,the rethinking of role and process,and the powerful,
unsettling transferencesaffected relationshipssignificantly.

Louise: I think what the impact it has on the therapist is [I sort of hard...
hard and constantthere isn't the light relief of being able to, erm, sort of,
you know, the therapeuticalliance where the therapistsand patients play or
think togetherso thosespacesare so much harder tofind, (L. 151)
Candace: It was so difficult to spenda couple of minuteswith someonewho
comesin in a wheelchair, who doesn't talk to you for the whole time. They
might have somescary looking thing that looks like a seizureor might go to
little
know,
you
very
response at all. (C. 99)
give
sleep or, you

Candacenotesthe strainsof addressingsecondaryhandicap,whilst Louise's quote

accordedwith Symington's (1981) descriptionof despairwhen facedwith the
apparentorganic damageof primary handicap. Paul madereferenceto this and
extendedthe conceptto encompasssocial networks, suggestingthat the tertiary
handicapalso impact on therapists:

Paul: Its very emotionally draining work to do over long periods of time,
changing resources,changing climates, changingpolicies, the whole lot, so
despair
is probably the malady of this century. (P. 194)
systemic

84

CourtesyStigma (Theme 3-3): The social context describedabovewas a constant

backdrop in people's narratives.The participantswere very awareof the social stigma
attachedto learning disabilities and were awarethat their clients had previously been
deniedopportunities,Alistair illustrated the unoffered chair:

Alistair: I don't think he had ever had this kind of dialogue with anybody,
down
him
have
him
had
in
that
way,
would
with
a
allowed
sat
really
no one
to explore,you know, someof thesecomplexthoughtsandfantasies that he
had had (A. 129)

The therapeuticmarginalisationprocesswas identified not simply in clinical settings,

but permeatedthe structureof training provided to fledgling therapists:

Alistair: Certainly during my training it had never comeup, never. You

know, not evenmentioned.(A. 63)
Kieran: I just remember [] having a sense that I don't have any training to
do this, my training hasn't equipped mefor dealing with this. (K. 100)
Candace: Every time I brought a case they turned it down, bring another
one turn it down, bring another one turn it down, really they didn't want to
supervise a learning disability case. (C. 206)

Closer inspectionshowedthat for most, the therapeuticdisdain identified for

clients
extendedto those working with them. There was an awarenessthat working in this
mannerwith this client group could leave one opento being underminedor even
by
attacked others:

85

Eta: People were very hostile to you, and if you tried to makeanything
different people were incredibly, incredibly unpleasantjust to the extentof
not evenbeing civil, becauseyou know their conviction that people with
learning disabilities was hopelesswas so strong. (E. 353)

Louise describedan experienceof attendinga professionalconferencewhere a paper

on work with peoplewith learning disabilities was presented. Sherecounted:

Louise: People did find it very hard, they were terribly moved by it but

somepeople were angry and said, " How could you call this
psychotherapy?" (L. 228)

The reality that clients were inextricably embeddedin a network of colleaguesand

carers meant that people felt vulnerable to the negative judgments of others in a
position to view their work. Interestingly, the attacks on competency which were felt
by many therapists as part of the counter transference were experienced again at a
systemic level:

Kieran: Shewantedto go out into the corridor and I was trying to get her
back into the room [1, in fact my managergetting very concernedabout me
coming out, "Are you OK, is everything all right? " (K. 95)

86

Denny: [when talking about a colleague'sdisdain] I don't know whether if

that's about me or about the client group we're working with and [I the
defencemechanismsthat comeinto play and thefeelings of inadequacyand
stupidity that get projected (D. 61)

Candace: I found myself being sort of behind everyoneelse becauseI

started late and thenyou know, [named learning disability colleagues]were
saying to me, "Oh, you're theperson with the learning disability. " (C. 227)

Candaceand Denny's commentsindicated an explicit awarenessof being identified

with their clients, and having characteristics projected into them by others and being

subjectedto the courtesystigma describedby Goffman (1963). Somecomments

imply that this identification could not fail to influence work practices:

Graham:

What I've always tried to is to balance the learning disability

work that I do [I and also my non learning disability work becauseI think
that, think that you needthat balance to have that kind of credibility. (G. 90)
James: Fortunately there was nobody elsearound so I felt brave enoughto
try something different. (J. 417)

87

Discussion

Relating Results to Previous Research

Despite the similarities with non-learning disabled clients, it was the differences in
presentation and issues which predominated in accounts, echoing Mannoni's (1973)
stance that work with this group was uniquely challenging. There was overlap with
theoretical models, although participants placed differing emphasis on the elements
described. For example, Hollins and Grimer's (1988) three secrets of disability, sex
and death were represented amongst the issues which emerged. However, the two
latter issues were not as well represented in participants' reports as might have been
expected. The theme of abandonment was more strongly represented than death per
se.

The theme of disability itself was universally raised and identified as central to work
with the client group. Participants' reports that clients recognised the limitations
imposed upon them by the condition, and showed an often acute awareness as to how
they were perceived by others accorded with findings of other researchers (Jahoda et
al, 1988; Szivos-Bach, 1993).

Secondary handicaps (Sinason, 1986) were identified by participants and often

underpinned presentations that were quite distinct from other client groups. Examples
of identification with Wolfensberger's (1972) stereotypes, for instance, as "menace",
"object of unspeakable dread" and "diseased organism"(p. 20-22) were given and
recognised both by the participants and the individuals themselves.

88

Theseroles madeup part of the social context in which the therapistwas inextricably
by
described
"ideological
This
transference"
the
counter
embedded.
accordswith
Retzinger (1998) in which the therapist is faced with the task of separatingout belief
systemsbefore being able to connectwith a client as an individual.

Participantsagreedthat countertransferencewas a key therapeutictool in finding

in
it
importance
in
than
these
afforded
was
meaning
presentationsand gave greater
previous descriptionsof therapy. In Jackson's(2004) review of fourteen descriptions
five
in
highlighted
therapeutic
tool
transference
therapy,
only
as
a
of
counter
was
cases.

The mannerin which clients communicatedfeeling resonatedwith Perry's (1990)

definition of acting out. Specific behaviourssuchas submissiveness,aggressionand
boundarybreaking, matchedthose of previous casedescriptions(Ruth, 1999;
Symington, 1981; Korfe-Sausse, 2004)

The embodimentof communicationwas widely describedand echoedcasematerial

by severalclinicians who noted the use of faeces,mucus and saliva in a way that
communicatedfeeling (Sinason,1992).The findings resonatewith Bick's (1968)
conceptof "psychic skin", with clients literally using skin to communicatediscomfort
and distress. The transferencesdescribedalso reflectedthose describedin previous
cases,although maternaltransferencewas lessprominent that might havebeen
supposed (Jones and Bonnar, 1996; Mannoni, 1972)

89

The technical adaptationsreportedinvolved a more flexible approachto medium,

languageand the use of non-verbal channels. Theseadaptationsmatchedthose in
other published case descriptions (Bungener and Mc Cormack, 1994; Hodges, 2003)

Whilst adaptationsof methodwere commonly agreed,the findings highlighted a

schismamongstpractitioners' roles which has not receivedmuch attention in the
literature. The degreeto which practitionersacknowledgedthe needto work with
systems appears to mark a shift in practice. Freud (1917) considered the intrusion of

carersto be dangerous,whilst Mannoni (1972) noted the importanceof information

gatheringfrom parents. Jackson's(2004) review showedthat a third of clinicians
reviewed appearedto incorporatethird parties,whilst almost all of the participantsin
this study reportedthis to be an acceptedpart of their work.

However, the way in which therapistsinterfacedwith systemsreflected a divide.

Stokes' (1987) had observedthe inherent difficulty in distinguishing betweenprimary
and secondaryhandicaps,but participantswere indicating that it may be equally
difficult to distinguishthesefrom tertiary or societalhandicaps.

The introduction of the idea of a tertiary handicapreflects the societalstigma models,

basedon Goffman's (1963) work. Social factors had previously been seenas
influenceson the psychebut outsidethe rangeof the therapeuticsessions.Here, the
participantsvaried asto whetherthey exclusively espouseda psychodynamicmodel
or whetherthey took on roles not previously encompassedby this model.

90
Another corollary of the stigma model which could be applied to the data was the
been
had
(Gilbert
Some
1995).
explicit
social
comparison
et
al,
participants
area of
in recognising the dynamic of comparison within the therapeutic relationship.
Although largely neglected in the literature, this counter transference had been noted
by Sinason (1995) and Reyes-Simpson (2004) who identified feelings of envy in the
client and complimentary guilt from the therapist.

This dynamic of the "dis-abled" client and the abletherapist appearedto reflect
shameand guilt states. Gilbert et al (1994) note that in guilt states,the self feels
intact and capable,yet is the sourceof hurt to others. Shamestatesare characterised
by the self as un-able; afraid, helplessor passive,inferior, the object of scorn disgust
or ridicule, with poor functioning, for instanceone's mind going blank. Also
characteristicof the phenomenologyof shame,was angertowards the self and anger
towards more able others.

When client presentationsare viewed collectively, there appearsto be a strong

similarity, with aggressiontowards the self and therapistand submissiveness
featuring strongly in accounts. The lessobservablefeaturesof shameare represented
in the participants' descriptionsof their transferenceexperiences.Explicit references
to shame,anxiety, inadequacyand impaired ability to think were recurring themes.
The findings that internalisedshamecorrelatesboth with abandonmentexperiences
(Claesson&Sohlberg, 2002) and stigma (Lewis, 1999)would seemto fit with the
specific issuesidentified for this client group.

91

This combination of observablepresentationand countertransferenceexperiences

suggeststhat the individual featuresof psychotherapywith this client group may be
reformulatedas indicative of shamepronenessor shamestates.Thus shamemay
representa more detailedcomponentof the cluster of issuessubsumedunder Hollins'
(1989) conceptof the disability itself.

The professionalcontext in which participantsworked showedsignsthat courtesy

stigma (Lewis, 1999, Mitchell, 2000) was being applied, particularly from

psychotherapycolleagues. There is little evidencethat the professionwas recognised

this or was using psychodynamicmodelsto considertheir exclusory practices.

