CBT For LD

A Manual of Cognitive Behaviour Therapy for People with
Learning Disabilities and Common Mental Disorders
Therapist Version
Authors
Angela Hassiotis
Marc Serfaty
Kiran Azam
Sue Martin
Andre Strydom
Michael King
2
A Manual of Cognitive Behaviour Therapy for People with Mild Learning Disabilities and
Common Mental Disorders
A training guide to help professional therapists in treating people with communication and
cognitive problems in CBT
© Camden & Islington NHS Foundation Trust and University College London, 2012
http://www.candi.nhs.uk/
The authors have asserted their rights in accordance with the Copyright, Designs and Patents
Act 1988, to be identified as the authors of this work. All rights reserved. With the exception of
the permission given below, no part of this publication may be reproduced, stored in a retrieval
system, or transmitted in any form or by any means, electronic, mechanical, photocopying,
recording or otherwise, without the prior permission in writing of the publisher and the copyright
owners.
Photocopying/printing permission
The discourse materials in part 3 including information sheets, resources and worksheets may
not be printed or copied without fee or prior permission by the purchaser subject to both of the
following conditions: that the item is reproduced in its entirety, including the copyright
acknowledgement; that the copies are used solely by the person or organisation who purchased
the original publication.
A catalogue record for this book is available from the British Library.
Cover designed by Bastien Cordier
This manual uses pictures from the Photosymbols collection (www.photosymbols.com)
Manual of Cognitive Behaviour Therapy for People with Mild Learning Disabilities and Common Mental Disorders ©
Camden & Islington NHS Foundation Trust and University College London, 2012
3
Table of Contents
Page
iii About the authors
iv Acknowledgments
Part I: An Overview of Cognitive Behaviour Therapy for Treating People with Learning
Disabilities
1 Chapter 1: An Introduction to the Use of CBT in People with Learning Disabilities
15 Chapter 2: Communicating with People Who Have Learning Disabilities in the

Therapeutic Setting
Part II: Protocol for Treating Depression and Anxiety in People with Learning Disabilities
23 Chapter 3: The Early Sessions (Sessions 1–4)
35 Chapter 4: Psychoeducation
44 Chapter 5: The Middle Sessions (Sessions 5–14)
51 Chapter 6: Linking Thoughts, Feelings, and Behaviours
59 Chapter 7: Specific Cognitive Techniques
68 Chapter 8: Specific Behavioural Techniques
78 Chapter 9: Additional Skills
81 Chapter 10: The Final Sessions (15–18)
83 References
Part III: Accessible CBT material
4
About the authors
Dr. Angela Hassiotis, clinical academic in the psychiatry of learning disabilities at Camden &
Islington NHS Foundation Trust and Division of Psychiatry, University College London. She has
carried out epidemiological and applied research studies on older people and adolescents with
learning disabilities, interventions for challenging behaviour, mental health services and stigma.
Dr Marc Serfaty, clinical academic and consultant CBT psychotherapist. He is chief investigator
in CBT trials in older people and adults with terminal cancer.
Miss Kiran Azam, Research Assistant, Camden Learning Disaiblities Service, Camden &
Islington FT. BSc in Human Psychology and MSc in Psychoanalytic Developmental Psychology.
Miss Sue Martin, Speech & Language Therapist, Islington Learning Disabilities Partnership,
Islington Social Services. Miss Martin is providing assistance with the development of accessible
materials and has supervised the communication methods of the CBT manual.
Dr Andre Strydom, clinical academic in the psychiatry of learning disabilities at Camden &
Islington NHS Foundation Trust and Division of Psychiatry, University College London. He has
expertise in epidemiological studies and investigation into older people with learning disability,
genetic disorders and Down symndrome.
Professor Michael King, clinical academic with extensive experience in national and
international epidemiological and intervention studies in primary and secondary mental health
care.
5
Acknowledgments
This manual is a product of independent research funded by the National Institute for Health
Research (NIHR) under its Research for Patient Benefit (RfPB) Programme (Grant Reference
Number PB-PG-0807-14121). The treatment views expressed are those of the authors and not
necessarily those of the NHS, the NIHR or the Department of Health.
We would like to thank Lorna Vincent, Cognitive Behavioural Psychotherapist, and Charles
Parkes, Clinical Psychologist at the Camden Learning Disabilities Service, for their contribution to
the manual, as well as Richard Lohan, who helped develop the accessible material.
We would also like to take this opportunity to acknowledge Camden Learning Disabilities Service
and Islington Learning Disabilities Partnership for facilitating the study.
Furthermore, we would like to thank Spencer Smith who worked as our developmental editor and
did the major revisions on the book.
6
Part I
An Overview of Cognitive Behaviour
Therapy for Treating People with
Learning Disabilities
7
Chapter 1
An Introduction to the Use of CBT in
People with Learning Disabilities
The World Health Organization defines learning disability as “a significant impairment of
intellectual ability” (i.e. IQ less than 70) and “difficulties in social and adaptive functioning” that
are present from childhood (WHO, 1993). Recent studies have shown that this population is
vulnerable to depression and anxiety (Azam et al, 2009) with reported prevalence rates of 6.6
percent and 3.8 per cent for affective and anxiety disorders respectively (Cooper et al, 2007a).
Incidence rates of 7.7 per cent and 1.5 per cent respectively have also been reported (Smiley et
al, 2007b). Unfortunately, learning disability has historically been considered an exclusion
criterion for psychotherapy, leaving those suffering from such disorders few (if any) options for
treatment.
There has of late been a growing interest, both within the psychotherapeutic community and in
the broader social sphere, in developing psychological therapies specifically designed for people
with learning disabilities and providing them with the same services the general population has
access to. For example, Valuing People (2001)—a UK government white paper designed to
improve the lives of people with learning disabilities—states that those with learning disabilities
should have the same access to healthcare as people without disabilities do. Movements like this
in conjunction with the ever-growing body of research that supports the use of cognitive-
behavioural therapy (CBT) as an effective treatment for depression, anxiety, and other
psychological disorders has led a few pioneering therapists to use CBT with clients who have
learning disabilities. We will review the history of the use of CBT in this population momentarily.
As you will see, the use of CBT for the treatment of depression and anxiety in people with
learning disabilities to date has been limited to single case studies and small group settings.
However, with a few modifications in therapeutic approach and communication style these early
attempts have indicated CBT may be a successful intervention for those with learning disabilities
(Lindsay et al, 1993; Lindsay et al, 1997; McCabe et al, 2006; McGillivray et al, 2008). Even so,
there have not yet been any attempts to evaluate CBT on a larger scale for this population using
randomised controlled trials, and no therapeutic protocols have been developed that outline best
practices for tailoring CBT for use with people who have learning disabilities.
This manual is an attempt to bridge that gap. It describes the process of treating depression
and/or anxiety disorders in people with mild to moderate learning disabilities using CBT1. It is
1
While this manual describes the treatment of depression and anxiety disorders, it excludes depression with
psychotic features as well as obsessive-compulsive disorder.
8
designed for therapists who have CBT training, but have little to no experience with clients who
have learning disabilities. For CBT interventions to be successful with people who have these
kinds of disabilities, they need to be made more accessible and modified appropriately to cater to
their cognitive abilities and complex communication needs. This manual provides instructions on
how to do that, and outlines a therapeutic protocol that can be applied in treatment.
In this chapter we will begin with a review of depression, anxiety, the cognitive behavioural
approach to therapy, and the therapeutic relationship. For many of you this will be review;
however, the information presented will be contextualised to the learning disability population so
we encourage you to read it. We will then follow up with a brief review of the use of CBT in
people with learning disabilities, and we will close with an overview of adaptations and specific
considerations that need to be kept in mind to successfully apply the model for these types of
clients. In Chapter 2 we will focus on communication, since it is such a critical component of
treating people with learning disabilities, and explain how you can modify your communication in
the therapeutic setting to more effectively address the needs of these clients. Then, in Part 2, we
will provide a three-part protocol for treating anxiety and depression in people with learning
disabilities and outline specific emotional, behavioural, and cognitive techniques you can use
with this population.
Depression and Anxiety in People with Learning Disabilities

Depression and anxiety are relatively common psychiatric disorders whose definitions and
symptoms are well-defined and well-known by most psychotherapists. However, the features of
these disorders tend to present themselves in relatively specific ways in people with learning
disabilities. Therefore, a brief review of the definitions and symptoms of each and a short
overview of the most prominent features in those with learning disabilities are warranted.
Depression2
The National Institute for Mental Health (NIMH) defines major depressive disorder as “a
combination of symptoms that interfere with a person’s ability to work, sleep, study, eat, and
enjoy once-pleasurable activities” (NIMH website). Symptoms of depression include (extracted
from Andrews & Jenkins, 1999):
 Feeling miserable. This misery lasts at least a week or two, where the feeling is present
most of the day and varies in its intensity.
 Loss of interest or pleasure in daily activities.
 Loss of appetite (and excessive weight loss).
 Loss of energy.
2
Some of the information in the sections that follow has been repeated in Chapter 4, where we discuss
psychoeducation.
9
 Loss of sleep even when exhausted. Sleep is usually restless and the individual wakes
up earlier than usual. (Some people may sleep more than usual.)
 Loss of interest in sex.
 Persistent worrying about things that are not important.
 Slowed and inefficient thinking, with poor concentration.
 Recurring unpleasant thoughts, particularly of guilt (of being a bad person and wishing to
die3).
 Slowed activity and speech.
 Fearfulness (of people and places). This often leads to withdrawal from family, friends,
and everyday activities.
People with learning disabilities are often unable to express their feelings easily in words, and
use behaviour to communicate with others. The emotional experience the person with a learning
disability has is often most obvious in its behavioural correlates. It is, therefore, critical to take
behaviour as well as mood into account in these clients. Sudden changes in behaviour (or mood)
and/or a client’s inability to engage in activities he or she could previously accomplish are
important signs that the client may be depressed.
It is also worth noting that depression is sometimes linked to low self-esteem in people with mild
and moderate learning disabilities. Methods for tracking behavioural changes and assessing self-
esteem will be outlined in Part 2.
Anxiety
According to the National Institute of Mental Health, “Anxiety is a normal reaction to stress. It
helps one deal with a tense situation in the office, study harder for an exam, or keep focused on
an important speech. In general, it helps one cope. But when anxiety becomes an excessive,
irrational dread of everyday situations, it has become a disabling disorder”
(http://www.nimh.nih.gov). Symptoms of anxiety disorder include (extracted from Andrews &
Jenkins, 1999):
 Nervousness or restlessness
 Trembling
 Trouble falling or staying asleep
 Sweating
 Poor concentration
 Palpitations
 Frequent urination
3
The issue of suicide and suicidal ideation as well as methods for addressing this in people with learning
disabilities will be addressed in Part 2.
10
 Muscular tension
 Easily fatigued
 Irritable mood
 Light-headedness or dizziness
 Hyperventilation
 Shortness of breath
 Depressed mood
Behavioural correlates of anxiety disorder include hyperventilation, aggression, increased

irritability, avoidance behaviour, self-injury, and unnecessary motor activity. These are
particularly prominent in people with learning disabilities. Symptoms such as excessive worrying,
avoidance of potentially feared stimuli, and common physiological signs such as feeling of
choking and palpitations may not be reliably diagnosed or even reported in people with learning
disabilities.
Irritability is a particularly common behavioural correlate to both anxiety and depression in these
clients and challenging behaviour is a key atypical feature of either condition. Relaxation
techniques for reducing arousal and coping skills for reframing cognitions to provoking situations
are useful interventions in these cases, and we will discuss how to integrate them into treatment
later in the book.
For now, let us turn our attention to the aetiology of these conditions and review the similarities
and differences in the development of depression and anxiety between those with learning
disabilities and the normal population.
Biopsychosocial Influences on the Development and Alteration of Depression and Anxiety

in People with Learning Disabilities
The presentation of depression and anxiety can be triggered (and therefore altered) by the
biological, psychological, and social make-up and circumstances of each individual according to
the type and severity of his or her learning disability. Any factors that influence the client’s
presentation of depression and/or anxiety must be considered in treatment. A comprehensive
review of all the potential factors that contribute to the development and presentation of these
illnesses would be impossible. However, it is worth examining each of the three major spheres of
influence—biological, psychological, and social—and the specific ways they may contribute to
the development of depression and/or anxiety in people with learning disabilities.
11
Biological Factors
We know that genetic predisposition and other biological factors play a role in the development of
depression and anxiety disorders in the normal population. These factors likely play a role in the
causation of common mental disorders, i.e. depression and anxiety, in those with learning
disabilities as well. Certain genetic conditions or pervasive developmental disorders are
associated with common affective disorders (Kim et al, 2000; Myers et al, 1991). One notable
biological factor that likely increases the risk of depression in this population is physical disability.
It is well-recognised that physical illness and physical disorders are predisposing factors to the
development of depression in the normal population. It stands to reason this is an important
causative element in the development of depression in people with learning disabilities as well,
especially since physical disability is so common in this population (Prasher, 1999).
Psychological Factors
It is a core tenet of this book that the development of depression and anxiety in people with
learning disabilities is likely mediated, at least in part, by psychological influences. This protocol
was developed to help you recognise these factors and treat them appropriately. A growing body
of evidence supports this approach.
While there are many psychological models that offer explanations as to how depression (and
anxiety) develops, three are particularly relevant to our discussion here:
 The cognitive-behavioural model (Beck et al, 1979)
 The self-control model (Rehm 1977, 1981)
 The learned helplessness model (Peterson & Seligman, 1981)
12
The Cognitive-Behavioural Model of Depression