All the participantsdescribedthe work as arduous,and suggestedthat "spoiled

identities" were intrinsically traumatic, to both client and therapist. This resonated
with Hollins and Sinason's (2000) attempt to equate learning disability to the
diagnostic definition of trauma (American Psychiatric Association, 1994)

Despite difficulties in reconciling the elementof "suddenness"associatedwith the

definition, somedata fitted with literature on vicarious trauma.Pearlmanand
Saakvitne(1995) describedthis asthe impact on an individual's inner world through
empathicengagementwith others' traumatic material. This was illustrated by the
commentson how the countertransferencewent beyondthe professionalto the
personal;the therapist role did not alwaysprotect the individual from the material.

92

Methodological Limitations

The study has a number of methodologicallimitations. One concernaroseover the

cultural homogeneityof the sampleand researcher.Accountsby therapistsfrom
ethnic minorities were not available,and results might thereforebe expectedto reflect
a cultural bias and limit transferability of findings. However, this may genuinely
reflect the natureof the professionat present.

Another significant issue related to the sample was that almost every participant

reportedcontactwith the ideasof a small number of key theorists.There would

therefore seemto be a risk that the data reflects a common learnt model rather than
just
However,
experiences.
as Smith and Osborn (2003) recognised the
unprocessed

impossibility of being a truly naive investigator,the naive participant is neither

possiblenor useful in terms of transferability of data.

This may beg the questionof whether the data from the study would have beenon
saferground if interpretedusing the principles of groundedtheory.
However, the aim of the study was to investigatethe experienceof the therapist,
despitethe "triple hermeneutic"implied by their roles.

As in any qualitative research,the issueof subjectivity needsto be addressed.The

author's prior interest in shamephenomenologyneedsto be acknowledged. Whilst
observationswere supportedby textual evidence,other interpretationsmay havebeen
overshadowedby the researcher'sareaof interest.

93
Clinical Implications

Findings suggestthat clinicians in this field may be at risk of compassionfatigue or

vicarious trauma, so supportnetworks suchas supervisionneedto be viewed as
essentialin the work. In particular, tools for managingnegativetransferenceneedto
be explored or there is a risk that the experienceof therapywill be unhelpful to both
parties(Story, 1979). Ideological transferencemay needto be addressedboth by
individuals and by the systemsand professionsin which they operate.

Significant thought needsto be given to the resolution of the role dilemma, by

determiningthe natureof the implicit schemasupon which decisionsare based.
Tertiary handicapsappearto havea significant impact on both client and therapist,
regardlessof which model predominates.

The implications of not explicitly recognising the shame dynamic are potentially far
reaching. Shame proneness has been linked to both inhibition and generation of
expressed anger, enhanced denial defences and reduced disclosure (Lewis, 1971;
MacDonald, 1999; Retzinger, 1999), and if left unrecognised, can lead to failures in
therapy (Frey et al, 1989).

Future Research
Researchon how psychodynamicprinciples can be appliedwithin networks for
dependentadults appearsto be a crucial areato explore to help clinicians determine
their responsibilitiesin the face of the addedcomplexitiesof this client group. The
role of shameappearsto be a significant avenuewhich hasbeenalluded to, but not
sufficiently exploredwith learning disabledclients and their relationships.Further

94
investigation is neededaround the attitudesheld by clinicians around offering
focus
to
this
a
on the phenomenaof
psychotherapy
client group with particular
ideological countertransferenceand stigma. Detailed analysisof the evolution of
therapistsin this field might be of interest with regardto recruitment.

95

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101

Part Three: Critical Appraisal

102

Introduction
In her comprehensive review of 2005, Morrow proposes four standards which indicate the

"goodness"of a piece of research.Theseare subjectivity and reflexivity, adequacyof data,

adequacyof interpretationand social validity. In this sectionI shall considerthe
methodologicallimitations of the study with referenceto thesestandards.The clinical
implications of the findings and their impact on future investigationswill also be
examined. The section concludes with a personal narrative of the research process.

Methodological Limitations

Adequacy of data: Perhapsthe first questionto be askedis that of whetherthe study

includes sufficient quality of data to ensuretransferability. Transferability is the criteria
which parallelsthe notion of generalisability in quantitative research,and relatesto the
be
findings
to
the
extent which
may consideredapplicableto other settings.

A numberof factors may contribute to transferability in the presentstudy, including

participants. Whilst clearly lacking power in quantitative terms, elevenparticipantsappear
to be sufficient for an ideographicas opposedto nomothetic methodology. Guestet al
(2006) report saturationoccurswithin twelve interviews, with the basic super-ordinate
themespresentafter six accounts. IPA doesnot, in fact, require saturation,studiesbeing
publishedwith as little as one participant (Smith & Osborn,2003), so the current sample
would seemable to generatenecessaryand sufficient data.

IPA requiresthe sampleto be purposive,and membershipcriteria of the IDP would seem

to clearly relate to the qualities and experiencesthat would be relevantto the research

103
question. However, the very specificity of the samplemay raise concernsover what might
be describedas "tautological sampling". Due to the stringentmembershiprequirements,
the IDP represents a very homogenous group. Almost every participant mentioned

ideas
few
Sinason
Valerie
to
the
the
and
publications
of
and
studied
at
one
of
exposure
institutions offering training in psychodynamic approaches for this client group.

The questionneedsto be askedasto whetherthe homogeneityof the samplemeansthat

the findings do not reflect peoples' actual experiencesbut their predispositionto interpret
events via a common learnt model. The high degree of agreement with participants
be
interpreted
in
light.
literature
As
descriptions
from
this
the
the
a
might
accounts and
methodology, IPA can be criticised for its underlying belief in language as being
representationally valid. This sample highlights the problem inherent in the constitutive

role in participants' language.

This would seemto be a risk particular to this professionalgroup as psychodynamic

therapistsare expectedto use personalexperienceto interpret that of their clients in the
form of transference.Whilst IPA is often describedas a "double hermeneutic"process,the
current study could be characteriseda "triple hermeneutic"with the participants
interpreting their own experiencein order to understandthat of their clients and in turn,
being interpretedby the researcher. With such sophisticatedaccountsthere is a concern
that what is describedis not genuinelyphenomenological.Participants' accountsare
already imbued with explanation rather than description.

This may beg the questionof whetherthe data from the study would have a better fit with
the principles of a different qualitative methodology. However, developinga model of

104

interaction from the principles of groundedtheory would ignore the fact that the basic
been
discursive
building
had
Similarly,
blocks
the
explored.
use
of
a
not
yet
experiential
focus
language
have
the
to
the
the
rather
social role and readjusted
model would
explored
than the individual. Whilst this might be a fruitful meansby which to explore concepts
focus
has
been
it
the
on
roles,
unexplored
when what
such as courtesystigma, perpetuates
in the literature is the relationshipbetweenindividuals.

Epistemological complexities are raised by the nature of the participant group but these can

be acknowledgedrather than resolved,as to use other methodologywould lose the essence

of the enquiry. To usethe argumentof reductio ad absurdum,therapistswould be
disbarredfrom any enquiry as to their inner world becauseof the risk of tapping into the
fulfil
to
their role.
they
need
constructions
very

The quality of data is also measuredby the quality and depth of the interviews. The
interviews were framed within the IPA model, where brief neutral questionswere usedto
minimise leading. There was a tension here betweenthe needto managesubjectivity, and
in
interpret
techniques
to
situ.
participants'
responses
verify, clarify and
using

As a researchernew to the qualitative approach,I had undertakena practiseinterview to

learn the technique,and in this it was apparentthat my unstructuredquestionswere often
leading
leading.
data
In
I
to
the
this
subtly
study, was anxiousnot contaminate
with
questions,and therefore madea consciousdecisionto limit unscriptedinput during data
collection. Whilst this minimised this risk, it also meantthat rich data or clarification may
havebeenlost by the limited use of funnelling techniques.However, it was apparentthat

105
interview
the
to
situations, whilst the
not
applicable
questions
universally
prompt
were
adaptations were open to question with regard to neutrality.

Using multiple data sourcesis recommendedfor qualitative research. Additional meansof

focus
included
journals,
have
in
information
this
groups
participant
might
study
collecting
financial
due
discounted
interviews.
These
the
to
the
time
and
available,
were
and multiple
from
based
100
the
travelling
to
over
miles
of
were
participants,all whom
contraintsof
field
data
The
to
therefore
notes,
confined
sources
used
were
multiple
researcher.
interviews, participant checksand interviewer observations.

Morrow (2005) cites the need to pursue adequate disconfirming evidence. Whilst there
in
further
have
been
between
an
pursued
accounts, which might
were contradictions
been
have
few.
did
be
More
to
these
attention
could
minor
and
appear
extended report,
given to Ela's account, as this differed from the others with a sociological rather than
different
her
have
had
However,
may
whilst
account
psychodynamic perspective.
emphasis, e.g. on pragmatics and systemic issues, there was still a high degree of
disconfirming
identified
Where
themes.
significant
evidence was apparent,
agreement with
across accounts, this was highlighted as a theme in its own right (e.g. Primary, Secondary

and Tertiary Handicap).

The participant checkswere anotherinstanceof inviting disconfirming evidence.

However, there was a risk of tokenism as the two participantsapproacheddid not
disconfirm any of the analysissharedwith them. Their preferredmethod of using email
communicationmay have inhibited a more engageddiscussionabout the data.

106

Managing Subjectivity and Reflexivity

As in any qualitative research,the issueof subjectivity needsto be addressed.Firstly, most

biases
implicit
assumptions
and
clear at the outsetof the
standardsadvisemaking one's
project. To this end, a profile of the researcher,providing a context for involvement in the
included
in
biases,
has
been
the thesisto promotetransparencyof
study and personal
process.

Following the guidelines of Glaser and Strauss, (1967), the literature review was not

decided.
interview
had
been
the
constructed
and
protocol
semi structured
undertakenuntil
However, I had a broad awarenessof the findings in the field due to my generalreading
interest
in
and specific
psychodynamicpsychotherapy.