The traditional model of cognitive-behavioural therapy (on which this protocol is primarily based)
proposes that an activating event (A), in association with an individual’s beliefs/thoughts (B), can
elicit certain emotional and/or behavioural consequences (C). While there are a number of
potential points where a therapist can intervene in this sequence (including cognitive, emotional,
and behavioural techniques), what is ultimately at stake is challenging and/or altering the
underlying belief(s) that create the tether between activating event and emotional or behavioural
consequences.
Beck’s (Beck et al, 1979) model suggests that these core beliefs, or schemas, are the root of
depression (and anxiety) and that they often perpetuate pain-inducing and self-defeating
attitudes and behaviours despite evidence that the beliefs themselves are false. The process by
which this happens can be described as follows.
Core beliefs developed in early childhood are typically deep-rooted and rigid. New experiences
are filtered through these beliefs and only information that supports them is retained, thus the
schema is reinforced. The type of schema employed by any given individual governs the way
they interpret their experience. When the core belief is irrational, it leads to one of a number of
thinking style errors. These errors in thinking are usually primitive, limiting, and, in the case of
depression, negative. As a result, the individual’s view of the world is distorted, low mood, and
the associated negative thinking and feeling are further perpetuated; this in turn influences
behaviour negatively; and the sufferer may eventually become caught in a downward spiral of
automatic negative thoughts they are no longer capable of challenging. These automatic
negative thoughts occur in one of three domains—the self, the world, and the future. This is
known as the cognitive triad.
A negative view of the self causes the individual to understand him- or herself as inherently
inadequate, unintelligent, or incapable. He or she thinks that unpleasant experiences or events
occur as a result of personal inadequacies. This leads to self-criticism and feelings of
worthlessness, and often the individual starts to believe that he or she will never be happy or
satisfied because of his or her lack of some specific set of attributes. A negative view of the world
leads an individual to believe the world itself presents obstacles that are too difficult to overcome
and makes impossible demands that he or she is unable to fulfil. As a result, even benign
experiences may be interpreted as adverse or threatening. A negative view of the future results
in the individual believing that any current difficulties being experienced will continue forever or
that the future only holds hardship and frustration. One typical outcome is the belief that any task
undertaken will be met with failure (Beck et al, 1979).
13
Below you will find an illustration of the cognitive-behavioural model of emotional disorders and
how this chain of events typically occurs (Figure 1).
Core beliefs developed

during early childhood
experiences
Events that may trigger

or activate core beliefs
Activation of cognitive
assumptions (thinking
style errors)
Activation of automatic
negative thoughts
Anxiety and/or
depressive behaviors’
and emotional states
Figure 1: Cognitive-behavioural Model of Anxiety and Depression (based on Beck et al, 1979)
Though Beck’s model was originally developed to explain how depression and other emotional
disturbances occur in the normal population, it seems to apply to people with learning disabilities
as well. For example, we know that people with learning disabilities who are diagnosed with
depression hold more negative views of the self than members of this population who do not
have depression. Interestingly, there are no significant group differences in negative views of the
world and the future. However, this may be because people with learning disabilities usually do
14
not have a positive view of the world or the future regardless of psychiatric diagnosis (Esbensen
& Benson, 2007)4.
While the cognitive-behavioural model forms the core theoretical foundation for the treatment
protocol found in this book, there are two other conventional models of depression we find useful
in understanding depression and anxiety in people with learning disabilities. Both have cognitive
and behavioural components, and both fit with Beck’s model as well as our own approach to
treatment. We would like to briefly review each of these before moving on to the social factors
that may influence the development of emotional disorders in people with learning disabilities.
The Self-Control Model of Depression

The self-control model of depression (Rehm 1977, 1981) explains depression as a cognitive-
behavioural deficit in self-control. The control an individual has over his or her behaviour is
divided into three processes:
 Self-monitoring—The individual selectively attends to negative aspects of experience or

events instead of the positive and assesses immediate outcomes rather than long-term
results.
 Self-evaluation—The individual constantly evaluates him- or herself using harsh and

very strict standards. Furthermore, the individual will attribute positive outcomes to
external factors and negative outcomes to internal factors.
 Self-reinforcement—The individual provides him- or herself with insufficient positive

reinforcement and excessive punishment.
Each of these processes describes common psychological patterns in people who have learning
disabilities who also suffer from depression and adds another dimension to our understanding of
the aetiology of the disease in this population.
The Learned Helplessness Model of Depression

Psychological factors such as learned helplessness may also contribute to depression illnesses
in people with learning disabilities (Prasher, 1999). Like the self-control model of depression, the
learned helplessness model of depression (Peterson & Seligman, 1981) sees control as a central
feature in the development of the disorder. However, in this model the emphasis is on the
individual’s perceived ability to influence (or control) his or her reality, the expectations that
develop out of these perceptions, and the attributions the individual makes regarding why
particular events are or are perceived to be uncontrollable.
4
It is worth noting that it still behooves the therapist to address and treat negative views of the world and the
future in this population to achieve results.
15
When an individual develops the belief that he or she does not have control over a given
situation, the person may extrapolate this experience to other situations in his or her life. Thus
the individual learns that he or she is helpless. The degree to which this sense of helplessness
infiltrates the person’s life is contingent on what he or she attributes the experienced lack of
control to. If the lack of control is attributed to internal, stable, and/or global qualities, the feeling
of helplessness is more likely to be generalised to other areas of the person’s life. If the lack of
control is attributed to external, unstable, and/or specific qualities, helplessness may not be
experienced or it may be felt only in specific situations. In either case, once the helplessness is
learned it leads to an expectation of adversity and the prediction of negative outcomes in future
situations. Greater expected adversity and uncontrollability leads to greater negative motivational
and cognitive deficits.
We know that people with learning disabilities are likely to acquire feelings of helplessness, as
underachievement in their academic and personal lives is usually attributed to their learning
disability (Reed, 1997). We also know that learned helplessness can be an aetiological factor in
depressive disorder (Abramson et al, 1978). Therefore, it’s logical to conclude that learned
helplessness may be a major factor in the development of depression in those with learning
disabilities. This adds yet another perspective to our understanding of the disease in this
population.
Social Factors
The social isolation model, which stems from the social learning theory, posits that limited or lack
of social contact may result in depression (Prasher, 1999). This may be a factor in the
development of depression in those with learning disabilities, since many of them operate in
limited social circles and the social interactions they do have may be stunted by their disability.
Additional social factors that may contribute to depression for people with learning disabilities
include health morbidity, unemployment, stigmatisation, low income, and few intimate
relationships (Prasher, 1999). Even though there are no definite causational links between these
factors and depression, the feelings that these situations elicit are likely factors in the aetiology of
depression. For example, not having an intimate relationship may result in the individual feeling
lonely (Prasher, 1999). Furthermore, changes such as moving to a different home or day centre
may trigger feelings of depression or anxiety for someone with learning disabilities. Loss, such as
a death of a close family member/friend or a change in his/her support worker, may have a
similar effect.
What we have reviewed in the last few pages outlines many of the likely aetiological factors that
lead to depression in people with learning disabilities; however, more research is needed. As
Prasher notes:
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At present, more work is needed to investigate aetiological

factors of depression in people with learning disability.
Research in the field of molecular genetics will have a
significant impact, when ‘candidate’ genes which increase the
risk of depression are identified. Community care will enable
researchers to investigate the social influence and social
consequences of depression. The potential for prevention of
depression in at least some individuals with learning disability
remains to be explored. (Prasher, 1999, p. 449)
We believe the modified form of CBT outlined in this manual is a step toward preventing
depression and/or anxiety in some people with learning disability regardless of the specific
aetiological focus. Whether learned helplessness, self-control, social isolation, biological
predisposition, or some other cause is responsible for the development of the disorders,
ultimately cognition and behaviour are at stake and it is therefore reasonable to assume that a
CBT-oriented therapy has the potential to help at least part of this population stabilise their mood,
resume a more normal life, and engage in society in productive ways. The research to date bears
out this hypothesis.
A Brief History of CBT Treatment in People with Learning Disabilities

While controlled trials to prove the usefulness of CBT for the treatment of depression in people
with learning disabilities are only now beginning, the use of this therapeutic modality has already
seen some limited success in this population. To date, CBT has been used in the treatment of
people with mild to moderate learning disabilities who suffer from anger (Rose et al, 2000;
Gulbenkoglu et al, 2006); psychosis (Kirkland, 2005); obsessive-compulsive disorder (Willner &
Goody, 2006); anxiety (Lindsay et al, 1997); and depression (Lindsay et al, 1993; McCabe et al,
2006; McGillivray et al, 2008). We will briefly review two of these studies to illustrate the overall
effectiveness of this approach.
McCabe et al (2006) and McGillivray et al (2008) reported on group-based CBT treatment

programs for depression in people with learning disabilities. McCabe et al (2006) developed a
five-week program in which the participants covered one to two key areas and were allowed time
to discuss, understand, and develop skills in these areas. The program was designed to enhance
social skills, promote participation in social activities, and identify and change negative
cognitions. Participants were taught how to self-monitor their moods and thoughts, and were
trained to self-reinforce adaptive behaviours. Emphasis was placed upon reshaping cognitive
distortions and on developing a more positive interpretation of events. Techniques such as
modelling, role-play, and structured feedback were used to develop these skills. McGillavary et al
(2008) trained staff members in a manualised CBT program, which was administered over twelve
weeks. The program was divided into three modules (feelings, thoughts, and social skills) and
17
was designed to help participants develop/improve social skills and teach them how to recognise
and link thoughts, feelings, and behaviours through individualised concrete examples, repetition,
and role-play. Both studies showed significant improvements in behavioural and cognitive
manifestations of depression. Positive changes in scores of depression, social comparison
ratings, and negative automatic thoughts were reported and maintained over time (assessed at a
three-month follow-up).
These studies indicate that a modified form of CBT may be a feasible and effective approach for
the treatment of depression, anxiety, and other mood disorders in the broader population of
people with learning disabilities. Now let us turn our attention to a high-level overview of what
such a modified form of CBT would look like. Details on how to apply this approach and the
specific modifications in technique required will be discussed in more depth in Part 2.
CBT for People with Learning Disabilities

As most of you are aware, CBT is a collaborative approach where a client works with a therapist
to identify links between his or her thoughts and feelings in order to alter maladaptive cognitions
in the “here and now”. The therapist provides strategies for the client to effectively cope with
situations and reduce distress, identify thinking style errors, and consider alternative explanations
for beliefs.
Several studies have concluded that people with learning disabilities have the necessary
prerequisite skills to engage in many of the interventions associated with CBT (Dagnan et al,
2000; Joyce et al, 2006; Sams et al, 2006). These skills include the ability to link situations to
emotions (Dagnan et al, 2000); the capacity to differentiate between thoughts, feelings, and
behaviour (Sams et al, 2006); and an aptitude for correctly identifying emotions (Joyce et al,
2006). Sams et al (2006) found that as the identification of behaviours and feelings is linked to
verbal ability (measured using the BPVS) and the identification of thoughts is associated with
general IQ, thoughts, feelings, and behaviours are more likely to be understood and correctly
identified by people with higher verbal ability and IQ. Dagnan, et al (2000), found that people with
mild learning disabilities perform better when linking situations directly to emotions than they do
when attempting to link the triad of beliefs, emotions, and situations (Dagnan et al, 2000).
This is all to say that while CBT appears to be effective in people with learning disabilities, some
approaches and techniques may not be appropriate. For example, in conventional cognitive
interventions, guided discovery is used to examine underlying core beliefs. In these cases,
therapists often adopt a formal approach such as schema-focused work (Kuyken et al, 2009;
Young et al, 2003). This approach is unlikely to be feasible with people in whom in-depth abstract
thought is limited or impaired. Kroese et al (1997) has pointed out that in people with learning
disabilities, the individual’s level of comprehension, level of expression, ability to self-report, and
18
self-regulation skills are important factors in their suitability for CBT. What this suggests is that
the specific approach and techniques used are contingent on each individual’s cognitive
capacity. Remember that learning disability happens on a continuum. Those with mild forms of
impairment will require different treatment than those with more severe impairment. While
cognitive factors such as frequency of negative automatic thoughts, self reproach, and feelings of
hopelessness are all seen in people with learning disabilities who feel depressed (Nezu et al,
1995), in contrast to people in the normal population, those with mild to moderate learning
disabilities will have more difficulty in understanding cognitive mediation, especially as the
complexity of the task increases (Dagnan et al, 2000). People with severe forms of learning
disability may not be able to understand this kind of intervention at all, and in such candidates
CBT may not be the most effective or desirable form of intervention.
This is why we suggest a more pragmatic approach in the application of CBT to people with
learning disabilities. The first step any therapist should undergo is evaluating each client
individually to assess whether or not he or she has the prerequisite cognitive skills to undergo
therapy. We outline how to make this initial assessment and suggest tools for doing so in
Chapter 3.
For those clients who are qualified for CBT interventions, the therapist must learn how to
effectively adapt treatment to people with learning disabilities. Typically this means being more
specific and didactic and presenting key concepts in extremely concrete ways. Providing extra
support in the form of visual aids such as pictures, drawings, and signs for certain tasks such as
mood monitoring, presenting temporal concepts, and identifying automatic negative thoughts is
particularly effective. To this end we suggest the use of images such as those in the
Photosymbols collection and have included many examples of these in the worksheets you will
find in Part 3 of this manual. Other modifications include taking therapy at a slower pace, using
repetition, and encouraging “overlearning” in some scenarios. These techniques will likely
enhance the client’s engagement and motivation in therapy. We outline specific methods for
modifying classic CBT techniques such as identifying thoughts, feelings, and thinking styles;
linking thoughts, feelings, and behaviour; verbal processing; visual processing; role-play; and a
host of other techniques in the relevant chapters in Part 2. Previously modified CBT interventions
for this population have also included sections on psychoeducation and relaxation training. We
have followed this approach and offer suggestions on how to address psychoeducation and offer
modified relaxation techniques for people with learning disabilities in Chapters 4 and 6
respectively.
Regardless of the level of disability or the amount of technical modification necessary, every
therapist should keep the following characteristics and approach in mind as he or she enters
treatment with people who suffer from learning disabilities.
19
Therapist Characteristics and the Therapeutic Approach
Warmth
The therapist should convey warmth by being encouraging and offering lots of positive
reinforcement where appropriate. The therapist will need to show an empathic approach coupled
with an informal and friendly attitude towards the client. These qualities are, in some ways, even
more important in treating people with learning disabilities, as they will improve response and
motivation to engage in therapy.
Genuineness
The therapist needs to be honest with the client without being too harsh or judgmental. When
treating people with learning disabilities it is particularly important to be careful that the client
doesn’t misinterpret directness as criticism, hostility, or rejection. This can be especially tricky, as
people with depression are more likely to focus on the negative.
The Importance of Rapport

As in all therapeutic relationships, the client has to feel secure and trust the therapist. In some
cases it can be difficult to establish trust in people with learning disabilities because these clients
are more likely to have had a variety of negative experiences with therapists, social workers,
and/or other authority figures. You may find clients who have developed distorted ideas and
representations of therapists or authority figures in general from previous experiences.
Overcoming this hurdle is essential to effective treatment. With time and patience it can be done,
but it may take perseverance on your part to establish trust.
Therapists who tested this protocol found that some people with learning disabilities have
significant trust issues. For some, there is considerable selective attention to past negative
encounters with people who have threatened or bullied. For others, significant trauma from
past life experiences and the memories and emotions that trauma holds can inhibit the
development of trust and the experience of safety. The difficulties that result can be very
delicate. Therefore, this is an important area to consider in the process of treatment.
The Therapeutic Alliance

In carrying out CBT with clients who have learning disabilities the therapist may be required to
adopt a more didactic role (as noted above). However, this needs to be done without being
coercive or dismissive. To this end, challenging the person’s beliefs too early in treatment is not
recommended. Rather, the therapist should slow the pace of therapy and offer several possible
answers to questions the client may otherwise find difficult, yet do this without ‘leading’ the client.
The key here is to be vigilant of the client’s expressions and other nonverbal cues.
Communicating with people who have learning disabilities (both verbally and nonverbally) can be
20
challenging for therapists who have little or no previous experience working with this population.
However, learning the necessary skills to effectively communicate with those who have learning
disabilities is essential for effective treatment. That is why we have focused on helping the
therapist develop a specific set of communication skills in Chapter 2.
Accurate Empathy
The therapist needs to try to understand how the client regards him- or herself and his or her
world. By doing this, the therapist gains a sense of what the client may be experiencing. As the
therapist develops empathy that is reasonably accurate, the therapist will be able to understand
how the client feels, understands, and responds to events (Beck et al, 1979). This is essential
both for developing rapport and for effectively treating the client.
Cultural Sensitivity
Being sensitive to cultural differences and taking them into account during sessions is extremely
important. There is considerable variation in the way mental health disorders such as depression
and anxiety are perceived and understood in different cultures. The treatment model in this
protocol is flexible and can accommodate racial, cultural, and gender differences and issues.
However, you must be sensitive to these issues to use the protocol to that end5.
The Role of the Caretaker/Support Worker

Yet another important modification in the use of CBT in this population is the role of caretakers
and/or support workers in the process of therapy. The involvement of a caretaker or support
worker is essential in assisting the client to move successfully through the program outlined in
this book, and it is especially critical when it comes to the completion of homework tasks (an
important part of treatment that we will discuss in detail in Part 2). Kazantis & Anderson (2008)
found that for people with mild learning disabilities, having a caretaker or support worker in the
session with the client helped to provide greater continuity and these people were subsequently
better able to assist participants in practicing skills outside the session. For this reason, when
possible we recommend that a caretaker or support worker be involved in the intervention and
come to sessions with clients.
Caretakers or support workers should assist the client with homework assignments and help the
client bring this material into sessions.
5
It is also worth noting that the therapist should try not to book sessions on religious holidays such as Eid,
Diwali, or others so as to avoid missed appointments. Other events such as Ramadan should also be taken into
account, as observance may affect concentration in the sessions or affect the tasks that the service user needs
to do between the sessions. Note that Ramadan is a religious month in the Islamic calendar where the
individuals fast (do not eat or drink) from sunrise to sunset for up to 29 days.
21
Amongst the therapists who tested this protocol, there was universal
agreement on the critical importance of the support worker as a part of the
therapeutic process. Each commented on the role this person played and the
improvement in continuity between sessions that resulted from this
involvement.
The inclusion of an additional person in sessions represents an interesting challenge to

therapists in that you need to be cautious of and regulate the involvement of the caretaker or
support worker to ensure that the client doesn’t become dependent on or rely too heavily on this
person during the course of treatment. The aim of CBT is to empower individuals to be “their own
therapist”. The hope is that over the course of therapy the individual will learn to use CBT
techniques independently as and when they are required. If a client relies too heavily on his or
her caretaker or support worker, he or she may not successfully integrate CBT techniques as
coping mechanisms in daily life. Therefore, the therapist needs to continually reinforce and draw
boundaries around the specific role the caretaker or support worker has during the treatment
process.
Having a caretaker or support worker in sessions will also bring up confidentially issues that need
to be addressed before treatment begins. Confidentiality ensures that information disclosed to
the therapist is not shared with a third party unless appropriate and agreed upon beforehand. It is
an essential element of the therapeutic process that allows the client to build trust in the
therapist.
The therapist, therefore, needs to establish how much and what information the client is willing to
disclose to the caretaker or support worker before bringing this person into the room. This is very
important, as the client may not feel comfortable discussing certain topics or issues in the
presence of a third party. If not addressed properly, these kinds of issues may hinder treatment.
Research has shown that in the presence of others (in the group setting), successful treatment
depends on individuals feeling safe enough to disclose personal information (Lasky & Riva,
2006). The therapist therefore needs to take an active role in determining what the client is willing
to share with the caretaker or support worker, and then must reassure the client that this person
will respect his or her confidentiality.
When it comes to treating people with learning disabilities—whether you are discussing
confidentially issues, identifying automatic negative thoughts, role-playing, or engaging in any
other part of the therapeutic process—the key is to learn how to properly communicate with this
special population. It is to that subject that we must now turn our attention.
22
Chapter 2
Communicating with People Who
Have Learning Disabilities in the
Therapeutic Setting
People with learning disabilities have complex communication needs. Clients may have difficulty
forming sentences, have a reduced understanding of key and abstract concepts, his or her
speech may be unclear, or the client may need increased time to process and retrieve
information. Furthermore, a person with learning disabilities is likely to have reduced vocabulary
(Burnip, 2002), and he or she will probably be more susceptible to suggestibility and may tend to
change his or her answers to questions when provided with negative feedback (Clare &
Gujonsoon, 1993; Everington & Fuller, 1999). This is all further complicated by the fact that
linguistic and cognitive abilities vary considerably from person to person within this population.
What’s more, people with learning disabilities have a lifetime of experiences that have allowed
them to mask their difficulty in understanding and following verbal communication by drawing on
social skills and set phrases that they know are contextually appropriate responses, even if they
do not fully understand what is being communicated. This can lead to the illusion that the client
has understood something that was said in the therapeutic setting when, in fact, this may not be
the case.
If the purpose of CBT is to help the client “learn from his or her psychotherapeutic experience”
and “begin to incorporate many of the techniques of the therapist”—that is, to “become his or her
own therapist” as it were—these difficulties in communication represent a challenge that must be
addressed and overcome to successfully apply the CBT model in this population. You will need
to properly modify the way you communicate to meet the needs of individuals with learning
disabilities so that you can pitch the material presented at an appropriate level and allow the
concepts of CBT to be more accessible.
One of the first steps in bridging this gap is to complete a thorough assessment of a client’s
cognitive and linguistic abilities in the early sessions of therapy. We will outline precise
recommendations on how to conduct this kind of investigation in the next chapter as we begin to
review the treatment protocol we recommend. However, it is best to equip yourself with the skills
to address communication issues before therapy begins. Therefore, in this chapter we will outline
some of the most common communication difficulties people with learning disabilities face and
provide you with tips and strategies to address these issues.
23
Understanding People with Learning Disabilities: On the Problems with Vocabulary,

Verbal Ability, and Speech
Even people with mild learning disabilities will generally have a more limited vocabulary and will
acquire fewer and less complex words than the general population (Winn & Baron, 2009). In
addition, the ability to form complete, grammatically correct sentences varies within this
population—some may be able to do this while others may not. These issues will impact your
communication with clients who have learning disabilities from the ground up. You may find they
have difficulty finding the words to express certain thoughts and feelings. Similarly, if the
language you use is too complex, the client may not follow what you are saying. Difficulties in
processing and retrieving information (like word-finding difficulties) may mean that it takes more
time for these clients to respond verbally. And, if the client cannot form complete sentences, you
may sometimes find it difficult to understand the meaning of what has been said.
Speech itself may represent another communication barrier that needs to be overcome, since
physical disability or anatomical differences can result in a variety of speech-related difficulties.
For instance, the anatomical differences found in people with Down Syndrome—low muscle tone
of the tongue, small mouth, and high palate—results in the characteristic alterations in
pronunciation in this population (Kelly, 2000). A person with cerebral palsy may have dysarthric
speech—weakness in the speech musculature and difficulties with breath support. Other causes
of speech difficulties may include dyspraxia—difficulties executing voluntarily and on command
the neurological sequence of muscle contractions required to produce individual sounds and
words (Murdoch, 1990); and dysfluency—impairment in the ability to produce smooth, fluent
speech—a problem that most often arises when someone feels under pressure to perform or
respond and where there may be a need to synthesise many different cognitive tasks to arrive at
a conclusion.
24
The following tips will help you overcome some of these basic difficulties with communication.
Note that these tips are based on Winn & Andrea Baron, 2009.
Tips to Help You Understand People with Learning Disabilities
1. If you do not understand what a client says, it is important that you

do not pretend to have understood. Try to make the client feel at
ease while acquiring the information you need. You might say,
“Sometimes it is difficult for me to understand; could you say that
again, please?”
2. Give the person plenty of time to respond; you might have to wait
longer than you’d expect. Remember, these clients do not necessarily
take longer to respond because they are unwilling or unable to answer
questions, but because it takes them longer to process information.
3. Make sure you listen carefully. Pay special attention to speech

patterns and pronunciations that are difficult for you to make out.
4. Make sure you look at the person when he or she is talking. Body
language (more on this below) and watching the words being formed
may help you comprehend what is being said.
5. If you still cannot understand, ask the client if it is okay to ask the
support worker for help with communication. While this is not a
technique you want to rely on consistently, it can help in cases where
repeated efforts at communication fail.
6. Be aware of other things that may affect communication. This could

include hearing impairment, visual impairment, physical and mental
health issues, epilepsy, medication, time of day (is the client a
“morning person”) general mood, interest in the topic, and more.
As you become more familiar with a particular client’s communication style, pronunciation, and
verbal patterns, you will likely be able to “tune in” to his or her speech and find it easier to
understand.
25
Being Understood by the Client: Presentation of Key Concepts, Abstract Thought, and
Contextualizing Communication
The majority of people with learning disabilities will have some difficulty understanding what you
say to them at least some of the time. How often this is a problem and the degree of
misunderstanding will vary from individual to individual depending on the severity of the disability.
While assessment can help tease out how much of a challenge this will be in therapy, there are a
few simple guidelines that will help facilitate good communication with these clients.
First, try to stick with simple, straightforward, everyday language and limit the number of key
concepts or ideas you communicate to no more than three per sentence. While some may be
able to understand more complex verbiage and sentence structure, most people with learning
Second, keep to concrete examples as much as you can, and either avoid disabilities will better
comprehend simple sentences and language, reword, or break down complex abstract ideas
when possible. While people with learning disabilities may be able to understand simple abstract
ideas such as “What are you doing today?” or “How are you feeling right now?” Complex abstract
concepts and questions that revolve around inference or emotions in the context of time are likely
to be more difficult for them. You will typically want to avoid questions like “What would happen if
you …?” “What would it feel like if you …?” or “What did it feel like when …?” These lines of
questioning are unlikely to be easily accessible by someone with a learning disability.
Let’s look at an example. Imagine you are discussing the events of the day with a client and he
or she says, “I couldn’t find my shoes” in a tone that indicates some sadness and/or frustration
around this event. Rather than asking, “How did you feel when you misplaced your shoes?”
which would likely be too complex, the interaction may be broken down as follows:
Client: I couldn’t find my shoes.
Therapist: Tell me what happened.
Client: I put them in the wrong place.
Therapist: How did that make you feel?
You will note in this example, we have deconstructed the “big” question “How did it feel when you
misplaced your shoes?” into two component parts so that the action and the feeling are
addressed separately. If you think through what you want to say carefully before saying it, in
most cases you will be able to find ways like these to communicate your thoughts or questions in
a simpler manner.
26
Finally, make sure you contextualise the information you are attempting to share with the client
as often as possible. Contextualising communication will often enable a person with a learning
disability to understand what has been said and respond appropriately even if the words aren’t
fully comprehended. Good caseworkers use context as communication constantly. For example,
imagine it’s the end of the day and time for the bus to come to collect Peter from the day centre.
Peter has had his afternoon drink, which he has as part of his routine each day before the bus
comes. The other service users are all getting their coats, and when Peter’s case worker asks
him to “Please go and get your coat and put it on, as it’s cold outside today”, Peter is able to
follow this verbal request, get his coat, and put it on. Peter is relying on his routine and the
behaviour of the people around him to understand the verbal request. You can use similar
methods in your practice.
There is one important caveat to note regarding the reliance on context. As mentioned earlier in
this chapter, people with learning disabilities may give appropriate verbal and/or non-verbal
responses to questions or comments while not completely understanding what has been said.
This is not an attempt at deception; it is simply the product of learned behavioural responses that
come from a lifetime of managing social situations.
It is important that you are mindful of this potential pitfall and ensure that clients understand what
you have said by regularly asking them to summarise or repeat what has been discussed during
sessions. If clients cannot sufficiently summarise the topic at hand, it’s an indication that they
may not have understood, despite what they say or what their body language tells you. Don’t
hesitate to reiterate what you have said or look for new ways to communicate the information you
are trying to share if you face this situation. While some people will find it difficult to summarise or
repeat back what has been said to them generally, most will eventually be able to do this with a
genuine understanding of what has been communicated.
In addition to the above, here are a few more strategies you can employ when communicating
with people who have learning disabilities to help them better understand you. Again, the
following is based on Winn & Andrea Baron, 2009.
27
Tips to Help People with Learning Disabilities Understand You
1. Speak slowly using everyday words. This means simple grammar, short
sentences, and plain English—no jargon.
2. Think about how to ask questions. Open-ended questions can be more

difficult for this population. Yes or no questions are also unhelpful, as
clients may respond the way they think you want them to. The best
method is usually to stick with short, simple either/or questions: Do you
like tea or orange juice? Do you feel happy or sad? However, make sure the
client is not simply repeating the last thing you said by confirming what has
been communicated.
3. Link your explanation with everyday things. This is especially important if

you need to talk about more abstract concepts like time. “Take your tablet
at breakfast, lunch, and dinner” is more easily understood than “Take your
tablet three times a day.”
4. Write the key information down. Then share the written information with
the client’s support person; that way they can go through it together after
the session.
5. Eliminate distractions. People with learning disabilities have a hard time

ignoring distractions. Make sure you are talking to them in a quiet place.
In addition6.
to these tips, there are two more strategies you may consider employing with people
who have learning disabilities: the use of pictures or symbols and a strong focus on non-verbal
communication. Let’s deal with each of these in turn.
Using Picture and Symbols to Communicate
If verbal communication presents a barrier, we encourage you to incorporate pictures or symbols

to help clients express themselves and/or understand what you are saying. This is an excellent
and simple method that can vastly improve communication in difficult situations. As you will see
in Parts 2 and 3, we have included pictures throughout the worksheets in this manual. These are
from the Photosymbols collection, the primary symbol resource for many of the organisations that
produce easy-to-read information for people with learning disabilities. Clients often find the
information communicated in these images easier to recognise and understand because they are
photorealistic and in colour6. Photosymbols work well in the therapeutic setting because they are
6
Using full colour is important. Please make sure you print and photocopy in colour when duplicating
information from this workbook or when using the Photosymbols collection .
28
simple and because extraneous details often found in photographs have been removed. You can
learn more about the Photosymbols collection at www.photosymbols.com.
Focus on Non-verbal Communication