As researcher,I tried to adopt a reflexive position by keeping a field diary to record

experiencesand thoughts which were usedduring the writing processto check for
included
by
initial
Further
the
transcript with an
safeguards
checking
assumptions.
were
independent reviewer, and comparing findings (see Appendix F. iii)

However, one dilemma which arose as part of this process of managing subjectivity was

the tensionbetweenmanagingbias, and two of the identified quality standards,those of

reflexivity and ontological authenticity. Ontological authenticity relatesto the needto
expandand elaborateon the participants' constructions,it might be seenasthe process
which looks in depth at the participants' experience,and goesbeyondthe descriptiveto the
interpretative.

107
The specific tension between these concepts for this study lay in my awareness that I had a
be
in
that
assumption
shame
experiences
would
represented
participants'
pre-existing
accounts of working with this client group. Initially my approach to managing this was
one of "bracketing" (Morrow, 2005) in which I set aside my assumptions to avoid
influence on the research. However, I was increasingly aware that all participants had
either directly referred to shame or described its phenomenology without labelling it as
such. Whilst usually minimising use of the funnelling technique, on one occasion this was
used to clarify a passing reference to shame and guilt. The respondent, Denny, replied
emphatically that shame was without doubt present in every one of the clients she had
seen.

The pervasiveness of the phenomenon in other accounts and Denny's emphatic answer
seemed to illustrate confirmability, so this was included in the report as a significant and
valid theme. However, it may not have been given such prominence had I not been
predisposed to notice its presence or phenomenology. Glasson (2004, p. 93) was clear for
the need to exclude "the beliefs, pet theories, or biases of the researcher". Yet without an

awarenessof the shameliterature it is unlikely that I would have noticed and groupedthe
descriptionsinto the one concept,and probed further. Whilst this did producewhat
appearsto be an ontologically authenticconclusion,my sensitivity to shame
phenomenologymay have overshadowedother interpretationsof the data. Ultimately,
however,my position was one of recognisingmy explicit bias, crossreferencingit with the
data and agreeingwith Morrow's (2005) position as shestates:

108

"I would arguethat the investigator alwaysbelieves somethingabout the phenomenonin

questionand that a greatergrounding in the literature militates againstbias by expanding
" (p. 254).
the researcher'sunderstandingof multiple ways of viewing the phenomenon.

Adequacy of Interpretation

Adequateinterpretationof data requiressufficient immersion in the data. It is hard to

quantify what "sufficient immersion" entails,but for the current study,this was addressed
by listening to eachtape in conjunction with the transcript at least once. The transcripts
were then read and re -read.

One difficulty with the immersion processwas that the sheeramountof data was
overwhelming. With over four thousandlines of data being generatedby participants,the
risk of overlooking subtlethemes,becausethey could not be retainedeasily, was
significant. The difficulty of creatinga coherentstructurewas addressedby using visual
display techniquesto help with conceptualisation.Where themeswere identified using the
IPA analysistechniques,the relevanttext was physically cut and pastedto form a wall to
ceiling display of related concepts. The relevanttext could be viewed as a group, to further
identify commonalitiesand differences,helping the refinementprocess.In this way, the
risk of disregardingor overestimatinga themewas reduced,and interpretationwas
groundedin examples.

Clearly, the processof writing the report is part of the iterative process,and this was
recognisedin the ongoing changesmadeto the drafts. One difficulty emergeddue to the
condensedform of the report. The report was written to matchthe criteria of the Journalof
Applied Researchin Intellectual Disabilities. This meantthat information neededto be

109

highly condensed,which may havebeen at the cost of rich detail and more comprehensive
presentationof the material.
Social Validity

Social validity may incorporatereflection on the appropriatenessof the aims of the study,
its processand its ultimate contribution. Key to the processis the ethical obligation of
researcherto participants.The risks in qualitative researchare often seenasthe impact of
the questionsupon participants. It was assumedthat the experiencesdiscussedin this
study might remind participantsof uncomfortablefeelings but the natureof the samplewas
suchthat the processof acknowledgingsuch feelings for a therapistwas expectedto be a
familiar and evenwelcome process.
In the event,no-one showedindications of distress. In the literature, where distresshad
beennoted for participants,researchershave found little evidenceof long term effects
(Turnbull et al, 1988,Corbin & Morse, 2003).

Benefits to participants have been hypothesised to include the opportunity for cathartic
experience, self-acknowledgement and validation, the contribution to a senseof purpose
and increased self awareness (Corbin & Morse, 2003).

Whilst noneof thesewere directly describedby the participants,severalpeople commented

on their belief that it was important to further the knowledgein the field, and that they
were pleasedto be able to contribute.

Oliver (1992) reflectedon the social,political and ethical implications of exploration in

this field. As he says:

110

"Researchon disability has had little influence on policy and madeno contribution to
improving the lives of disabledpeople... theprocess of researchproduction has been
alienatingfor both disabledpeople andfor researchersthemselves." (p. 101)

There is a risk that interviewing therapistsmay perpetuatethe disempowermentand

alienation of clients describedby Oliver. The serviceuser representativequestionedwhy
the researchwas being conductedwith therapistsrather than the peoplewith learning
disabilities.

One of the initial drivers for the research was the recognition of the "unoffered chair"
(Bender, 1993). Since accessto services appears determined by individual clinicians this
shows therapists to be of supreme importance when determining whether services are
developed. Therefore, there appeared to be a prima facia reason to explore individual
therapists' experiences.

However, one of the authenticity criteria named by Guba and Lincoln (1989) is that of
catalytic authenticity. This refers to the extent to which research can be justified in that it
prompts action. Patton (2002) speaks of the similar concept of consequential validity in
achieving social and political change. The degree to which the findings of this study may
prompt action are still speculative.

Clinical Implications
So the questionremainsas to what specific findings may be relevant in promoting action?
Firstly, whilst people's narrativesasto their evolution astherapists' were ideographic,one
common elementwas the contactwith theoriesof psychodynamicwork with peoplewith

111

learning disabilities. This is necessarilydependentupon the extentto which information

dissemination
is
Thus,
of
this
wide
mannerof working accessible.
and experienceof
information would appearto be recommendedto catalysepredisposedstaff. The findings
highlight the needfor peoples'work and experiencesto be madeaccessible.Highlighting
the positive challengeof the work may be particularly effective in inspiring prospective
practitioners.

For the purposeof social validity, disseminationhasbeen included in the processfor the
both
involving
client groups and colleagues.
study,
current

From the available literature, the emphasis and content of the dissemination process thus
far has been client based, justifying the inclusion of clients with learning disabilities on the
interventions.
demonstrable
intelligence
the
the
of
effectiveness
and
grounds of emotional
The study suggests that this has been effective in piquing the interest of therapists with
certain setting conditions.

However, the wider implications of the findings as to what may be valuable at this stage
may indicate taking a therapist based approach. This could involve using psychodynamic
and shame models to explore exclusion. There may be a huge legacy of stigma which
determines the ideological counter transference we may have with people with learning

disabilities, unrecognisedevenby those specialisingin identifying unconsciousprocesses.

There is needto recognisethe contribution this client group can make,rather than
perpetuatinga societalprojection of worthlessness.

112
Using the psychodynamicand shamemodelsto discussthe meta- dynamicwithin the
therapeuticcommunity may clarify the role courtesyshameplays in limiting the
development of services and training opportunities.

At an individual level, the implications for the aims and the role of the therapistfor this
client group are lesseasyto identify. Ratherthan indicating a clear direction, the findings
suggestthat there needsto be an ongoing exploration of the tensionbetweenpsychotherapy
in its purest application,and the needto engagewith the implications of the "tertiary
handicap". Participantsare clear aboutthe ways in which they have adaptedintra-session
techniquesto keepthe principles of psychotherapywhilst adaptingto the individual's
limitations. Perhapsthe focus now needsto be on how similar adaptationscan be madeto
allow applicationsat a systemiclevel, without losing the therapeuticstance.

Whilst the findings have emergedfrom the experiencesof psychotherapists,they may have
implications for the relationships others have with this client group. Whilst generalisability

cannotbe guaranteed,dueto the issuesdiscussedpreviously, it is not unreasonableto

postulatethat similar responsesmay be evoked in carersand staff. Thus, using a
psychotherapeuticmodel to understandthe relationshipsaround individuals and groups
with learning disabilities would seemvalid.
Further Research
The clinical implications above naturally suggest fruitful areas for further research.
This study was unable to pursue a detailed exploration of the early stages of therapists'
evolution in this field. The data suggested that there may be a mine of rich data to be
found from qualitative studies focussing on the contemplative stage of pursuing an interest
in therapy with this client group.

113

The areaof shameresearchwould appearto be hugely significant in terms of its potential

instance
determining
degree
in
field,
for
to which
the
this
to
clients
and
workers
relevance
impacts
how
this
and
on
and
shame
proneness,
shame,
clients experiencestate
in
difficulties
(1998)
Andrews
the
operationalising
myriad
notes
relationshipswith others.
is
for
form
The
that
of
questionnaires,
problematic
of
measurement,
most common
shame.
thosewith learning disabilities and may be both insensitiveto the different nuancesof
distinguish
between
Direct
to
general
negative
affects.
shameexperiencesor unable
it
is
be
that
this
to
an emotion of
area,
particularly
given
questioningmay one way explore
format
issue
focus
in
had
has
Gilbert
the
group
using a
success addressing
concealment.
(Gilbert, 2004). This may be a particularly valuable methodologyfor clients, whom
being
bullying
discussed
freely
the
experiences
of
common
shaming
reported
participants
and teased.

Eliciting the experiencesof clients with learning disabilities brings with it difficulties in
terms of ethics of consentand practicalities of data gathering. However, this does seema
in
knowledge
in
both
terms
to
and
recognition of the
of
vital avenue strugglewith,
potential alienation of clients from the researchprocess.

Exploring the way in which therapistsmanagethe interfacewith networks could be

investigatedto clarify how clinicians settheir boundariesand the consequences
of these
decisions.A rangeof methodologiesincluding questionnaires,semi structuredinterviews
and focus groups might be appropriatehere.

114
Finally, the epistemological problems identified for this particular purposive sample may
be clarified by designing complimentary studies to this, for participants with different roles
with regard to people with learning disabilities, who have not received training in
in
findings
be
This
the
clarifying
current
are
whether
psychotherapy.
would
valuable
indeed generalisable, and inform the debate regarding how best to manage carers and

systemsaround clients.