You are likely aware that non-verbal communication such as body language, facial expressions,
gestures, signing, tone, pitch and intonation, and behaviour all play an important role in
conveying messages. Body language has been found to provide up to 55 percent of the
information in a given communication (Argle, 1970). This is quite fortuitous when working with
people who have learning disabilities, because they tend to be keyed into non-verbal
communication as a method of both expression and comprehension.
When working with these clients, try to tune in to what their body and other mechanisms of non-
verbal communication are telling you. Learn to interpret this silent language and you are likely to
find it conveys much more than the person’s words do. Conversely, you can use your body, facial
expressions, etc. to communicate information to your clients. In some cases, you will find
communicating this way enhances their ability to understand your verbal exchanges. So become
aware of your non-verbal communication and make sure it accurately reflects what you are
saying. Make sure to be active with your body and use lots of non-verbal feedback like nodding
your head and changing your facial expression to indicate you are listening and that you
understand (or don’t understand) what has been said.
Using these concepts and techniques to enhance your ability to communicate with people who
have learning disabilities is essential. If a client finds it difficult to understand what has been said,
it is likely he or she will become distracted or unmotivated to participate in sessions. This may
make treatment more problematic and less successful. By learning about and integrating the
strategies above at the very outset of treatment, you can minimise communication difficulties and
provide the client with a better experience in therapy
Before we close this chapter, there are two final issues we need to address that are related to
communication: verbal problems specific to certain learning disabilities, and the difficulty of
suggestibility.
Idiosyncratic Communication Issues Specific to Certain Populations with Learning

Disabilities
In some cases you may encounter clients with very specific, idiosyncratic verbal difficulties that
are associated with their particular learning disability. For example, echolalia or echoed speech
where a person repeats words or sentences spoken by others is often found in people with
autism (though you may find it in people with other learning disabilities as well). If a client is
29
affected by this he or she may immediately repeat a word or phrase that has just been said. For
example, if you say, “Mary’s coming today” the person may start saying “today” or even repeat
the entire phrase over and over again.
A similar, but slightly different, difficulty that some people with learning disabilities have is called
perseveration. This is where the individual continues to talk about a distressing event or subject
that is of interest to him or her when it is no longer appropriate. The person may repeat the same
words over and over again or may continue discussing the same topic with slight alterations.
In cases like these, it can be extremely difficult to break the client out of these patterns and
engage him or her in anything other than what he or she wishes to discuss. Interestingly, his or
her ability to communicate about the topic at hand may be extremely misleading about his or her
ability to communicate in general. The client may discuss these issues with much greater or
much less eloquence than he or she is capable of in everyday life. This can be a challenge,
especially when you are trying to assess the individual’s overall communication abilities, so it is
important to be aware of these issues before entering therapy.
Whether you are facing echoed speech or perseveration, the key is patience. It may be useful to
suggest a break, or if attempts at distracting the client fail, it may be worth considering a shorter
session. Occasionally it helps to draw a “contract” with the client. Agree to a short two- to three-
minute talk on the subject he or she wishes to discuss, then go back to the topic at hand in
therapy. Continue to encourage the client to come back to his or her session next time.
Another problem you are likely to face when treating people with learning disabilities is a
hesitation to openly express thoughts, feelings, ideas, and beliefs. Many people who have
learning disabilities have come to believe that what they are saying is either incorrect,
unimportant, or both. Luckily, a recent study points toward a way to overcome this problem. The
use of “Socratic questioning is a helpful way of overcoming this obstacle where, by a series of
questions, [the person] is helped to explore, reassess and challenge his or her beliefs” (Stallard,
2002, pg. 21). We encourage you to employ Socratic questioning in cases like this, and draw out
your clients’ thoughts and feelings. When doing this, always remember that questions need to be
simple and direct. For example, instead of asking “What did you do yesterday?” you should ask,
“What did you do yesterday after you got back from the day centre?”
Finally, it is worth noting that cultural “rules” can come into play with this population just as they
do in people who do not have learning disabilities. Be sensitive to any cultural issues the person
may have particularly with regard to eye contact, personal space, and gestures that may have
different meanings than what you are accustomed to. Make sure you check what language the
person is most familiar with and employ an interpreter as necessary.
30
Addressing Suggestibility
As we noted at the beginning of this chapter, studies have concluded that even people with mild
learning disabilities are much more susceptible to leading questions than the normal population.
It appears this link between higher suggestibility and learning disabilities may have to do with
memory. Beail (2002) linked poorer memory to higher suggestibility. The studies cited earlier in
this chapter offer further support to this tether between memory and suggestibility, as each found
that memory recall was poorer in people with learning disabilities.
While suggestibility is always an issue a good therapist is paying attention to, it represents a
particular challenge in treating people with learning disabilities. Throughout this chapter we have
shown how to simplify communication; reduce abstraction in language; contextualise your
thoughts; and use pictures, symbols, and non-verbal communication as methods for more
effectively relating to your clients. All of this must be done while avoiding leading questions and
keeping suggestibility at a minimum throughout treatment. Focus on making sure clients
understand what has been said and give clear instructions without leading them. Doing this and
using the other strategies and tips in this chapter should set the stage for quality communication
starting with the very first sessions of therapy. In the next chapter we will outline what these early
sessions might look like and provide you the tools needed to assess your client’s communication
and cognitive abilities.
31
Part II
Protocol for Treating Depression and
Anxiety in People with Learning
Disabilities
32
Chapter 3
The Early Sessions (Sessions 1–4)
The treatment process is divided into three phases. These are:
 Early/initial phase (sessions 1–4)
 Middle phase (sessions 5–14)
 Final phase (sessions 15–20)
In this chapter we will describe the initial phase and outline the items you need to cover in these
first sessions with the client.
Goals of the Initial Phase7

During the initial phase of therapy, you should seek to achieve the following:
1. Complete a language assessment and evaluate the client’s suitability for CBT.
2. Explain the role and extent of involvement of the support worker in therapy to the client.
3. Address the reasons the client has been referred for treatment.
4. Describe the CBT model of treatment and the importance of homework.
5. Confirm that the client will attend all therapy sessions.
6. Provide psychoeducation.
We will review the first five goals above in the remainder of this chapter. Psychoeducation is a
larger topic and requires more in-depth analysis; therefore, we have dedicated Chapter 4 to that
subject specifically.
7
Each of the goals outlined in this chapter is in the “Checklist of Topics Covered During Treatment” worksheet,
which you will find in the Appendix of this manual. We encourage you to fill out this worksheet at the end of
each session during the entire course of treatment. It will allow you to easily track what you have covered,
take notes, and assess what still needs to be addressed during therapy.
33
Assessment and Screening of Language, Cognitive Skills, Motivation, and Suitability

for CBT
At the outset of treatment it is essential to make an assessment of the client’s language and
cognitive abilities. This will allow you to identify whether or not the client is an appropriate
candidate for CBT, adjust your communication as necessary to fit his or her specific linguistic
capabilities, and establish a foundation for you and the client to make the most out of the time
spent in therapy. The assessments we recommend follow below. However, what ultimately use
to assess your clients is up to you.
Cognitive Level and Language Skills

There is an excellent tool that will help you assess language skills in people with learning
disabilities. It is the Test for the Reception of Grammar (Bishop, 2003). The latest version of the
test is called the TROG-2 and has been standardised on a group of 792 children from ages four
to sixteen and seventy adults from ten regions across the United Kingdom. The test takes
approximately fifteen to twenty minutes to administer.
Determining the client’s vocabulary level and grammar comprehension will help you select
appropriate materials for the individual and tailor your own communication style to fit his or her
needs. It will also be one of the factors that allows you to determine the individual’s suitability for
CBT. Research has shown that performance on language tests correlates well with an
individual’s ability to identify and label emotions, one of the key prerequisites for successful
treatment (Joyce et al, 2006). A low score on these tests may indicate the individual needs
specialised treatment or that aspects of the CBT intervention may be less successful.
Memory
It is also useful to carry out a few short and easily administered tests to determine the extent to
which the client is able to process and retain information. The Logical Memory sub-test of the
Wechsler Memory Scales-III (Wechsler, 1997) involves recalling short stories and can be used to
assess both short-term and longer-term retention of information. In addition, the Word Lists sub-
test involves recalling words from four separate lists which are read out by the therapist and will
provide an indication of the efficacy of the individual’s working and short-term memory functions.
Reading Ability
A number of adults with learning disabilities have reading difficulties. In these cases, it’s likely the
individual will not be in a position to make independent use of written materials (i.e. homework),
and therapy will either need to be adjusted as necessary or the client will need to rely on his or
her support worker for assistance. To determine a client’s reading ability, we recommend
administering the Schonell Graded Word Reading Test (Schonell, 1972). The test provides a
reading age and an indication of the level of complexity of written material the client will be able
to understand.
34
Writing Ability
Similarly, a number of adults with learning disabilities experience difficulties with writing.
Therefore we recommend assessing potential problems in this area in advance as well. In order
to test writing ability, the client can simply be asked to copy out a few sentences presented by
the therapist, and then asked to generate a few sentences of his or her own. If the client is
unable to do this effectively, it is likely that any self-monitoring will be problematic and alternative
means of feedback may need to be considered.
Attentional Control
Some people with learning disabilities have poor impulse control and other attentional difficulties.
These clients may find it difficult to maintain focus during sessions and concentrate on the task at
hand and/or become easily distracted by extraneous stimuli in the immediate environment.
Observe the client’s responses to the tests outlined above. If he or she is unable to maintain
focus during the test or incapable of completing the tasks presented, particular consideration will
need to be given to the therapeutic environment and the way therapy is structured and paced to
optimise the client’s ability to understand and benefit from it.
Perception of Control and Self-efficacy

A client’s perceptions about how much he or she controls and influences events in life are
particularly important in CBT. If the client does not feel in control of his or her feelings or believes
him- or herself to be incapable of effective positive changes in thought and behaviour, it is more
likely therapy will be unsuccessful. Assessing and addressing these underlying beliefs before
treatment begins is critical. This can be done by considering the client’s responses to general
questions regarding his or her experiences with decision making and taking control, such as:
 Could you tell me who decided what you were going have to eat last night?
 When you last bought clothes, who chose them?
 If someone knocks on the door, who answers it?
 If someone phones, who takes the call?
 If you see someone fall over in the street, what would you do?
 If you are feeling unhappy about something at the day centre, what would you do?
Answers like “I did” or other positive responses that represent the client’s ability to take initiative
are indicative of an internal locus of control—the individual believes that events can occur or
change as a result of his or her actions. Answers such as “I don’t know” or references to other
people taking action suggest an external locus of control—the client believes that events are
35
random or controlled by others. An external locus of control or a reduced sense of self-efficacy

will need to be addressed in the early phases of therapy if treatment is going to be successful.
Insight
Most clients with learning disabilities who come to therapy are referred by caregivers, family
members, support workers, or health professionals. They rarely come of their own accord.
Therefore you will need to assess the client’s motivation and willingness to engage in therapy. It
is important that the client wants to change and is willing to try CBT as a means of overcoming
depression and/or anxiety if treatment is going to succeed. You should explore the client’s
understanding of his or her illness (more on this below) and discuss whether he or she thinks a
“talking therapy” could help.
Biopsychosocial Factors
Finally, you will need to consider any biopsychosocial factors that have a bearing on the
individual’s mental health. (See Chapter 1 for a more detailed explanation of considerations you
need to make in this realm.) Some of information may be in the case notes and referral. If not or
if more is needed, it is essential that you discuss these factors with the client and support worker,
whose role in the therapeutic process should be discussed with the client in these early sessions
as well. Let us now turn our attention to this matter.
Explain the Role of the Support Worker

In Chapter 1 we discussed why it is important to include a support worker in the therapeutic
process when treating clients with learning disabilities and explained the complications that need
to be resolved when incorporating an additional person in therapy. All of this needs to be
discussed with the client and the support worker in these early sessions. Here is what we
recommend.
Begin therapy with just you and the client in the room. Once the assessments are completed and
when it is appropriate, introduce the idea to the client of including the support worker. At this time
you should discuss:
 Why including the support worker is useful
 The extent to which the support worker will need to participate in sessions and homework
 How much information the client is comfortable sharing with the support worker
 Confidentiality issues—that the support worker will abide by the rules of confidentiality
but that he or she has a duty to report disclosures made by the client that indicate risk to
self or others
36
Once you have reached an understanding with the client regarding these issues, the support
worker should be brought into therapy and you should review these issues with him or her as
well. It is particularly important that a frank discussion regarding confidentiality and its limitations
happen when all three of you are in the room together.
At this time, you should also provide the support worker with the Carers guide (in the CD
provided) that accompanies this protocol. It contains information about:
 What CBT is and how it works
 Why homework is important and how the support worker can best help the client with
assignments
 Communicating with people who have learning disabilities
 Psychoeducation on depression and anxiety, including symptoms and what to look for
 The structure of the sessions over the course of treatment
The support worker should read this manual in its entirety within the first few weeks of receiving
it.
Address the Reasons the Client Has Been Referred