Personal Account

In this section,I aim-to write a commentaryon the processof carrying out this piece of
from
implementation,
difficulties
include
This
the
encountered
origins,
and
research.
will
the researcher'spoint of view. The sectionconcludeswith a summaryof the learning
future
from
to
the
practise.
outcomes
work with regard

Origins of the Project

"Do you know what it's like to have a learning disability? It's like a dog on bonfire night
when boys tiefireworks to its tail and stand around laughing. " (J. B., 1992)

The descriptionabovewas given by a client who was trying to make me understandwhat it

felt like to havea spoiled identity. The power of her words has stayedwith me over many
left
into
know
to
themesof
translated
and
me
years
with a profound need
more which
interest for future research.

I initially enteredthe Sheffield Doctoral coursewith a proposalfor researchrelating to the

issueof identity in peoplewith Down's syndrome. This was to havebeen a quantitative

115

disabilities.
However,
learning
recruiting the
participants
with
and qualitative study with
impracticable.
This
identified
was a
power
was
as providing sufficient
eighty-participants
between
highlighted
frustration,
the pragmatism
tensions
the
and
point of profound

instilled in me by my role as a clinician, and the needto avoid risk taking to ensurethat I
met the academicstandardsrequired.

This resultedin the uncommitted pursuit of two other researchproposals,before the

impact
in
interest
I
the
to
of a
wanting examine
current studywas adopted. retainedmy
learning disabledidentity but the time constraintsled me to examinethe issueof therapy
from the clinician's perspectiverather than the clients'. This was due to the historical
difficulties of obtaining ethics approval for projects involving direct contactwith people
disabilities.
learning
with

Implementation
The first draft of the research protocol was ready for submission in November 2004.
However, shortly after this, my mother, for whom I am the main carer, became critically ill
in
The
the autumn of
restarted
project
was
and as a result my registration was suspended.
2005. The proposal was submitted to the Research Panel in December of that year, and
final approval was given in March 2006.

A consultationmeetingwith the serviceuser representativewas held the following month.

This proved interestingin that it highlighted an important but difficult dilemma. The
issue
the
representativeparticularly raised
of the needfor me and participantsto use
respectfullanguagewhen speakingor writing about clients. Whilst I had confidencethat
respectwould be shown, I was also awarethat the issuesraisedcould and indeedshould

116

addresssomepainful and sometimesunflattering issuesabout disability. Honest but

painful language was likely to ensue.

The difficulty raisedherewas that to adherestrictly to the serviceuser's requestwould

underminethe purposeof the study in taking a detailedlook at the real relationshipspeople
with and without learning disabilities had with eachother. Sinason(1992) had written
about the way in which terminology was changedto avoid the pain inherent in the topic
and there seemedto be a risk of somethingsimilar happeningin the researchprocess.

I was initially anxious about how this might be resolved. I was concernedthat the subtle
differencesbetweenusing respectfullanguage,and the respectshownin honest
descriptions may not be apparent to the representative, who by the nature of his position

had somecognitive limitations and an understandableemotional investmentin how he and

those he representedwere portrayed.

The issuewas resolvedby explaining this to the representativein letter form, and then
discussionof examplesfrom the completedstudy (seeAppendix G.). In the event,the
distinction was understoodand agreedupon.

Submissionto the University Ethics Sub Committeefollowed, and approvalwas given

(seeAppendix B.). Although further ethical clearancewas consideredunnecessary,I
retainedsomeconcernsregardingthe recruitment of NHS staff as participantsand arranged
to discussthesewith key membersof my employing NHS Trust in April 2006.

117

Following informal discussionaroundthe principles laid out in the Governance

Arrangementsfor the NHS ResearchEthics Committees,it was agreedthat recruitment
further
basis
IDP
that
the
experience
and
confirmed
of
membershipand personal
was on
for
be
The
the recruitment and
then
clear
sought.
way
was
need
not
ethical permissions
data collection stagesof the project to be implemented.

The Institute of Psychotherapy and Disability was successfully approached for permission
to contact its members in May and responses from potential participants were received
from then until September 2006 (see Appendix D. ). Seven interviews took place in June,
October.
further
four
between
July
and
with a

Data analysistook placeconcurrently and an initial draft of the thesiswas provided to my

in
in
October.
Amendments
to
submission
made
prior
were
academicsupervisor
November 2006. Dateswere setto disseminatethe information to colleagues,the
Advocacy and Self Advocacy groups in November and December 2006.

Supervision

Supervisionhad beensomewhatproblematical,in that my initial supervisorhad

unfortunately experienceddifficulties with his health resulting in a significant period of
time whereby no supervisionwas available. Peer supportand supervision,which had
intake,
due
been
the
originally
set up with my cohort and
previousyear's
was unavailable
to most of the group having either abandonedor suspendedtheir studies.

The provision of a new supervisorhad beenhelpful. However, accesswas difficult both

due to geographicalseparationand the supervisor'shigh level of other commitments. As a

118
form
in
largely
2006,
took
the
than
three
contact
of email
meetings
result, other
communication. One significant drawbackwas that both the medium, and awarenessof
it
detailed
difficult
heavy
demands
time,
that
to
the
meant
ask
on
supervisor's
was
other
questions,or havecreative discussionsaround the process.

Motivation

Motivation proved to be the greatestbarrier to the work. My initial enthusiasmhad been

diminished by the false starts to the project. The loss of a supervisor and support group

had left me feeling very isolatedwith few external prompts to maintain momentum.

My confidencehad also beenerodedby the previous coursework assignments.I was

in
field
been
having
a
working
where the emphasiswas
unpractisedat academicwriting,
disabilities.
learning
Despite
to
successfully
people
with
upon making material accessible
it
hard
found
I
to gaugethe required standardsand I
the
completing all
other assignments,
beganto doubt whether I was capableof completing the degree.

At the point at which my registration was reactivated,from having had complete

confidencein my academicabilities, I was now seriouslyconsideringabandoninga course
for the first time in my academiccareer. Supervisionproved invaluable at this point,
finite
drawback
in
fact
direction.
In
time
the
that
available,
a
whilst
giving reassuranceand
evenslight delaysin the implementationprocessraisedconsiderableanxieties,was
actually helpful in focussing my efforts. However, the anxiety that coursemight be critical
rather than educationalor facilitative meantthat the processwas unremittingly stressful.

119

be
had
I
learning
in
the
itself
not
approach,which
about
The process
poseda challenge
I
in
interviews
The
familiar with previously.
proceededquite smoothly although retrospect
interest.
felt
freer
have
to
to
of
pursuepoints
wished
would

The
to
the
did
however,
thought
processes.
ethical
The process
make me give more
hesitancyof one participant to talk about his countertransferenceexperiencesmademe
been
to
the
having
that
the
elicit personal
study
were
of
aims
that,
clear
whilst
realise
be
been
had
that
I
of concern
not
responses
would
peoples'
assuming
actually
experiences,
becauseof their professionalstatus. As I wrote in the field diary after the interview:

"Realisedthat it was a brave admissionfor theparticipant. I wonder if I have beena little

blaseabout the impact of the interviews?" (Field diary, Tuesday,8.8.6)

I had not beenawareof the contradictory position I had beenholding until that point.
Following this interview, I took greatercareto gaugethe emotionalresponsesof the
participants,to checkwellbeing.

Future work practise

In terms of future practise,the project provided me with a valuable overview of the

logistical aspectsof researchprocess,which had changedconsiderablyin the years since
my last study. In particular, the experiencehighlighted the needfor comprehensiveethical
indirect
direct
incorporating
importance
the
or
considerationand
of
user views, whether
involvement. The potential dilemmas in this field are not resolved,but I havea heightened
awarenessof the philosophicalpositions involved which should inform my attemptsto find
working resolutionsto suchdilemmas.

120

The project introduced me to the field of qualitative research,which expandsthe repertoire

of methodologyupon which I am now able to draw, and honedthe skills necessaryin
writing to publication standards.I also have a greaterawarenessof the ethical obligations
upon the researcher.

Finally, one lessonwas drawn from the experienceof tension betweenthe needfor
academicrigour and pragmatism. I remain intensely curious about the experienceand self
in
be
in
feel
future,
less
daunted
I
I
that
this
conceptsof
client group.
will
easily
pursuing
answersto questionsI feel to be valuable.

121

References

Andrews, B. (1998). Methodological and definitional issues in shame research. In P.

Gilbert, & B. Andrews (Eds.). Shame:Interpersonal Behaviour, Psychopathology

and Culture (pp. 39-54). New York: Oxford University Press.
Bender,M. (1993). The unoffered chair: The history of therapeuticdisdain towards people
Forum,
Clinical
Psychology
54,7-12.
learning
difficulties.
with
Corbin, J. & Morse, J. M. (2003). The unstructured interactive interview: Issues of
Qualitative
Inquiry,
9,335dealing
topics.
sensitive
with
reciprocity and risks when

354.
Glaser, B., & Strauss, A. L. (1997). The discovery of grounded theory: Strategies for

qualitative research.New York: Aldine.

Gasson,S. (2004). Rigour in groundedtheory research: An interpretativeperspectiveon
generating theory from qualitative field studies. In M. E. Whitman & A. B. Woszynyski
(Eds.). The handbook of information systems research (pp. 79-102). Hershey, P.A. Idea
Group. New York: Macmillan

Guba,E. G., & Lincoln, Y. S. (1989). Fourth generation evaluation. Newbury Park, CA: Sage.
Guest,G. (2006). How many interviews are enough?An experimentwith data staurationand
variability. Field Method, 18(1), 59-82.
Morrow, S. L. (2005). Quality and trustworthinessin qualitative researchin counselling
psychology. Journal of Counselling Psychology, 35(2), 250-260.

Oliver, M. (1992) Changingthe social relations of researchproduction?Disability &

Society, 7,101-114.

122
Patton, M. Q. (2002). Qualitative research and evaluation methods (3'd edition). Thousand

Oaks, CA: Sage.