Once the support worker has been introduced, the next topic that should be addressed is the
reason the client was referred to therapy. As we mentioned above, clients with learning
disabilities rarely refer themselves for psychological treatment. Changes in behaviour and
symptoms of depression and/or anxiety are usually noticed by and are cause for concern for
people around the client. The client may not share these concerns or may not believe that the
problem requires help. It is of great importance that you explain and elicit the client’s
understanding of the emotional and behavioural difficulties he or she faces. This typically
happens in three steps.
Step 1: Orient the Client

This consists of a simple introductory statement, such as “I am seeing you because I hear you
feel sad/scared/worried/etc.”
Step 2: Explore the Presenting Complaint in More Detail

After introducing the reason for the referral you may then go into a more detailed discussion of
the problems your client faces. You may use information in the referral and/or ask the client for
his or her views on the matter. In either case, it is essential that you keep this discussion simple,
specific, and focused so that the client develops an understanding of the issues at hand. Ask the
client to repeat back his or her understanding of what you have said, as necessary. (See Chapter
2 for strategies on how to do this.)
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Step 3: Ask the Client to Rate His or Her Distress

It is also helpful to obtain the client’s perception of how much the problem affects him or her. You
can do a depression and anxiety assessment, but this needs to be kept very simple. The normal
questionnaires used to assess depression and anxiety typically will not be comprehensible for
people with learning disabilities. We recommend that you use pictorial diagrams to estimate the
extent of the problem. These have been included in the worksheets for clients in Part 3 of this
manual. Give the client “Resource 1—My Cognitive Behavioural Therapy (CBT) Book and
Personal Details” and ask him or her to fill in the appropriate details.
Describe CBT and the Importance of Homework

After you have discussed the reason the client has been referred and he or she understands the
reason for the referral the natural next step is to explain what CBT is, how it works, the rationale
for treatment, what the aim will be, what the rules of therapy are, and how important homework is
during the process.
Clearly this can be complex material to cover, and it may be challenging to ensure that a person
with learning disabilities understands the fundamentals of treatment. However, it can be done,
and we will provide you some tips on how to best communicate this information in a moment—
but first a word on homework.
Homework
As you are likely aware, homework tasks are an essential part of CBT, and homework
compliance is associated with improvements in treatment outcomes (Kazantis, Deane & Ronan,
2000). Homework provides the client with an opportunity to practice new skills and incorporate
them into his or her daily routine. It is an important part of treatment for people with learning
disabilities just as it is for the normal population. However, when assigning homework to these
clients, there are a few things to keep in mind.
Research shows that there are several factors that affect a client’s compliance with homework
tasks. These include the client’s ability to complete the assignment and the task’s characteristics
(Kazantis, Deane & Ronan, 2004). This means you should tailor assignments according to the
client’s needs. Homework should be relevant to the topics covered in a given session and should
help the client build on the skills and behaviours practiced during therapy. It should encourage
the client to engage in the kinds of changes necessary while still being realistic and manageable
for a person with learning disabilities. Furthermore, homework should be assigned in graded
steps so that the degree of difficulty slowly increases over the course of treatment and each
assignment builds one after another to provide continuity from session to session.
38
Improving compliance with homework can be further achieved by:
 Involve the client in deciding what tasks he or she will be doing outside the
session. Most clients find tasks more enjoyable and useful if they are involved in this
decision-making process.
 Setting tasks that provide a no-lose situation. While you want to encourage the client
to complete all homework tasks, being “successful” at homework is not what’s at stake
here. Keep in mind and work to make the client understand that homework is a skill-
building process and that there are no “failures”.
 Confirm that the client clearly understands what the task entails. As above,
understand that the task is of key importance in compliance.
 Confirm that the client clearly understands the rationale for the task. This is slightly
different from understanding the task itself. Since homework should be a method for
resolving symptoms it is important to help the client understand how each assignment is
a part of that process.
 Inform the client about benefits and importance of doing the homework tasks.
Explaining to the client the specific benefits he or she may achieve through homework is
likely to encourage the client to complete a given assignment.
As homework is completed the following questions adapted from the “Homework Rating Scale”
(Kazantis, Deane, & Ronan, 2005) should be kept in mind:
 How well did the client understand what to do?
 How well did the client understand the reason for doing the task?
 How well did the client do in completing the task?
 How much of the task was the client able to do?
 How difficult/easy did the client find the task?
 How much did the client enjoy the task?
 How well did the task match the goals of therapy?
 How much did the task help the client gain control over his or her problems?
 Did the task help the client progress in therapy?
39
Some therapists have found that clients with learning disabilities have difficulties with
self-reporting. This can make assessing improvement in therapy or experience with
homework challenging. The involvement of the support worker can be helpful in this
regard.
In most cases, the therapist will need to consult with the support worker, whose function is to
encourage the client to complete his or her homework, regarding these points. To help ensure
that homework is completed it is also useful to confirm that the support worker understands what
the homework tasks entail and how he or she can best help the client to complete the tasks.
What to Do with Incomplete or Partially Completed Homework

At times the client may partially complete the homework task or not attempt it at all.
Incomplete/incorrect homework can provide as much, if not more, information as homework
tasks that are completed successfully. If the client has left the task incomplete it can be used as
a topic for discussion within the session to bring up issues that may be at stake. Understand that
the client’s reasons for not doing the task will provide you with further useful information for
treatment. There may be a number of reasons a client does not complete homework. These
include:
 The client may have found it more difficult than he or she initially thought.
 There may have been extraneous circumstances beyond their control that precluded the
client from completing the task.
 The client may not attempt the task for fear of doing it “wrong”. (See above about
creating “no-lose situations”.)
If the homework task was not completed, you should ask the support worker to fill out the
“Resource 2—Checklist of Reasons for Not Completing the Homework Tasks” (adapted from
Beck et al, 1979) in Part 3. The checklist can then be brought into the next session and you can
go over it with the client (and support worker as needed) and address any issues with homework.
How to Integrate Homework into Treatment

We recommend you begin homework and develop a regular rhythm with it from the very outset of
therapy (in the first session if possible). This will set the stage for the client to successfully
complete assignments that are more complex in later sessions (especially in the middle sessions
when the tasks and objectives become slightly more complex). We have provided a set of
worksheets in Part 3 of this manual, and we will outline how we recommend you use these
worksheets during treatment. However, you should regularly assess whether or not assignments
help the client to progress in therapy. If the order outlined in this manual does not appear to
40
serve a particular client, do not hesitate to alter the order or nature of the assignments as
necessary. Simply make sure you are providing appropriate assignments at appropriate times,
and make sure you explain to the client why it is important that he or she complete homework
assignments.
In addition to the materials already mentioned in the early session you may consider covering the
following homework assignments:
 Creating a list of issues or problems that the client would like to address during
therapy. The worksheet “Worksheet 1—I Want to Talk to the Therapist About …” in Part
3 of this manual can be used for this exercise. Having such a list at the outset of therapy
is helpful, as it provides you a point of reference over the course of therapy and allows
you to weave the specific problems the client wishes to addresses into sessions.
 Completing a weekly activity schedule (WAS). You can use “Worksheet 2—What Do I
Do in a Week” worksheet for this. The WAS allows you to see how much/little the client is
currently doing and what tasks he or she is engaging in. This information may inform your
choices in therapy and it can also be referred to later in the treatment process and
compared to other WAS worksheets as a concrete example of how the client is
progressing during treatment.
As we mentioned above, before assigning homework, you should explain why it is important to
the therapeutic process and outline the other elements of CBT treatment mentioned above. Here
is how we recommend you address these issues.
Structure the sessions where this conversation occurs so that it allows for short breaks from time
to time to give the client a chance to ask questions about anything he or she may not
understand, refocus and regain attention and concentration, and review material as necessary.
As always, when communicating with people who have learning disabilities it is advisable to stay
away from overly abstract explanations (this is particularly important when you are explaining
what CBT treatment is and how it works). It also bears remembering that asking the client to
summarise what has been discussed in his or her own words is a useful strategy for ensuring
comprehension. Make sure you address any misconceptions or misunderstandings about
therapy in a sensitive manner and reinforce anything that the client has understood correctly.
41
In addition, the following worksheets will help provide the client with a better understanding of
some of the fundamentals of CBT:
 Info Sheet 1—What Is Cognitive Behavioural Therapy?
 Info Sheet 2—Linking Thoughts, Feelings, and Behaviours for Depression
 Info Sheet 3—Linking Thoughts, Feelings, and Behaviours for Anxiety
 Info Sheet 4—Linking Thoughts, Feelings, and Behaviours for Anger
Confirm the Client Will Attend All Sessions

The final item you will need to cover during the initial phase of treatment is a commitment from
the client to attend all the sessions offered (up to twenty). Be aware that depression and anxiety
can cause a lack of motivation to do anything or seek help. The client may seem reluctant or
even hopeless about the prospects of treatment. Assuming you can overcome this and acquire a
commitment to stick with the sessions early on, it’s possible that motivational problems will return
later in therapy8. Therefore it is important that you help the client maintain motivation throughout
therapy.
We recommend you use motivational interviewing (MI) to encourage the client “try out” CBT.
Strategies for improving and/or maintaining the client’s motivation for treatment (Miller & Rollnick,
1991) include:
 Developing discrepancy: You can identify the gap between where the client is and
where he or she wants to be in a positive manner. Keep reminding the client of the goals
that he or she has set out to achieve during therapy while being sensitive to his or her
concerns about the efficacy of treatment.
 Avoid arguments: Conflict over resistance to treatment is generally counterproductive. It

can distract the therapist from the goal of motivating individuals towards change, whilst at
the same time increasing the client’s distance from and lack of motivation to engage in
therapy.
 Support self-efficacy: Clients who are able to see themselves progressing, believe in
their ability to make changes, and perceive recovery as successful are more likely to
achieve their goals. This can be difficult for people with learning disabilities as they may
lack confidence in themselves or have self-efficacy deficits. Provide clients with learning
8
Surprisingly, motivational problems are actually most problematic toward the end of treatment (Anderson &
Kazantzis, 2008).
42
disabilities with plenty of positive feedback over the course of treatment and regularly
take notice of their improvements.
In addition to these MI techniques, it’s also extremely useful to create a timetable of weekly
activities the client engages in, including scheduled therapy sessions. Set the day and time of
sessions at the beginning of treatment, and create a timetable the client (and support worker)
can refer to as needed to remind him or her of scheduled appointments.
Summary of the Initial Phase of Treatment

By the end of the initial phase of treatment (session 4) you should have answers to the following
questions:
 What skills does the client possess that will help him or her?
 Does the client understand what treatment entails?
 What materials and tasks can help the client to practice and improve these skills?
 Does the client have any concerns or worries about the treatment?
This is valuable information, as it sets the stage for the remainder of treatment. We will outline
how to handle the middle and final phases of treatment in the chapters that follow. However,
before we move into that material we must first turn our attention to psychoeducation and how to
address people who have learning disabilities.
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Chapter 4
Psychoeducation
One of the objectives of the early sessions of therapy is to provide the client with
psychoeducation regarding depressive and anxiety disorders. The purpose of this process is to
enable the client to cope better with these disorders by providing greater knowledge and
understanding of the symptoms. In this chapter we will review the basics of psychoeducation for
people with learning disabilities and outline special strategies we recommend when working with
this population.
Psychoeducation of Depression
As we reviewed in Chapter 1 the symptoms of depression include (the following has been
extracted from Andrews & Jenkins, 1999):
 Feeling miserable. This misery lasts at least a week or two, where the feeling is present
most of the day and varies in its intensity.
 Loss of interest or pleasure in daily activities.
 Loss of appetite (and excessive weight loss).
 Loss of energy.
 Loss of sleep even when exhausted. Sleep is usually restless and the individual wakes
up earlier than usual. (Some people may sleep more than usual.)
 Loss of interest in sex.
 Persistent worrying about things that are not important.
 Slowed and inefficient thinking, with poor concentration.
 Recurring unpleasant thoughts, particularly of guilt (of being a bad person and wishing to
die).
 Slowed activity and speech.
 Fearfulness (of people and places). This often leads to withdrawal from family, friends,
and everyday activities.
You will need to explain each of these symptoms to clients using the communication strategies
we have provided in earlier chapters. In Part 3 you will find a sheet that provides information
about the reasons and symptoms of depression and a worksheet that will help you and the client
identify thoughts, feelings, and behaviours that arise when the client feels depressed.
44
These are:
 Info Sheet 5—What Is Depression?
 Worksheet 3—When I Feel Depressed I …
In addition to these worksheets we recommend the picture book Feeling Blue published by the
Royal College of Psychiatrists website (Royal College of Psychiatry, 2009). In the book a
character named Ron has lost interest in the things he usually enjoys. This pictorial story will be
a good fit for many clients with learning disabilities and provides an easy-to-comprehend visual
and textual representation of how depression develops and how it can be healed. Feeling Blue is
available online at:
http://www.rcpsych.ac.uk/publications/booksbeyondwords/bbwonlineversions/feelingblue/bluecov
er.aspx
The therapist, client, and support worker should review these materials and fill out the symptoms
worksheet together. Once complete, the client will be able to take the worksheet and refer to it
when he or she needs to. We also recommend that you review these worksheets and the client’s
symptoms and behaviours at the end of the treatment in order to help him or her catch and
address any relapse as soon as possible.
Always keep in mind that people with learning disabilities are often not able to express their
feelings easily in words and use behaviour to communicate with others. It is very important to
watch for any sudden changes in behaviour or mood as important signs of depression. For
example, if the individual is not able to do things that he or she could previously do, this is an
indication that further action may need to be taken or treatment extended. It’s also important to
reiterate that depression is linked to low self-esteem in people with mild and moderate learning
disabilities, so any fluctuations in self-esteem should be considered possible signs that problems
may be developing or recurring. Self-esteem problems—often linked to a lifetime of criticism and
bullying—are quite common amongst this population. Therefore, it’s likely you will encounter self-
esteem issues and the resultant negative feelings low self-esteem inspires in sessions. If
problems like these arise, make sure you address self-esteem with the client and help him or her
understand its connection to depression and its relevance to treatment. It may be necessary to
revise worksheets to refine and update the thoughts, behaviours, and feelings that are linked to a
client’s depression as symptoms like these arise. Consider this an ongoing work in process over
the course of the therapeutic relationship.
By taking this approach and working with the client to increase his or her knowledge about
depression and exploring how the client feels and behaves when he or she is depressed, you will
set the stage for the client to eventually become his or her own therapist and for healing to occur.
45
Addressing Suicidal Thoughts and/or Parasuicidal Behaviour

Suicidal thoughts and wishes are common in depression, and the therapist will need to address
them when and if they arise. It is important to understand why the client is having such thoughts
and use intervention strategies to overcome them promptly. Begin by exploring the motivation for
the suicidal thoughts and/or parasuicidal behaviour. This information will inform you as to how
you should proceed (Beck et al 1979). Common reasons include for suicidal thoughts/behaviour
include (from Beck et al, 1979):
 The desire to escape from life. In this case, you should focus on and address the
client’s feelings of hopelessness and lack of positive feelings.
 Social isolation. Developing appropriate social interventions is essential in these cases.
 A distorted or pathological view of self or others. When this is the case you should
help the client to identify and work through his or her misconceptions and irrational
beliefs.
 To influence or manipulate others. You should focus on helping the client understand
and work through his or her desire to manipulate or influence others.
Once the motivation for the suicidal behaviours or ideation has been addressed, you will need to
employ some techniques to help the client cope with these suicidal thoughts and actions. The
first strategy we recommend is asking the client to list his or her reasons to live and contrast
those with his or her reasons not to live. During this exercise you should elicit specific, concrete
examples from different aspects of the client’s life (including their personal, social, and family
lives). For depressed clients it may initially be difficult for them to think of reasons to live at this
point in time. If this is case, we recommend encouraging the client to explore reasons he or she
would have considered it worthwhile to continue living at a time when he or she was happier.
However, you will need to determine which of these past reasons are still valid in the present and
which will continue to be valid in the future (Beck et al, 1979). After valid reasons for living have
been identified, it is useful for the client to rate each reason. This helps put a quantitative
assessment on otherwise abstract material.
The worksheet “Worksheet 4—Good and Bad Things in My Life” in Part 3 will facilitate this entire
exercise and provide a place for you and the client to write down the answers that are developed
during the session. We recommend writing down all of the legitimate responses that are
developed as well as the rating for each. This allows the client to refer to this material in the
future, as individuals who are suicidal are likely to forget, ignore, or discount the value of their
positive reasons for living, particularly when they are in a bout of suicidal ideation.
46
Performing this exercise with individuals who have suicidal thoughts will allow the client to view
such thoughts more objectively, ideally making the rationale for the thoughts or behaviours seem
less absolute and/or compelling (Beck et al, 1979). It will also allow the client to think in a less
dichotomised (black and white) manner. All of this is useful as a first step in getting past suicidal
thoughts and behaviour.
In addition to the exercise above, we recommend undertaking a number of additional intervention

strategies with the client in order to reduce the occurrence of suicidal thoughts. These include but
are not limited to:
 Brainstorming and applying solutions to personal problems.
 Focusing attention away from the suicidal thoughts—providing distractions.
 Developing behavioural strategies the client can use when suicidal thoughts reappear.
Writing these down on flashcards can provide the client an easy way to access the
strategies when in the midst of suicidal ideation. Behavioural strategies may include:
o Calling a friend or a family member.
o Visiting a friend or a family member.
o Going out for a walk at his or her favourite park or place.
o Having his or her favourite food.
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Suicidal Behaviour Checklist
The following behaviour strategies checklist for therapists (adapted from Marsha
Linehan, 1993) may also be helpful.
1. Assess the risk of suicide and parasuicide.
2. Get the client and the support worker to remove lethal items from the
client’s living space.
3. Empathically instruct the client not to commit suicide or engage in

parasuicide.
4. Hold and reiterate the view that suicide is not a good solution.
5. Generate hopeful statements and solutions for coping with suicidal

thoughts.
6. Discuss the risks of a particular client’s parasuicidal behaviour and

contribute to a risk management plan. This is the responsibility of the
entire clinical team.
7. Make sure the client and support worker are aware of appropriate services
available.
As always, we recommend the support worker be brought into these conversations as much as
possible. It is important for the support worker to reinforce the points discussed above and those
brought up during therapy outside the therapeutic setting as needed to make the work done in
the clinical setting stick. It’s also important that the support worker disclose any knowledge of
suicidal thoughts or intent on the part of the client. This helps provide a more complete
understanding of how severe the problem is.
In the most severe cases, the client may need to be referred for an emergency evaluation by a
mental health professional.
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Psychoeducation of Anxiety
In addition to psychoeducation regarding depression, it is also important for you to educate the
client about the symptoms of anxiety disorders as needed. We reviewed the following symptoms
in Chapter 1 (as extracted from Andrews and Jenkins, 1999). These should be shared and
discussed with the client. Common symptoms of anxiety include:
 Nervousness or restlessness
 Trembling
 Trouble falling or staying asleep
 Sweating
 Poor concentration
 Palpitations
 Frequent urination
 Muscular tension
 Easily fatigued
 Irritable mood
 Light-headedness or dizziness
 Hyperventilation
 Shortness of breath
 Depressed mood
In addition to the above, there are a number of behavioural correlates that commonly appear in
people with learning disabilities who suffer from anxiety disorders. These include:
 Aggression
 Increased irritability (see the special note on irritability below)
 Avoidance behaviour
 Self-injury
 Unnecessary motor activity
It’s important to be aware of these behavioural correlates and discuss them with the client as well
as the symptoms of anxiety disorder outlined above. For some people with learning disabilities
these behavioural correlates will be more prominent than their cognitive counterparts. So
recognising them and helping the client to understand the relationship between behaviour and
anxiety is of particular importance. On the other hand, symptoms such as excessive worrying,
49
avoidance of potentially feared stimuli, and physiological signs such as feelings of choking and
palpitations may not be reliably diagnosed or even reported in people with learning disabilities.
One of the best ways to educate this population about anxiety is through the use of “body maps”.
We recommend using an informational body map to illustrate common physiological symptoms
associated with anxiety as well as a blank version that allows the client to point to and discuss
physical symptoms he or she experiences when feeling anxious.
Using body maps to help clients with learning disabilities familiarise themselves with the ways
in which the body reacts to stress was a very effective method according to some therapists
who tested this protocol.
Body maps are particularly useful as you work to help the client attribute normal explanations to
his or her anxiety symptoms and separate psychological symptoms from bodily sensations. For
all people with anxiety disorders, bodily sensations can be misinterpreted as an approaching
physical or mental catastrophe such as fainting, a heart attack, or death. This “catastrophising”
can lead to increased anxiety and worry (Butler & Fennell, Hackmann, 2008), thus creating a
negative feedback loop in which clients can easily become trapped. This kind of extreme reaction
to an event is particularly prominent in people with learning disorders and should be addressed
carefully and consistently.
During the early sessions when you are educating the client about anxiety you should use and fill
out the following worksheet in Part 3 of this manual:
 Info Sheet 6—What Is Anxiety?
 Info Sheet 7—Signs of Anxiety (Body Map)
 Worksheet 5—When I Get Anxious I Feel (Body Map)
As with the depression worksheets discussed above you need to fill these out during sessions
with the client and loop the support worker into this process as necessary. Having a tangible
takeaway with written information is as important when addressing anxiety as it is when
addressing depression. In both cases, the client can refer back to these materials as needed
outside the therapeutic setting.
We recommend you review this material at the end of treatment in order to help catch and
prevent relapse.
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A Special Note on Irritability

Irritability is a very common behavioural correlate of depression and anxiety in people with
learning disabilities, and challenging behaviour is a key atypical feature of either condition.
Relaxation techniques can help reduce arousal, whilst coping skills can help reframe cognitions
to provoking situations. We suggest you remain particularly attentive to irritability issues with
these clients, work to help them understand the link between their irritable feelings and their
underlying depressive or anxiety disorder, and cope with these feelings in real time using the
techniques described here. The following techniques and considerations may also help.
Working on Anger with People Who Have Learning Disabilities

From a CBT perspective you need to understand the specific problems that drive the client’s
anger. Ask the client to keep an anger diary for a week so you and the client can begin to make
the link between his or her triggers and the resultant thoughts and feelings. The more the client
can understand the links between what triggers his or her anger and how he or she responds to it
the more the client will feel able to manage it.
Examples of Triggers in People with Learning Disorders
1. Problems with communicating feelings

2. Feeling misunderstood
3. Feeling scared or intimidated
4. Believing that they can’t trust themselves due to past experiences (e.g.
a past example of reacting to a situation with anger and physical
aggression and worrying it might happen again)
The therapist should be aware that in many cases, situations where the client is experiencing
anger are related to the individual’s appraisal of the given situation. The client will often have
demand-driven rules in his or her head about how others should think and behave. This may fuel
emotional responses. For example, one client described how people often repeated things when
around him and how he felt angry that these people seemed to assume he was stupid. He
believed that people should not make assumptions about his intelligence and began to shout at
them as a defence. In this case, a gentle exploration by the therapist examining the client’s
assumptions about what others may or may not be thinking and also questioning whether others
should always behave in a reasonable way was undertaken. This considerably lessened the
client’s anger. Processes such as these need to be undertaken very sensitively without
invalidating the client’s experience.
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Depending on severity, clients with learning disabilities may find it hard to link situation or triggers
with the resultant thoughts and feelings they elicit. For many people with learning disabilities
focusing on physiological responses may be more helpful. For example, you may want to help
the client think about a recent situation where he or she felt angry, where he or she was when
this occurred, and the situation out of which the anger arose. Once you have developed the full
scenario together, ask the client where he or she felt the anger in his or her body during this
situation. This will help to give the client a physical experience feeling anger and help him or her
realise there is a physiological response when anger arises. Once the client is able to recognise
where he or she feels the anger, the individual can then put this skill into practice when in trigger
situations.
It may also be helpful to agree to a way for the person to start noticing anger on a scale. You
may use a number scale like the following:
 Not angry = 0
 Getting angry = 5
 Very angry = 10
You could also use an anger dial, a volcano (so the more angry the person get the more likely
the volcano will erupt), or a traffic light system (red represents anger, etc.). Any useful method for
rating the anger that the client can understand will likely be helpful.
Additional strategies you may employ to help the client manage anger could include:
 Role-play to help the client try out new behaviours.
 Gently challenge dysfunctional assumptions and help the client to come up with a more
balanced view of a given situation.
You may also provide the client with some simple behavioural interventions he or she can use
when dealing with anger.
These may include:
 Walking away. Encourage the client to get some distance from the anger-making event.
 Get calm. The client can engage in pleasurable and relaxing activities such as having a
bath, listening to his or her favourite piece of music, or watching his or her favourite TV
programme when anger arises.
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 Rethink. After the client is calm, encourage him or her to ask the following questions:
o Does my angry response foster a good relationship with the person I am angry
with?
o Do I have other options instead of anger?
o When the client is calmer, he or she can then engage in these alternative
responses.
Whatever methods you utilise, the key is to understand that there are two parts to the anger
management process. One is to help the person recognise what he or she is feeling. The second
is to help him or her feel confident enough to communicate it effectively. Because communication
is often difficult for people with learning disabilities, you may need to spend more time on helping
the client to label what he or she is feeling.
It is also important to make sure the client has understood what you are explaining. It can help to
ask the client to repeat back what has been discussed in the session. This will help you notice
any gaps in understanding before he or she leaves the session. Always be aware that clients
with learning disabilities may agree with what you are saying or reiterate pieces of it without fully
understanding the task or concept. It’s important to take the time necessary to ensure adequate
understanding.
According to one therapist who worked with this protocol, all the clients
she saw expressed anger regarding unfairness about the way they were
treated in the past. This is an area you may want to consider when
addressing anger, irritability, and the way these emotions influence
anxiety and depression.
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A Special Note on Medication

Some of your clients may already be taking medication for anxiety disorders and/or depression.
These medications are usually antidepressants such as selective serotonin reuptake inhibitors
(SSRIs)—examples include sertraline and fluoxetine—and anxiolytics such as benzodiazepines
or beta-blockers.
You may discuss wish to provide some education on how medication can help people with
depression and anxiety disorder. A good website that provides information on numerous
psychiatric drugs in accessible format is the University of Birmingham’s “LD Medication
Guidelines” page at http://www.ld-medication.bham.ac.uk/medical.htm. This site also contains an
accessible template on “When and How to Use Your Medication”, which is very useful for people
with learning disabilities.
It is important for you to also liaise with the prescriber as treatment may require changes in the
client’s medication regime, and to stay in the loop about any changes in medication the
prescriber may recommend. Furthermore, you should also be aware of any side effects of
medication your client is taking that may affect treatment. For example, a client may have
difficulties concentrating during the session due to medications he or she is taking.
This concludes the module on psychoeducation. In the next chapter we will outline the protocol
for the middle sessions of therapy and the specific interventions we recommend you take during
these critical sessions.
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Chapter 5
The Middle Sessions (Sessions 5–14)
In the first sessions the focus was psychoeducation and assessment. Once these tasks are
completed, it’s time to move into actively altering the client’s depressed/anxious thoughts,
feelings, and behaviours. The middle sessions are designed for this and are the stage of
treatment where the client engages actively in CBT and starts to discuss and work through his or
her problems. During this time you will work with the client to generate new, more adaptive ways
of thinking and behaving. The general goals of these sessions are to:
 Discuss and work through different life situations and how to better manage them.
 Manage anxiety and depression.
 Discuss relaxation techniques and healthy living.
 Explore the client’s thoughts, feelings, and behaviours and establish the links between
them. (We will provide more information on linking thoughts, feelings, and behaviours in
Chapter 6.)
 Train the client to use alternative techniques to cope with negative thoughts and
unhelpful behaviours. (Specific cognitive interventions and behavioural interventions will
be dealt with in Chapters 7 and 8 respectively.)
 Explore additional skills that will encourage the client to use CBT techniques
independently. (We will address assertiveness skills and social skills specifically in
Chapter 9.)
In this chapter we will review the format of these middle sessions, discuss the relaxation skills
and healthy living techniques you should share with the client, and provide some
recommendations regarding the midpoint review. Then in the following three chapters we will
cover the specific interventions you need to employ as outlined above.
Format of the Middle Sessions

Developing a consistent format and structure during these middle sessions is important. Knowing
what to expect will help clients with learning disabilities stay focused and relaxed. What follows is
the format we have found to be most effective.
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Set the Agenda