Smith, J. & Osborn,M. (2003). InterpretativePhenomenologicalanalysis.In J. A. Smith (Ed.).
Qualitative Psychology(pp.51-80). ThousandOaks, CA: Sage.
Turnbull, J., McLeod, J. D., Callahan, J.M. & Kessler, R. C. (1988). Who should ask?

Ethical interviewing in psychiatric epidemiology studies. American Journal of

Orthopsychiatry, 58(2): 228-23 9.

123

Appendix A

124

Department of Psychology.

The
University
Of
Sheffield.
Clinical Psychology Unit
Department of Psychology
University of Sheffield
Western Bank
Sheffield S10 2TP UK

Clinical Psychology Unit.

Doctor of Clinical Psychology (DClin Psy) Programme
Clinical supervision training and NHS research training
& consultancy.
Telephone: 0114 2226649
Fax:
0114 2226610
Email:
c. a.gillespie@shef. ac. uk

10thSeptember 2006

Julie Pehl

Dear Julie
I am writing to indicate our approval of the journal(s) you have nominated for
publishing work contained in your research thesis.
Literature

Review:

Research Report:

Journal of Research and Intellectual

Disability

Journal of Research and Intellectual

Disability

Please ensure that you bind this letter and copies of the relevant Instructions
Authors into an appendix in your thesis.
Yours sincerely
CCM

1
c "Andrew Thompson
Research Tutor

to

125

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128

Appendix B

129

Subj:
Date.
From:
To:

FW: Ethics of "An Exploration of Therapists' Experience... "

07/0612006 15: 57:59 GMT Daylight Time
Julie. Pe @derbysmhservices. nhs. uk
JuliemozzvCcDa
o0m

-Original Message---From: PaschalSheeran[malito:p.sheeran@sheffield.

ac.uk]
Sent: 11 May 2006 10:00
To: Pehl,Julie; [email protected]

Subject: Ethics of "An Exploration of Therapists' Experience..."

Dear Julie, '

Thank you for your submission to the Department of Psychology Ethics Sub-committee ("An Exploratlon of
.
Therapists' Experience of Psychodynamic Psychotherapy with People with Learning Disabilities"). I spoke to
Nigel Beall about your proposal, and he indicated that participants would not be recruited through the NHS
and that data collection would not take place on NHS premises,
Assuming that these aspects of the procedure are accurate, then I am pleased to inform you that the ethics of
your research are approved.

Yours sincerely,

ProfessorPaschalSheeran
Chair, Department Ethics Sub-committee

Paschal Sheeran, PhD

Professor of Psychology
Department of Psychology, University of Sheffield
Sheffield 810 2TN, UK
Phone: +44 (0) 114 222 6578
Fax: +44 (0) 114 276 6515
http://www. shef. ac.uk/psychology/staff/acaderhic/paschal-sh eeran. html

The Information transmitted by or with this email 1s intended only for the named addressee and may contain confidential material which
Is subject to 4w.
It you have received this email In enor, please contact the sender and delete It from your system.

130

Derbyshire
Mental
Health
Services
NHS
Trust

RESEARCH

GOVERNANCE

FRAMEWORK

By signing this page, the Principal Investigator acknowledges that:

1. They have read the Research Governance Framework

2. Agree to comply with the responsibilities of the principal investigator

as set out in the Research Governance Framework

65-ignature of Principal Investigator

Printed name of Principal Investigator

Pleasereturn completed form to

Corinne Gale
Mental Health Research Unit
Kingsway House
Kingsway Hospital
Derby
DE22 3LZ

Z,9.6. L
Date

131

Derbyshire
Mental Health Services NHS Trust
Mental Health Research Unit
Kingsway House
Kingsway Hospital
Derby
DE22 3LZ
01332 623579
01332 623576
E mail: Corinne. Gale(@DerbysMHServices. nhs. uk

22 June 2006
Outlook
99 Briar Gate
Long Eaton
NG10 4BQ

Dear Julie
RE: An exploration of the therapist's experience of psychodynamic
psychotherapy with people with learning disabilities
I am writing to inform you that the Derbyshire Mental Health Trust Clinical
Research Committee has been notified about the above study.
As part of the dissemination process within the Trust, please can you provide
a short summary of your research findings once the study is complete.
If you require any further information please do not hesitate to contact me.

Yours sincerely

Corinne Gale

Acting Research Coordinator

Trust Headquarters, Kingsway Hospital, Derby DE22 3LZ

Chief Executive: Mike Shewan

Tel: (01332) 362221

Fax: (01332) 331254

Chairman: Judith Forrest

WPI

132

Appendix C

133

Interview Schedule

1.

How did you come to work psychotherapeutically

with people

with learning disabilities?

Why did you work with this client group?

2.

Can you tell me about the first time you saw a client with learning

disabilities?
What do you remember about your early contact with clients with learning

disabilities? (If participants are unable to recall first contact)

3.

Have you worked psychotherapeutically

with any other client

group?
What was that like?

4.

What is it like working with clients with learning disabilities

now?

Can you tell me about your recent experiences working with learning disabled
clients?

5.

Psychotherapists

work within a model which identifies

transference as part of the therapeutic relationship..

Can you tell me what

it's like working with transference with clients with learning disabilities?
Have you found this with other clients?

134

6.

Whilst working in a psychotherapeutic

counter transference.

model, we pay attention to

Can you tell me what you have experienced in

counter transference whilst working with people with learning

disabilities?

Have you found this with other clients?

7.

How would you explain to a psychotherapist,

with clients with learning disabilities,

what it is like?

What would you tell them about your experiences?

who doesn't work

135

Appendix D

136

THE UNIVERSITY OF SHEFFIELD

Clinical Psychology

Unit

Department of Psychology

Doctor of Clinical Psychology (DClin Psy) Programmes (Pre-registration and post-qualification)

Clinical supervision training and NHS research training and consultancy
Clinical Psychology Unit
Department of Psychology
University of Sheffield
Western Bank
Sheffield S10 ZTP UK

Telephone: 0114 2226649

Fax
0114 2226610
Email:
c. a.giIlesgie( sheffield. ac. uk

Julie Pehl
C/o Erewash CTLD
OUTLOOK
99 Briargate
Long Eaton
NG 10 4BQ
Date: 19,6.6

Dear IPD member,

I am a clinical psychologist working with people with learning disabilities in
Derbyshire. I have a particular interest in psychotherapy with this client group
and am currently undertaking research on the topic as part of my studies for a
post qualification Doctorate in Clinical Psychology (D Clin Psych. ) at Sheffield
University.
Under the supervision of Professor Nigel Beail, 1hope to explore therapists'
experiences of psychotherapy with people with learning disabilities. To this
end, 1am presently seeking participants who are willing to engage in an
interview and share their experiences in this field.
I have enclosed an information sheet on the study. If you might be interested
in participating in the study, I would be most grateful if you could contact me
by:
Email - juliemozzy(cbaol.com
or julie. pehl
nhs. uk
-derbysmhservices.

'Phone - 07792 314620

Or alternatively, you could fill in the reply slip overleaf and return it to me in
the envelope provided.

pto
Thank you for your time,

137

Yours sincerely,

Julie Pehl, M.A., MSc. Clinical Psychologist

Name:
I would be interested in participating / hearing more about the study.
I can be contacted on

(tel no. )

I would prefer to be contacted at the following days or times

138

THE UNIVERSITY OF SHEFFIELD

Clinical Psychology Unit

Department of Psychology

Doctor of Clinical Psychology (DCIin Psy) Programmes (Pre-registration and post-qualification)

Clinical supervision training and NHS research training and consultancy
'Telephone: 0114 2226649
Fa)c
0114 2226610
Email:
c. a ctillespie(sheffield.

Clinical Psychology Unit

Department of Psychology
University of Sheffield
Western Bank
Shefheld S10 2TP UK

ac. uk

INFORMATION FOR PARTICIPANTS

Project Name: An Exploration of the Therapist's Experience of

Psychotherapy with People with Learning Disabilities
Researcher. Julie Pehl, Clinical Psychologist, Postgraduate student on the
Doctorate of Clinical Psychology Course, Sheffield University.

You are being invited to take part in a research study. The study is being
undertakenas part of the requirementsfor my studies towards a Doctoratein
Clinical Psychologyat the University of Sheffield.

What is the purpose of the study?

To find out about what it is like to work therapeutically with people with learning
disabilities.
Why might the study be useful?
There is currently only a small body of research investigating the therapeutic
relationship with people with learning disabilities. This study would add to that body
of research. In particular, there is a long tradition of people with learning disabilities
being denied access to psychotherapy, so descriptions of the experiences of
therapists may be valuable in investigating this issue further.
Who is taking part?
I am looking for 8 -12 participants, who fulfil the membership criteria for the institute
of Psychotherapy and Disability (IPD), and work with people with learning disabilities
within a psychodynamic model

139

What does it involve?

The study involves an interview in which I will be asking you to describe your
experience of working therapeutically with people with learning disabilities. The
interviews are expected to last between one to one and a half hours and will be
taped. The tapes will be transcribed and main themes identified from the
participants. The results will then be fed back to you in a phone call to check they
accurately reflect your experiences.
Confidentiality
All information given will be treated as confidential. Tapes will only be heard by the
research team. Nothing that can identify you or your clients will be included in the
study report.
If, during the interview, a disclosure is made which may indicate abusive practise,
this issue will be discussed with the research supervisor and may be referred on to
an appropriate professional body.
What rights do I have if I agree to be contacted about participating?
If you agree, I will contact you by phone whereby you can ask further questions. An
interview will be arranged at a time and place to suit you. Before the interview we
will go over the information about the study and you will be given a consent form to
sign. You will be able to withdraw at any time or decline to answer questions if you
wish.
Any participant who was unhappy with their experience, has the right to make a
complaint. A complaints procedure has been established by the University. In the
first instance, complaints should be addressed to Professor Nigel Beail, Sheffield
University Clinical Psychology Unit, Western Bank, SheffieldS10 2TP (ol 14
2226570).
Thank you for your time.

140

Appendix E

141

THE UNIVERSITY OF SHEFFIELD

Clinical Psychology

Unit

Department of Psychology

Doctor of Clinical Psychology (DClin Psy) Programmes (Pre-registration and post-qualification)

Clinical supervision training and NHS research training and consultancy
Telephone: 0114 2226649
Pax:
0114 222661 0
Email:
c. a.nillespie Asheffield. ac. uk

Clinical Psychology Unit

Department of Psychology
University of Sheffield
Western Bank
Sheffield S10 2TP UK

CONSENT FORM
Title of project:

An exploration

of the therapist's

experience of psychotherapy

with people with learning disabilities.

Name of researcher. Julie Pehl (M.A., MSc., ) Post graduate student, Sheffield University
Doctorate n Clinical Psychology (D Clin. Psych).

1.1

have read and understood the information sheet

2.1

have had an opportunity to ask questions and these have

been answered.

3.1

understand that the interview will be recorded, but that my

identity will be kept anonymous in any material used.

4.1

understand that I can choose whether or not to take part

and that i am free to terminate the interview at any time.

5.1

agree to take part in the above study.

Name of participant :

Date:

Signature:

Name of researcher.

Date:

Signature:

142

Appendix F

143

Figure 8. Overview of the Research Process

RECRUITMENT

Grantedpermissionto contactIDP members.

Letter of invitation and information re study sent. Members invited to contactresearcher.
Potential participants contact researcher (N=17).
Further information given as requested.

Someoffers declined due to location, membershipcriteria or time.

Appointments madewith remaining participants (N=1 1).

DATA COLLECTION

Interviews held and taped.

Consentcheckedprior to recording.
Field diary completedafter eachinterview.
Pen portraits made of participants to maintain context.

Tapesfor eachinterview transcribed.

Each tape replayedby researcherto check accuracyof transcript.
Amendmentsmadeas necessary.
ANALYSIS
Transcriptsanalysedusing principles of IPA.
Micro Analysis: Ideographicanalysisof interview. Emergentthemesidentified.
Crossreferencewith field diary.
Samplevalidity check with separaterater. Samplecheckedwith participants.

Macro Analysis: Master themesidentified from repeatedthemeswithin and across

transcripts.
Iterative processof adjusting interpretationswith new information and familiarity.
Crossreferencingthemeswith observationsfrom field diary.
Super-ordinatethemesidentified from the masterthemes.
REPORT
Themes described in narrative account.
Iterative process continues throughout.

DISSEMINATION
Information sharedwith stakeholders

144
Field Diary Excerpts

The following sectionillustratesthe analytic processusing examplesdrawn from a range of

participantsto demonstratetransparencyof process.

Pre-transcription analysis: extractsfrom field diary

The following extractsare included to demonstratethe recommendedprocessof keeping a
field diary during the researchprocess. The content of the extractshighlights the reflective
process,with observationsbeing madeon the technical aspectsof the interviews, the ethical
issuesinvolved, the awarenessof the researcher'sintrojections, and the emergentthemes
acrossparticipants.

Graham's Interview
Graham warned me that he may "dry up" and requested prompting if necessary. In the
event, I prompted minimally although I struggled not to ask questions about some interesting
areas he described. Again, I am struggling with the distinction between "Funnelling" and
"Leading", by choosing areas I may have a vested interest in. But I find it frustrating not
being able to home in on something for fear of introducing too great a bias.

Interestingthat transferencenot dealt with directly, - Different perspectivedue to working

with young people?(7.8.6)

Alistair's

Interview

Again realising that the countertransferenceissueswere personal,and that I wantedto, and

neededto, make somereflective commentsto keepthe "human" quality in the interview.
Realisedthat it was a brave admissionfor the participant. I wonder if I have beena little
blaseaboutthe impact of the interviews?(8.8.6)

145

Example of Preliminary

Analysis

J. J

225

and so he was talking about working with learning disability which is that's the

226

guild
first time that's actually come into tle main stream of the

and people did

a4

J\
We

227

find it very hard, they

228

(21.8) were terribly moved by it but some people were angry and said how could

229

you call this psychotherapy and so I think sometimes people get ve

230

defensive.

231

That's interesting, erm is there anything when you're in that situation, you sound, its

232
233

like you've actually been in a situation of, you know, seeing an opportunity for
(elct
Li.
L
r.
--c.
.a-o L.: ;.,
talking to others and focussing about it, or other people have, and I was wondering

234

what kind of feelings that invoked, you know?

235

To me?

236

Yes and so what sort of things you'd have liked to have said
.

vc
;tos

eW

237

Erin I suppose I'd have liked to have said that in a way we are all, working in a=

238

field of k

239
240
F

very
._

ag. disability. because wi

all trying to, b)ring a sort of

r. `
ti
,j"r
,

understanding to somebody, else'sexperience soits not that different and yes it's
Are

a different degree but actually its what were all doing, so it's, one of the

241.

criticisms was that with all this theory we're talking about its for your benefit,

242

not the client, because they can't really understand it, but I guess that would be

243

the case for all theory in a way - its for the therapists' benefit in that it helps
U,
know; its

,'sue

244

them

245

recognising how defended against it are people, again thinking back to

All
had, and the therapists maybe
and how the battle that

,,..

247

more than most people, though they shouldn't be, are defended against the

N.

248

reality of the messiness of it all, you know, - want to get into the sort of the

249

flow of language, its

or defend against some of the material.

-understand

I don't

ash

p//

246

.. _ _i

hard to stay with mopping up the mess.

Fei1c{
,(
VS

Cv. Sru.

rcttilt'

lf

hneSS,

IhJb

}tl

a-

146

Representation Check

225

and so he was talking about working with learning disability which is that's the

226

first time that's actually come into the main stream of the guild and people did
f`

''27
228
9
o

ov

Olt,

it very hard, they

(21.8) were terribly moved by it but some people were angry and said how could
and so I think sometimes people get very

you call this psychotherapy

230

defensive.

231

That's interesting,erm is there anything when you're in that situation, you sound,its

V
232
233

k/,
,

like you've actually been in a situation of you know, seeingan opportunity for
,
talking to others and focussing about it, or other people have, and I was wondering
what kind of feelings that invoked, you know?

To me?

V,

"'

236

Yes and so what sort of things you'd have liked to have said

"

237

Erin I supposeI'd have liked to have said that in a way we are all working in aip

dJC

2-"

field of learning disability becausewere all trying to bring a sort of

-W,
239
Crr
JOL kV.
. c-

'242

2ct
.

vi`ptlerent degree but actually its what were all doing, so it's, one of the
criticisms was that with all this theory we're talking

not the client becausethey can't really understand it, but I guessthat would be

244

them by understand or defend against some of the material. I don't know, its

247

about its for your benefit,

the casefor all theory in a way - its for the therapists' benefit in that it helps

-0246

'o(ti'"3
f\VZ
lwjll

understanding to somebody else's experience so its not that different and yes it's

243

245

1-10

recognising how defended against it are people, again thinking back to

and bow the battle that
more than most people, though they shouldn't

had, and the therapists maybe

be, are defended against the

248

reality of the messinessof it all,you know, - want to get into the sort of the high

249

flow of language, its very hard to stay with mopping up the mess.

UWk

lc
Vzz
j

fy

-,
ESL,,;

CK cp

147
Macro Level Analysis

Individual master themesand models: At this stage,themesfrom the interviews were

organisedinto initial masterand subordinatethemes. An exampleof this level of analysisis
given below, drawn from Graham's transcript:

Figure9. Early model of Themes from Graham's transcript:

and Similarities, & Role of Therapist.

Involvement, Differences

Involvement

Exposure to people with learning disabilities

(G. pl, 10; G. p2,30, G. p2,41)
11
Curiosity
(G. pl, 19; G. p2,57; G. p.3,68)

Combining experiencewith therapeutic interest

(G.p2,25, G.p2,50)

Medium of communication
Cognitive limitations
(G. p14,313, G. p16,340)
(G. p16,346)

Similar processes
(G.p15,322)

Adaptations to therapy:
*Use of transference (G. p5.104, G. p8,177; )
" Language (G. p5,101, G. p15,323))
* Structure (G.p15,328)
4,
/
1

Role of Therapist

I/
Educational
(G.p14,309)

1
Neutrality vs. Politically aware
(G.p13,279; G.p16,359, G.p17,367)

11

148

Figure 10. Early model of themes from Graham's transcript (contd): Issues Specific to
People with Learning Disabilities, and Context for Therapists.

Issues Specific to People with Learning Disabilities

Social identity
(G. p6,125; G.p16,346;
G. p8,162)

Sexual ambiguity
(G. p 13,287)

Historical oppression
(G.p16,351, G.p363)

xx/
Psycho ogical impact
(G. p6,122; G. p6,133)

Context for Therapist

Need to balancelearning disability work

with clients without disabilities: credibility.
(G.p5,91; G.p5,94, G.p5,107)

Staff attitudes
(G.p9,196)

Impact on therapist

Counter transferences:
* Guilt (G. plO, 208; G. pl1,239)
* Identification (G. p10,212; G. pl1,247
G. p 12,272; G.p 14,297))

Need for supervision/therapy

(G. p12,253)

149

Participant

Validation

Participant checks: Thesewere included in order to addressconcernsregarding

in
it
i.
that
the
to
that
the
participant's
reality
reflected
e.
ensure
was
was
representation,
research. The following is the written feedbackemailedto Belinda, for her comments
following individual analysisof her transcript.

EVOLUTION AS A THERAPIST You described early issues that shaped your career, including your wish to
work with others who were disadvantaged.
I wanted,want to work with peoplewho, who are in need,who are erm disadvantaged
peopleso I think that's someof those stringspulling away at me.
You had early positive contact with people with learning disabilities and
described being intrigued by the differentness of their world. You described
an impactful early therapeutic contact and a curiosity about peoples' inner
lives.
I wasjust absolutelyintrigued by this other world, it was like erm, it was like a kind of
anotherworld, it was, it was like a almost like a old Victorian factory type of world and, and
it was almost, I felt as if I had enteredinto a Dickens erm book erm where this Dickensian
type charactersthat you don't really seeout in the streeterm and that really thinking back I
meanwere really segregatedI meanyou hardly saw peoplewith learning disability out and
about, erm and it was interesting.
One of the things that has stayedwith me throughout theseyearshasbeenthe work that I did
do
it
had
like
felt
it
it
know
John
I
to
that
something
with
erm
erm was, was you
with
attachment,had somethingto do with bonding, erm it had somethingto do with erm you
know sticking with somebodyand engagingwith them and them knowing that and feeling
that and respondingto that.
You explained how you became aware of the limits of "normalisation" as a
model, and found yourself in a sympathetic environment which, almost
accidentally fostered your interest in therapy.
If you could teachpeople and teachpeopleto live independentlyand recreatetheir lives so
it
in,
into
beautiful
flats
then
them
that,
new,
everything
would put right
with
you move
it
idea
kind
happened
And
I,
that's
to
them.
simple
er
quite
a
and
and
all
everything
was
we
of fresh and we all thought it was great idea at the time, (laughter).