At the beginning of each session you should set an agenda. This should be done in conjunction
with the client. A good way to start sessions is with simple questions like “How have you been
since the last session?” Such an inquiry helps the client open up and discuss items he or she
wishes to address during the session while also providing you with an opening to go over the
learning points from the previous session as well as any homework tasks that have been
assigned. Addressing these items early in the session will help you and the client develop the
agenda for the time you are together.
If the client has difficulty expressing him- or herself or is hesitant to open up to such questions,
he or she may be given a number of choices about items you may wish to address together
during the session. These choices should be simple, straightforward, and not too complicated.
You can also use the worksheet “Worksheet 6—What We Will Do Today” as needed to help set
the agenda.
Review the Previous Session

Once the agenda has been set you should briefly review the main ideas that were covered in the
previous session. This helps create continuity between the sessions and offers an opportunity to
address any specific points, interventions, and ideas you wish to drive home that were discussed
in your previous work together.
Review Homework
The next step is to review homework. You should set aside about ten minutes at the beginning of
each session to go over homework tasks from the previous session(s). Inquire about the client’s
experience with the homework, not just about the tasks assigned. Clients should be encouraged
to give both positive and negative feedback. One way to facilitate this is by using the “Homework
Rating Scale” in Part 3. This offers a non-threatening, non-confrontational way for the client to
honestly assess how he or she felt about the task(s). Of course, direct verbal inquiry regarding
the client’s level of enjoyment and overall experience with homework is also important.
You will need to discuss any difficulties that the client may have experienced while attempting to
complete homework tasks and address these as needed. Refer to Chapter 3 for more
information on homework tasks and how to address any difficulties that arise.
Since a support worker will ideally be helping the client with his or her tasks, it is also important
to ask for the support worker’s feedback on how the homework went, how much the client
seemed to enjoy it, and the client’s overall willingness to engage in the tasks at hand.
Discussing and Addressing Problems: Setting Goals and Working Toward Resolution
Once the above objectives have been completed, the bulk of the remainder of the session should
be allocated to discussing and addressing and problems the client would like to explore. These
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problems may be items the client comes into the session with or they may be items that come up
during your discussion about the homework. Refer back to the agenda created earlier in the
session, update it as needed if you and client wish to spend additional time and specific
problems related to homework, confirm with the client that all target complaints have been
identified, then set goals to tackle these problems during the session. The number of goals
addressed in a session will depend on the client’s abilities and the simplicity of the goals you
have set. Generally, no more than three goals can be adequately handled in a given session.
Understand that ability levels vary considerably amongst people with learning disabilities.
Moreover, ability levels may also vary within the individual based depending on the skill the
person is attempting to acquire or execute. It is therefore important that you closely assess each
goal in this regard.
It is important that you and the client work together to create goals that are:
 Specific: Goals need to be simple and precise, not involving too many components and
rules.
 Realistic: The goals need to be achievable for the client and they need to involve
solutions that he or she can utilise independently.
 Can be monitored: It is essential for the goal to be observable, so the client can see and
recognise the changes taking place. The goal could be as simple as meeting at a day-
care centre or sitting next to someone on a bus. Being able to see changes helps
maintain motivation during therapy. Identifying strategies that work for the client versus
those that don’t is also useful.
 Positive: Positive language may help encourage change in the client. For example, you
should model goals as an opportunity to “develop new skills” or “improve extant skills”,
not as a way to “avoid mistakes” or “overcome personal failings”.
 Time-limited: As CBT is a structured therapy; goals need to be achievable in certain
time limits. This is also important for people with learning disabilities to keep them
involved and focused. Typically, one or two attempts to manage a particular goal are
sufficient. After that it is important to consider whether some of the work done can be
transferred to another goal. For example, it has become apparent that generalising is
very difficult for people with learning disabilities. So it is important to allow some time for
the client to get used to a task and rehearse it again with the support worker as needed.
Once the goals have been set, you and the client should work together to identify concrete
behaviours and/or concrete events that indicate the client has successfully achieved the goal. If
we continue with the examples of sitting next to someone on the bus mentioned above, the
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concrete evidence this goal has been achieved would be the client reporting that he or she has,
in fact, sat next to someone on the bus. The worksheet “Worksheet 7—My Goal” in Part 3 will
help you facilitate establishment of goals as well as the concrete evidence that said goals have
been achieved.
Establishing Homework Task(s) for the Next Session

You will want to set aside about ten minutes at the end of the session to discuss the homework
to be completed for the next session. Homework tasks should be relevant to the client and to the
topics discussed in the session. Please refer to Chapter 3 for guidelines on setting homework
tasks. Take the time to explain and rehearse the homework task(s) with the client. Enlist the
support worker’s assistance as needed to encourage the client to complete the homework task(s)
in time for the next session.
Session Summary and Mutual Feedback

It helpful to spend the last few minutes of the session going over the main points you and the
client discussed. When possible, end with a simple message for that the client can take with
them as they leave therapy for the day. You may even wish to write this message down and give
it to the client.
We also recommend taking some time to explore any misconceptions that may have arisen
during the session. Over the course of each session you will want to summarise main points and
work to reinforce the topics being covered. Similarly, you should regularly check in with the client
and ask him or her to summarise what you have discussed to ensure understanding. When
misconceptions arise, make sure you address them at the time they arise and at the end of the
session. Going through this process is especially important with people who have learning
disabilities, as it can be difficult to make sure what has been addressed in the session has been
adequately understood. As you review and investigate client’s level of understanding, be wary of
responses which seem designed to please you or make you think understanding has taken
place.
It’s also useful to have a discussion with the client about how the session went. Both of you can
share your ideas and opinions about the session. Keep this positive and provide the client with
positive feedback and reinforcement about the progress that is being made.
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Remind the Client of the Next Session

Before you part ways you should remind the client and the support worker of the time and date of
the next session. This will help reassure the client that the sessions are regular and that your
work together is not at an end.
Obviously, there are many possible concepts, skills, and techniques you may introduce and
explore over the course of these critical middle sessions. We will provide specifics on some of
what you may include in the chapters that follow. However, two topics you will definitely need to
address are relaxation and healthy living. We would like to briefly discuss those now.
Relaxation and Healthy Living

Over the course of the middle sessions it is critical that you introduce, discuss, and reinforce the
importance and benefits of healthy living and relaxation techniques in maintaining good mental
health. When treating people with learning disabilities, such an introduction is particularly
important, as many will not be familiar with the topic. What follows is brief set of suggestions on
what you may wish to address as well as a few tools you can take advantage of to assist in the
process.
Reducing Anxiety and Stress Levels: Using Relaxation Techniques

As most therapists are aware, educating clients about and training them in the use of relaxation
techniques such as deep breathing, visualisation, and progressive muscle relaxation can be very
helpful in reducing anxiety and stress levels and maintaining overall health. When practiced
regularly, these activities lead to a reduction in everyday levels of stress and boost feelings of
joy.
However, introducing these techniques to people with learning disabilities can present a
challenge unless handled appropriately. Taking a person with learning disabilities through a
complex regime of progressive muscle relaxation or long visualisation exercises is typically not
useful. This is why the Camden Learning Disabilities Service has developed a fifteen-minute
Easy Relaxation CD for people with learning disabilities that provides instructions on simple
breathing and muscle relaxation techniques. If you choose to provide this to your client, he or she
can use it at home with the help of his or her support worker.
Whether you use the CD or other simplified relaxation techniques, you should discuss the
techniques and why they are useful in the early part of the middle sessions. Once introduced,
these techniques should be added to the client’s daily schedule. The support worker may be
enrolled to reinforce the use of these techniques by reminding the client to do them or providing
materials (such as the aforementioned CD) for this purpose. Review the techniques as needed
and ask the client about his or her experience with them in subsequent sessions.
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Healthy Living Techniques

You should also discuss other healthy living techniques that will help reduce stress and increase
overall feelings of joy with the client. These may include:
 Reducing caffeine: Caffeine is a stimulant and can stay in the system for a long time.
Too much caffeine can make individuals feel restless, anxious, and irritable. It can also
inhibit quality sleep and cause headaches, abnormal heart rhythms, or other problems.
You may suggest that the client moderate caffeine intake and avoid drinks containing
caffeine starting in the mid-afternoon. Tea, coffee, energy drinks, many soft drinks, and
chocolate contain caffeine.
 Improving sleep habits: Good sleep habits are essential for physical and mental health.
To improve sleep habits we recommend you encourage clients to create a sleep
schedule, avoid napping during the day, and establish a pre-bedtime routine to help the
client realise it is getting close to bedtime. Work with the client and the support worker to
decide what may be included in such a routine. Examples include having a warm bath,
listening to relaxing music, having a glass of warm milk, or other activities that help the
client relax.
 Promoting exercise: Regular exercise can improve mood and is good for sleep.
Exercise in the morning can help the client feel good throughout the day and relax in the
evening. Make sure to keep exercise gentle and encourage the client to avoid exercising
close to bedtime as this stimulates the body and is bad for sleep. Exercise should be
added to the client’s daily schedule.
It is worth noting that the Camden Learning Disabilities Service has also developed a 35-minute
Canned Health CD for people with learning disabilities that provides information on healthy living
and covers topics such as healthy eating, walking, sleep, working, the importance of being with
friends, laughter, and hydration.
The Midpoint Review

Approximately halfway through the treatment programme you will need to spend a session or two
reflecting with the client and the support worker about progress being made in treatment and the
client’s goals for the remainder of treatment.
A good way to start this process is by asking the client to fill out a WAS form. This can be
discussed and compared to the WAS produced in the early sessions to provide a concrete guide
regarding improvements made up to this point in therapy. These improvements can be
concretised by helping the client focus on particular thoughts, events, behaviours and/or
situations where he or she has successfully used the skills acquired in therapy to address
otherwise threatening or emotionally disturbing situations. Take the time to provide the client with
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an overview of the skills you have covered in previous sessions, and practice them with the client
as necessary to reinforce learning. This help the client have a clear understanding of what has
been covered and the successes he or she has made during therapy.
You should also discuss how close the client is to meeting the goals that were established early
in the therapeutic process, how he or she feels about meeting these goals, what parts of the
goals may need further work, and what, if anything, needs to be added to the original list of
goals.
This review will set the stage for the final sessions where you will close the loop, reinforce the
techniques and skills learned, and end therapy with the understanding that the client has
acquired the needed knowledge to “become his or her own therapist”. In Chapter 10 we will
review how these final sessions should look. But before we get to that, let’s look at the additional
skills and topics you need to address during these middle sessions.
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Chapter 6
Linking Thoughts, Feelings, and
Behaviours
A key part of CBT is helping the client to understand the links between his or her thoughts,
feelings, and behaviour. As we explained in Chapter 1 the traditional model of CBT proposes that
an activating event (A), in association with an individual’s beliefs/thoughts (B), can elicit certain
emotional and/or behavioural consequences (C). While there are a number of potential points
where a therapist can intervene in this sequence (including cognitive, emotional, and behavioural
techniques), what is ultimately at stake is challenging and/or altering the underlying belief(s) that
create the tether between activating event and emotional or behavioural consequences.
Clients with learning disabilities often have a difficult time with this part of treatment unless it is
addressed in a specific sequence. For these clients it is advisable to start with their emotional
responses, help them understand how thoughts arise from these feelings, and then add in the
behavioural link as a final step.
In this chapter we will review a method for linking thoughts, feelings, and behaviours that starts
from the emotional response and describe some specific nuances you may need to consider
when working with people who have learning disabilities.
Using the techniques in this chapter to establish the links between thoughts, feelings, and
behaviours has proved very useful according to the group of therapists who tested this protocol.
Begin by Discussing and Identifying Feelings

Rather than starting with a conversation about how a particular thought or situation makes the
client feel, for people with learning disabilities it is generally more useful to begin by having a
simple discussion about feelings. Try to understand what the client means when talking about
different emotions. To do this, you may start by asking what the client is feeling in the present
moment. As it will likely be difficult for many clients with learning disabilities to verbalise a
description of their feelings when asked, you can offer the client a list of feelings to choose from
(in written or verbal form), encourage the client to draw his or her feelings, or ask him or her to
identify the feelings from a series of pictures like the ones provided in “Resource 3—Image Bank”
in Part 3. You may also find it useful to do a role-play of different emotions with the client and/or
support worker to help the client accurately understand and identify various emotional states.
Role-play has proven to be a very effective technique throughout the therapeutic process with
people who have learning disabilities, according to therapists who tested this program.
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Make sure to target simple emotions and keep any verbal descriptions or definitions of feelings
simple and personalised to the client. The following is a list of different emotions and alternative
words that can be used to describe particular emotional states. Focus in on emotions and terms
the client resonates with when sharing this information.
 Sad: Depressed, down, tearful, blue
 Anxious: Agitated, bothered, edgy, frightened, nervous, nervy, restless, worried, scared
 Angry: Aggressive, annoyed, bad-tempered, complaining, cross, irritated
 Ashamed: Humiliated
 Disappointed: Frustrated, let down
 Embarrassed: Awkward, humiliated, uncomfortable
 Guilty: At fault, in the wrong
 Hurt: Devastated, harmed, injured, offended, wounded
 Jealous: Green-eyed, envious
 Love: Admiring, adoring, fond
Once you are confident the client is able to accurately identify his or her emotions, the next step
is to make the thought-feeling link.
Some clients with learning disabilities actually have an enhanced awareness of their own
emotions and the emotions of others. These clients are typically remarkably sensitive to
the feelings and emotional responses of those around them. For example, they can often
detect whether or not people like them. One explanation may be that these clients have
developed this ability to protect themselves against threats such as criticism and attack by
others. For this reason they may be hyper-vigilant where emotional responses are
concerned. It is important to keep this in mind as you proceed with therapy.
Establishing the Thought-Feeling Link