150

I turnedup at the door and shesaid I thought you were trainee psychologist, and I said no
I'm a therapistand shesaid well it so happens,it was complete coincidencethat er one of her
psychologistwho had beendoing sometherapy had left, and shereally did want somebody
to pick up the work.
You identified your willingness

to take on a challenge.

I thought crikey can I do this, and I erm I, up for a challengeme so you know I took it on.
COMMON GROUND You noted similarities in therapy with clients with learning disabilities to other
clients, with whom you had worked.
I guessfor any therapist its like really about realizing its not hopelessand helplessand erm
like with all counselling and therapy and psychotherapyits about finding your points of
engagementerm which is necessary.
PARTICULAR ISSUES You identified a number of issues which were particularly represented in the
clients you described. These included, experiences of abandonment, abuse,
envy, lost histories and frustrated sexuality.
He was putting into me that uncomfortablesexuality that uncomfortablesexualfeeling.
You noted that a major theme was the disability itself - and gave a powerful
account of a client's ability to recognise how he was viewed as "monstrous"
and "other".
This terrified him so much that his flat mate was calling him Frankenstein so it was why is
he calling me but I could see for JT it was more than name calling it was something that he
it
it
like
it
living,
like
him,
that
was
was more a reality.
was something
was
pulled at

INEED TO ADAPT THERAPY You identified particular ways in which you adapted techniques and mediums
to meet the needs and limitations of your clients, including working in tandem
with other staff outside the therapeutic environment.
It did help for me in this situation to bring with me the books without words.
What I found was effective is I'd put my hand over my mouth for quite a long period of time
I wantedto do somethingquite symbolic to show him how it felt being with him when he
...
let
me through. A piece of work with the community was quite helpful here,they
wouldn't
went with him to visit his grandmawhere shewas buried, and he found that a valuable
experience.

151

PRESENTATION You described some of the ways in which your clients presented, which
included the "handicapped smile", going to sleep, concealing information,
breaking boundaries of therapy and dominating sessions.
I've got many experiencesof peoplewith Down Syndromethe smile.
He was very strong powerful in the sessionsin that he would monopolize.
USING THE BODY AS A MEDIUM You described the self injurious behaviour of clients who damaged
themselves as a way of communicating, and intended or feared that they were
intrinsically damaging to those they were around.
He picked at his cut on his finger, he picks his plaster away and gauging and gaugingaway
at his cut, and it was absolutelyunbearableto watch him do this erm and erm this when I told
him how I felt he smiled and it was very painful as I felt that he was so disassociatingreally
from the pain erm and he was watching my responseand smiling at my response.
THE IMPACT ON THE THERAPIST You described the sense that the work was often difficult, particularly the pain
of addressing the disability itself. You had experience of being verbally and
emotionally abused and identified the physical impact of some sessions.
The thoughts camethrough my mind are that your sayingI'm damagedand and that you
do
anything about it can you erm and I'm going to hurt myself and continueto hurt you
can't
erm you know and that was very painful.
I did actually leave the sessionswith a terrible headacheand that has mademe really wonder
aboutthe power, the intensity of these,of our relationship you know where your containing
erm the fearsyou know real fearspeoplesnegativity and how they are affecting other people
erm and how powerful that is really so you can actually get physical ailments.
You also had to deal with maternal counter transferences,
that were frightening.
I felt quite frightened sometimes.

and experiences

152

EFFECTIVENESS Despite this, there was a sense of achievement in seeing improvement in

clients, where you were able to provide a secure base, acceptance and rectify
damaging experiences by your input.
It was like we had worked through somethingand worked through what shewantedto tell
me and once shehad told me that, that was enough.
THERAPISTS' ROLE You described how there was conflict between the philosophical
position, and the work of the therapist.

"rights"

Therapyis more concernedabout finding out what's it like to be a personwith learning

disability and the exploration is about what its like for peopleand erm that might be at odds
with humanrights.
You gave examples where the care environment was actually damaging to the
person.
Therewas somethingI felt quite perverseabout the whole thing that really worried me, erm
becauseon the surfaceof it, it was like an activity that you can do but on anotherlevel it was
like really rubbing her in, rubbing the wound in.
You try to resolve this by working as a team to address issues outside the
therapy space, whilst maintaining the therapeutic relationship.
There's two of us and we decidewith eachcasewhetherwe can do the network meetingand
be quite strongvoice for the other personso we are not going to compromisethe relationship
or whetherwe can do it ourselves.
POLITICAL -SOCIAL IMPLICATIONS You saw the role of the therapist as sometimes controversial because of the
need to go against the community or services' agenda sometimes, and on a
wider scale felt that therapy acted against the societal death wish for people
with learning disabilities.
As a therapistits just being awarethat there's anotheragendathat there's an outsideagenda
aswell as the clients internal agenda its very strong.
We are actually opposed to erm something that is societies death wish and this idea generally
that people that aren't perfect don't have a place in the world and we are working with
people showing the world that actually people do have place in the world and enabling them
to become erm more to find that space so its that structure as well in the therapy.

153

The openings to providing therapeutic opportunities, and a proper service for

people was currently a little limited, but you were optimistic that things
appeared to be improving.
Looking around there aren't any other therapy jobs in PLD and so it's a growing thing, I
hope somewhere its going to flourish somewhere apart from here,

However, this client group was still avoided by others in therapeutic training.
I was quite surprisedat the number of studentsof counselling erm that weren't wanting to
just
kind
know
how
I
I
this
the
to
of
got
client
group
and
responses
with
wouldn't
work
how
do
do
it,
how
do
do
it
Alex
I
I
mean
mean
you
and that sort of thing, and so
you
work,
the senseof hopelessnessand helplessness.
Environments were not always supportive of psychotherapeutic ways of
working and there was a sense of conflict between the agendas of the staff
and the clients, and a lack of understanding of what counselling was.
There's hardly any self referrals its all via care managers,or erm nursesor homesor that sort
of thing erm and its quite interestingbecausea lot of what we pick up is an agenda.
It feels like a strongbattle erm particularly where this were there is also quite strong
behaviouralerm move and er in a secureunit where I havegot someof my clients erm there
is, the behaviour,the behaviouralside of the psychiatric, medical side is very strong.
I find that erm even health staff, like community nurseserm er occupationaltherapist and
speechtherapisthere you know, I though that they might know a bit about counsellingbut
often peoplereally don't.
"REAL" ISSUES
You noted that, like the broader political issues, there was also an external
reality to some of the issues that might be seen as psychological.
In therapy I pick up what its like being the client like sometimesthey can havebit of a
moaning sessionabout their workers and that's an interestingthing becauseI, I'm never sure
whether its, whether its er the clients, what's going off in the clients in relation to their
workers and erm there are times when I really do wonder whether, I mean,have evidence
that the workers aren't really working kind of aswell asthey could be.

154
Participant

Response

Managing subjectivity: Participant checks are used to control subjectivity and ensure
following
is
Belinda's
The
reply to the analysis.
appropriate representation.

Page 1c

Message

Subj:
Date:

RE: feedback
20/10/2006 10:57: 20 GMT Standard Time

Dear Julie,

Thank you so much for this. I am very impressed by how you worked through my transcript and happy that
my experience has been of value.

have been very busy this week with some difficult situations in relation to my clients network. I have an
example of the kind of situation I find my self in which I feel is encapsulated under the heading "you gave
examples where the care environment was damaging the person". (Although I would not be able to put it
like this myself to the carers, essentially this is what is happening).
A client of mine has become distressed over the fact that she has just found out that a member of staff
within her home has become pregnant. She became immediately distressed and very sad because she has
chosen not to have a baby because of the risks, (havinghad genetic counselling). The staff have said that
everyone should be happy for the staff member and so my client avoids being at home as she feels very
sad. While in a network meeting I explain the point that in order for my client to cope with her feelings, it is
important for her to be able to mourn and feel sad at home, be supported in this. The point is barely heard
and so I have to repeat this and explain the dynamics. There is then concern that the client has missed her
contraceptive injection and so nursing say that they will have to deal with this, advise her to have it
a. s. a. p. My concern at this point is the fact that insistence on the contraceptive injection is like "rubbing the
clients nose" in the fact that she wants a baby but knows that it would be risky, and perhaps her
contraception can wait until she has come to terms with her terrible distress, triggered by hearing the
news about her carer.

The need to gain control by the service was far more prevalent than thinking empathically about her
situation.
Maybe there's also something about the therapist as advocate here also.
Hope all is well and look forward to hearing from you.

155

Identification of Super Ordinate Themes

Visual

tetiual

The following is an example of the cut and paste system used to

display:

identify areascommon across participants

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The resultant super ordinate themes not displayed in the report are shown in Figures 10. and 11.

156

Figure 11. Super ordinate theme 1. with subordinate themes with textual references.

Super-ordinate Theme 1:
Similarities & Differences

Subordinate Themes

Master
Themes

" Continuum Model

" Universality of Principle
" Emotional Intelligence

Common
Ground

Specific Issues

Therapeutic
Adaptations

Primary
Secondary &
Tertiary
Handicaps

"

"
"
"
"
"
"
"

Disability itself
Anger
Shame
Social Factors
Abuse
Loss and Abandonment
Sexuality

"
"
"
"

Use of counter trans.

Medium
Communication
Pacing
Primary versus
Secondary handicap
Vulnerability to systemic
abuse
Therapists role

Sample
Evidence

L. p4,68; J.p17,369;
D. p 11,231; P.p 16,354,
C. p23,517; D. p5,91;
B. p42,957, L. pl 1,238
E. p5,107; P.p17,378
A. p 15,317; L. p5,106
C. p 16,353; C.p20,451;
B. p26,587. C.p23,519;
D. p7,137; A. p9,197;
G. p13,293; S.p12,253;
P.p9,186; J.p19,427;
E.p2,40; P.p17,374;
B. pl 1,229; D. p16,353,
D. p16,353, B. p17,373.
Bp25,569; D. p16,345,
D. p 15,321; C.p 14,298;
C. p22,487; D. p 15,322;
L. p6,120, K. p 11,228;
P.p11,247, G. p5,104;
S.p 10,218. J.p8,167;
B. p33,755; C.p2 45;
E. p32,721; D. p9,190;
A. p 14,305; G. p9,187;
C. p24.537; P.p9,218.
G. p15,328; S.p14,296;
K. p 13,274; C. p 17,382;
B. p21,482; A. p6,113;
E. p 17,375; D.p 17,368;
P.p10,217, J.p10 216;
L. p12,271; S.p12,268,
C. p22,504; P.p2,36;
G. p9,195, D. p17,380;

157
Figure 12. Super ordinate theme 2. with subordinate themes with textual references.

Super-ordinate Theme 2: Working with Spoiled Identities

Subordinate Themes

Master
Themes

Evolution
Therapist

as

" Early contact

" Supportive Environment
" Intellectual Curiosity
" Mentor
" Challenge
" Unplanned career

Courtesy

Stigma

Sample
Evidence

D. p6,128; G. p2,30;
S.pl, 6, K. p1,6;
L. p1,12; C. p4,79;
J.p6 129; B. p 1 5;
,
,
A. p3,56; E.p3,67;
P.p4,101; G. p4,78;
E.p5,95; J.p2,35;

" Exclusion from Training

" Negativity from

S.p1,15; C. p11,244;
B. p41,932; L. plO, 223:

colleagues

P.p 16,360; J.p 10,206;

E. p16,353; G. p5,96;
C. 22,493; E. 10,227.

" Self-Consciousness

A. p3,60; K. p 12,263;

158
Pen Portrait
Maintaining focus on the individual : The drawing of pen portraits of participants assists

the researcherand readersto be awareof the context of the data produced. Whilst
"thumbnail sketches"of participantswere kept by the researcher,there were concernsthat
the small number of membersof the IPD might meanthat anonymity could not be
identified
histories,
for
participants
with
easily
or prominent roles. Thereforethe
guaranteed
included
in
have
been
the appendices,but an anonymisedexampleof one of the
not
portraits
is
below:
given
participants

[X] is an [ X] year old woman who currently lives and works in [City]. She is white and
from
degree
in
[
].
She
Region
took
a
social sciences prior to starting work
comes originally
in a Social Services Training Centre, where her role was one of teaching occupational skills.
She progressed through management roles, but pursued psychotherapy training after
She
time
therapists
completed a counselling qualification
observing
other
at
work.
spending
and worked initially with [client group]. She later combined this with her learning disability
learning
to
the
offered
opportunity
see
clients
experience after she was unexpectedly
with
disabilities following her training. She now works as a full time counsellor in a learning
disability service in [District] and has held this role for X years.

159

Appendix G

160

THE UNIVERSITY OF SHEFFIELD

Clinical Psychology Unit

Department of Psychology

Doctor of Clinical Psychology (DClin Psy) Programmes (Pre-registration and post

qualification)
Clinical supervision training and NHS research training and consultancy
Clinical Psychology Unit
Department of Psychology
University of Sheffield
Western Bank
Sheffield S90 2TP UK

Telephone: 0114 2226649

Fax:
0114 2226610
Email:
c. a.c illesoietshefelci.

ac. uk

01.6.6

Dear Simon,
Thank you so much for your help with my research. Our meeting was very
useful.
We said that I would write up what you said, so you could make sure J had got it
right, So, the main points I think you made were:

1. What do you think about what I am doing?

It is worth doing, because people with learning disabilities often do not get the
same choices as everybody else. Sometimes people don't get a choice
because people say a therapy won't work because of learning disabilities, but
this might not be true all the time.
2. What do you think about how I am doing it?

Although it is an OK first step to talk to therapists, in the future, studies should

be done asking people with learning disabilities about what it feels like for them.
The report needs to explain why they were not asked first
It might also be good to talk to therapists who do not work with people with
learning disabilities, to ask why.
The therapists need to sign a consent form to show they agreed to take part.
People reading the report need to know what questions were asked.
It would be interesting to know whether the therapists chose to work with
people with learning disabilities, or if they felt they had to.

161

3. Should I do anything differently?

No problems with the way it is being done.
The questions seemed reasonable.
4. Does it treat people with learning disabilities

properly?

It is important to use respect when talking about people with learning

disabilities. There are words that should not be used in the report words
that are insulting (you read out a list forme to note).
/ thought about this some more after we talked. I realised that / will have to
put in what people wrote a while ago. This means that they may use words
that now feel insulting. / do have to put down exactly what people said, but
can point out that this is not what we would say now.
Also, in finding out why therapists might find it hard to work with people with
learning disabilities, / am going to have to talk about things that might be
painful to think about. I hope you agree that trying to show an honest picture
of what happens is a way of being respectful to people with learning
disabilities.

5. How should I involve people with learning disabilities?

Results should be fed back to the Self Advocacy Group, the Quality Forum,
along with the people who took part. The Advocacy service might like to know
too. I will also go over the report with you, to get your comments and make
any changes we think we should.
6.

Have you got any other comments about it?

People who have severe learning disabilities might be left out. It might be that
there are some people who can't use talking therapy. You could have people
in to support them, but the carers might answer the questions.
It would be interesting to do another study looking at service user views and
people who choose not to work with people with learning disabilities. Maybe
a three way talk between all the groups would be interesting.
It would be good to get a mix of men and women in the study, but this might
not be possible because lots of psychologists are women - but that would be
another study question itself as to why!

162

I hope that / have got right what we talked about. You also gave me some
helpful information from your educational talk about people with learning
disabilities.
/ aim to take notice of what you said as I do the study, especially when I write
it up. You thought it helpful for me to include the number of people with
learning disabilities in the report, and I will try to do this. I know you were
keen to include the numbers of people locally, but to keep from letting on
where I am based; I didn't think I would be able to do that.
However, you gave me some very valuable suggestions for web sites and
government papers to look at. I will be using those suggestions in my
research around the study.
So, once again, thank you very much for your time and help. It has been
really useful. If you think I have got things right in this letter, could you sign
the bottom and send it back to me? I have put an envelope in with the letter.
If I have missed important points, or got something wrong, could you ring me
to let me know? We can always change it until I get it right.

Many thanks,

Julie Pehl

r
JGt-E

163

THE UNIVERSITY OF SHEFFIELD

Clinical Psychology Unit
Department of Psychology

Doctor of Clinical Psychology (DCiin Psy) Programmes (Pre-registration and post-qualification)

Clinical supervision training and NHS research training and consultancy
Telephone: 0114 2226649
Faut
0114 2226610
Email:
c. a.gillespie9Dsheffield. ac. uk

Clinical Psychology Unit

Department of Psychology
University of Sheffield
Western Bank
Sheffield S10 2TP UK

24.10.6

Dear Simon,
Thank you again for your comments at our meeting last week. We said that I
would write up what we talked about Here are the main points of what
people said:
People had talked about how people'with
same as everyone else in lots of ways.

learning disabilities

were the

"

They had the same problems.

"

They could feel things just as deeply, and be very smart about knowing
how they felt.

"

AH therapy is about talking to people trying to understand their

problems - that's the same for anybody.

Some things were different. People with learning disabilities

problems that came up a lot;

"

They felt bad about having a learning disability.

"

They had often been treated badly because of it.

"

They were angry and ashamed.

"

They had to rely on other people.

had some

164

People showed how they felt in different ways.

it.
They
how
felt
talked
than
they
about
showed
rather
9
"

They sometimes used their bodies to show things.

"

They sometimes broke the rules - (you said how someone might walk
around instead of sitting down).

Therapists had to change how they did things.

"

They might go slower.

"

They used easier words.

"

They might not talk. They might draw or use things instead.

"

They might not use a special room.

"

They used how they felt to try and understand - (like you said about
picking up someone else's mood).

THERAPISTS TALKED ABOUT WHAT IT WAS LIKE WORKING WITH

PEOPLE WHO GOT LOOKED DOWN ON:
They said how they got to do their jobs.
"

They had all known people with learning disabilities before.

"

They were interested in understanding.

"

They worked in places that thought it was a good idea to talk to people.

"

They found out about the work form a book or a person.

"

They were not scared of trying something that might be hard.

"

They thought it was worth it.

165
They said how it made them feel.

"

They said it was hard when people showed things differently or did not
follow the rules.

"

They sometimes felt angry, or sleepy or stupid.

"

They sometimes felt like they wanted the person with a learning
disability to go away.

"

They sometimes felt disgust with what people did.

We talked about these, because you had been worried before about people
being treated properly, and not being called names. I explained that I felt that
people were being honest as part of understanding the person they were with.
We talked about how other people feel the same things, but do not try to
understand them - they just treat people badly. You said how you had seen
that yourself.
They said how they got treated like their clients.

"

People treated their clients badly.

"

People were not interested in their work.

They could not get training very easily.

They had to choose how to work with people.

"

It was hard to know what things they could help with and what they
could not.

"

They had to take care not to treat people badly making sure the
person wanted to see them.

"

They had to decide whether to help people speak out.

We talked about how I could tell other people about this, and we agreed to
make sure I told the people we agreed on before. You reminded me that it
was important that the people who talked to me got the results.

166

We talked about the need to ask people with learning disabilities what they
thought and I agreed to put that in the report.
You made a very interesting point about whether people with learning
disabilities could become counsellors, if they had support. I thought that
some courses might be too hard because of the reading and writing. But
others might be possible with help.
I also thought that people with learning disabilities could be helpful to each
other even without training, because they could feel as well as other people.
I hope that I have put everything down that we talked about. If I have
forgotten anything or got it wrong, please let me know. If I find anything else
important, I will let you know.
Thank you again for all your help.

Best wishes,

Julie Pehl.