Establishing the link between feelings and thoughts can be challenging for people with learning
disabilities. The key to successfully accomplishing this is staying simple and concrete. Start by
explaining that sometimes people have unpleasant feelings and dwell on them or avoid thinking
about them. Since this is likely to be an experience the client has had, this will be a nice segue
into the clink between feeling and thinking.
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Next, work with the client to establish a set of examples from the client’s personal experience in
which the client felt a particular emotion and a particular thought arose as a result. The simpler
and more explicit you can keep the examples, the more likely you are to effectively communicate
the relationship between thinking and feeling. Develop a significant set of problem areas that
have come up the client’s past, and try to ensure that the client can identify the feeling that arose
and the thought that came up as a result of this feeling. Keep in mind that “trying not to think
about it” is a thought.
Assuming that the above links can be established and the client is sufficiently cognitively
advanced, you may wish to explain at this point that the goal of CBT is to help the client carry on
and live a good quality of life in his or her daily life in spite of these feelings. The feelings and the
thoughts the individual generates may or may not be reduced over time, but by identifying the
relationships the client can still live well. This discussion, if it is possible, will segue nicely into the
behavioural component. As always, it is essential to keep these concepts as simple and
straightforward as possible to ensure the greatest understanding.
Establishing the Relationship Between Thoughts, Feelings, and Behaviours

The final step is to help the client bring the links together and understand the relationships in the
cognitive triad. While a full explication of core beliefs is unlikely to be useful to these clients, it is
important for you to explain that there is a relationship between negative thoughts/beliefs, that
these thoughts and beliefs are at the core of the “unwanted” feelings, and that thoughts and
feelings have led to the client’s behaviour.
While establishing the link between negative thoughts and unwanted feelings is important and
the techniques for linking thoughts, feelings, and behaviours in this chapter useful, the therapists
who tested this protocol found that unnecessarily focusing on negative thinking for too long was
detrimental to the therapeutic process. Clients with learning disabilities easily get “caught” in
negative thinking and sometimes have a hard time breaking free of the cycle. So be wary about
the amount of time you spend on negative thinking.
One option in this regard is to take an ACT approach—where you help the client focus on negative
thinking as process, not content, and try to help him or her cease engaging with individual
negative thoughts. For more on ACT see Acceptance and Commitment Therapy: An Experiential
Approach to Behaviour Change.
Using a visual to help explain these relationships can be very useful. Figure 6.1 shows a
diagrammatic representation (modified from Willson & Branch, 2006) of the links between a
trigger event, “I think people look at me in a ‘funny way’”, and its connections to the core belief at
the centre and associated emotions, behaviours, and physical sensations at the periphery. You
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can use this, or a simplified version of it, to help when you are explaining the relationships
between thoughts, feelings, and behaviours.
Trigger: I think
people look at me Attention focus:
in a “funny way”.
Focusing on how much
my stomach aches
Key thoughts and Physical

Emotions: meanings: sensations:
Nervousness, My stomach tying in Sweaty,
paranoid, knots and I feel heart racing
panic/irritability angry.
, anger.
Behaviour:
Talk to support worker,

leave the situation, start
shouting at my support
worker
Figure 6.1: Linking Thoughts, Feelings, and Behaviours
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In addition to a didactic explanation of the relationships in the cognitive triad, it’s essential to
qualify this against the client’s own experience. We encourage you to ask the client to keep a
simplified “Worksheet 8—Thoughts and Feeling Diary” like the one in Part 3. After the client
tracks his or her thoughts and feelings for a certain period of time, you can then begin to discuss
the relationship between the trigger events the client experienced, the beliefs activated, and the
emotional and behavioural consequences. The following worksheets in Part 3 will further
facilitate this process:
 Worksheet 9—Thoughts, Feelings, and Behaviours
 Worksheet 10—Good Times
 Worksheet 11—Bad Times
According to all the therapists who have used these techniques with clients who have learning
disabilities, a “Worksheet 8—Thoughts and Feelings Diary” and identifying good and bad times are
extremely effective ways to help clients identify what they enjoy and what they find difficult. They
are also useful in helping the client plan enjoyable activities to lift his or her mood.
Review the client’s “Worksheet 8—Thoughts and Feelings Diary” during sessions and talk
through the various relationships between thoughts, feelings, and behaviours with him or her.
Again, all of this material needs to be kept as simple as possible. Use lots of repetition so that the
client becomes familiar with the links between the trigger, thoughts, feelings, and behaviour. A
flip chart may be used with simplified language to give examples.
Here is a sample of how this dialogue might occur:
Therapist: “In your diary, you said you felt sad yesterday…. Where were you?” (This enables
you to identify the mood state and the possible trigger.)
Client: “I went to the shop.”
Therapist: “Were you sad before you went to the shop?”
Client: “No, but the man shouted at me.”
Therapist: “So you went to the shop, the man shouted at you, and you felt sad.” (Reiterating this
way helps the client understand and make the links between the sequence of events.)
Client: “Yes.”
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Therapist: “So that upset you. Why was that?”
Client: “It’s not nice to shout. It scared me.” (Several approaches could be used here, but
challenging the evidence at this stage may not be helpful, as it might invalidate the client’s
feelings.)
Therapist: “So the man shouted…. What did you think would happen?”
Client: “I might get into trouble…. He might call the police.” (There is evidence of a thinking style
error here, but rather than challenge it you might proceed further using the downward arrow
technique.)
Therapist: “So what did you think would happen if the man called the police?”
Client: “They may tell me off and I might get taken to the police station.” (At this point you may
explore the anticipated outcome and challenge the fortune-telling.)
Therapist: “Have you ever had the police talk to you? Could they be nice? How do you know
that they might not take your side?”
Once the client has been given time to consider alternatives, you can then demonstrate how his
or her ways of thinking are linked to the feelings experienced and illustrate that if the client
thought differently, the emotional responses may be different. For example:
Client: “I talked to a policeman one time before and he was really nice to me.”
Therapist: “So if a policeman showed up yesterday, he may have been nice to you?”
Client: “I guess so.”
Therapist: “If he were nice to you, how would you feel then?”
Client: “I would feel happy.”
Conversations of this nature may need to happen many times before the client fully begins to
recognise that his or her thoughts, feelings, and behaviours are linked. We encourage you to
continue having these much-needed conversations with the client as often as necessary to help
instil this understanding. During the middle sessions, getting the client to see, as fully as
possible, the relationship between thinking, feeling, and behaving should be a top priority.
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Chapter 7
Specific Cognitive Techniques
Over the course of treatment you will want to employ a range of techniques to help the client
recognise and reframe problematic thinking patterns. Helping the client explore and address
maladaptive cognitions which might be leading to feelings of depression and anxiety is essential
if the client is going to heal.
While there are any number of interventions that may be used, including verbal processing,
visual processing, role-play, and others, in this chapter we have focused on adapting a handful of
relatively complex CBT techniques so that they can be more successfully used with clients who
have learning disabilities. We encourage you to try some of these techniques in addition to your
normal cadre of strategies when working with people who are learning disabled.
Identifying and Challenging Key Thinking Style Errors

While it is not absolutely necessary, nor even realistic, for clients with learning disabilities to
understand all the thinking style errors, it is appropriate for you to help the client understand
particular thinking patterns and ask questions that will challenge the client’s way of thinking. The
aim here is to help the client identify not only the content of what he or she is thinking but also
the process of how he or she is thinking.
The following chart outlines key thinking style errors and typical methods that are used to treat
them. You can explain some of these to the client as necessary, but you will need to simplify the
terminology and keep the information contextualised to the client’s personal experience for the
best results.
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Thinking Style Errors and Useful Treatment Methods
Thinking style error Method
Black-and-white thinking Visual analogue scales
Labelling Imagery
Mental filtering Positive data logs
Disqualifying the positive Challenging
Mind-reading experiments Role-plays/behavioural
Emotional reasoning Flash cards, challenging—feelings not fact
Catastrophising Reframing beliefs; pros/cons
Masturbatory thinking Helping with preferences
Overgeneralisation Pie charts
Personalisation and blame Role-plays
Fortune-telling Considering alternatives
Low frustration tolerance Preferences
People with learning disabilities will likely have difficulties identifying their thinking styles and
understanding that some of their thoughts may not be logical or helpful. Furthermore, it may be
difficult for people with learning disabilities to recognise that they have control over their
thoughts. To break through this, it is helpful for you to gently challenge the assumptions the client
makes about specific situations and explore alternative possibilities which may explain said
events while you are working together.
The following materials will facilitate this process:
 Worksheet 12—Unhelpful Ways of Thinking
 Worksheet 13—“How I Am Thinking” Diary
 Worksheet 14—A Different Way of Thinking
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Using the Survey Method to Challenge Beliefs

You may use the “Survey Method” to help some clients challenge beliefs. Try the following:
Set three questions the client should ask up to ten people they know and trust. These questions
should revolve around an irrational belief. For example, a client may hold the belief that the
reason he or she is still at home at the age of twenty-five is because he or she is backward. You
might set the following three questions for the client to ask other people:
1. How long was it before you left home?
2. Would you prefer to stay at home or leave home?
3. Why might people take a long time to leave home?
Hearing objective answers to these questions from trusted resources may help the client realise
that his or her underlying belief is inaccurate.
It is also possible to introduce props in this exercise. For example, one of the therapists testing
this protocol had a client who believed that people did not like her because she was often angry
(incidentally, this woman had been severely abused in her past). The therapist took two photos of
the client, one while she was looking angry and bad-tempered and another while she was happy
and smiling. She then asked the client to take the photos and survey people using the following
questions:
1. Which photo do you like more?
2. In which photo do I look more approachable?
3. Why do you like one photo over the other?
The responses the client received helped her realise that people did not inherently dislike her,
but that her presentation made it more or less difficult for people to engage with her.
Schemas Work
It is understood that negative schemas (attitudes and assumptions) are formed due to an
individual’s negative experiences in childhood such as parental criticism, criticism from teachers,
and peer rejection. When a new experience presents itself to an individual holding negative
schemas, this experience is incorporated into the framework of the schema and reinforces the
negative core beliefs. Common negative schemas in people who have learning disabilities
include:
 I’m a failure. (Negative view of the self)
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 Everyone thinks I’m stupid. (Negative view of the world)
 I’ll never be good at anything. (Negative view of the future)
Obviously, beliefs of this nature can impact behaviour and mood. Classically this is an area that a
CBT therapist would work on with a client. Whether you will be able to include schemas work in
therapy with people who have learning disabilities depends very much on the individual’s level of
functioning.
Therapists have found this to be a particularly difficult area for some clients with learning
disabilities. Because some people with learning disabilities have a hard time generalising,
analysing core beliefs, assessing patterns, and working to alter them can be challenging.
Assess your client’s ability in this area before you attempt schemas work.
Even if the client is not capable of schemas work it is important for you to be aware of some
common schemas that develop for people with learning disabilities. Many of these clients
develop negative schemas around the following:
 Criticism
 Bullying
 Rejection
 Poor self-worth
Keep this in mind as you work through sessions with clients.
People with mild to moderate learning disabilities may be able to engage in schemas with a few
modifications. First, you can develop case conceptualisations that help clients tether their past
experiences to their present experiential state and assist them to identify how negative core
beliefs and thinking style errors may contribute to their current unhappiness or anxiety.
To make up such a case conceptualisation, work with the client and the support worker to identify
long-standing cognitive and behavioural patterns. Once this has been established you can then
write up the case conceptualisation in very simple terms and give it to the client to take away and
study. Here is a sample case:
Amy always compared herself negatively to her sister and holds a core belief that she is
unlovable and that she will fail at anything that she tries. As a result of these beliefs, Amy avoids
new challenges and social contacts. (Adapted from Scior, 2009).
In subsequent sessions the main points may be discussed with the client and the support worker.
During such sessions you may wish to explore and collect evidence that challenges the client’s
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negative thoughts and beliefs about him- or herself and highlights his or her thinking style errors.
You may also encourage the client to try new activities and evaluate the changes in her moods
and thoughts, with the aim of ultimately shifting her cognitions and dismantling negative
schemas.
The following additional materials designed to help with schemas work (in cases where it can be
used) have been included in Part 3:
 Worksheet 15—My Good Thoughts About Me
 Worksheet 16—My Thoughts About Me That Are Not Nice
 Worksheet 17—My Worrying Thoughts About Me
 Worksheet 18—My Worrying Thoughts About Things That Will Happen
 Worksheet 19—My Good Thoughts About Things That Will Happen
 Worksheet 20—Core Beliefs
 Worksheet 21—My Core Beliefs
The following case study may further help you understand how schemas work may be applied
with clients who have learning disabilities.
Case Study
Background: Robert is a 48-year-old man with mild learning disability. He lives independently.
Robert has had a difficult relationship with his parents, especially his father. He was put in care
from the age of ten when his parents returned to Jamaica. We have been working together for
nine sessions.
Identified Problems:
 Feels very tense when around new people. When Robert approaches someone or
someone approaches him, he becomes very anxious and is aware of tension in his back
and feet. To manage this he avoids meeting new people and has a very limited social
group.
 Feels angry very quickly, and has not been able to manage it well.
 Avoids eating. Robert reports never feeling hungry.
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Goals:
 Feel more confident in new and old situations; this could be a meeting at a day centre or
sitting next to someone on the bus.
 Learn to recognise anger and develop strategies to manage it.
 Regulate eating pattern by eating three meals per day and using picture cues to remind
him to do so.
Identified Assumptions:
 People will think I am strange.

 People will be able to see that I am anxious.
 I will have to hide what I am feeling or people will avoid me.
Core Beliefs:
 I am different.
 People cannot be trusted.
Treatment:
 Understanding symptoms of depression

 Identifying where he feels anxiety in his body
 Behavioural experiment/graded task assignment—asking someone for the time, sitting
next to a new person, saying something at a day centre meeting. (For more information
on behavioural experiments see Chapter 8.)
 Diary keeping
 Positive data log—identifying when good things happen, like someone saying something
nice or enjoying a film.
Robert has been very engaged in CBT. He reports in sessions that he finds the agreed goals
helpful. Although he cannot identify changes in his thought process, he is able to recognise
changes in his physiological arousal (i.e. feeling less tension in his back and shoulders). He has
identified that when he does the things he has previously avoided he becomes more confident in
dealing with them.
Therapist Reflection: Before I started on the project I was concerned that I would not be able to
do CBT with this client group due to their learning disabilities. I thought it would be hard to
communicate and they wouldn’t understand. However, I realise these were my assumptions, and
my experiences have shown me that I was wrong. I have seen that the people I have worked
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with have engaged in the therapy, have been open to the possibility of change, and have been
willing to give it a try. They are a positive and inspiring group of people who we could learn a lot
from regarding living in difficult circumstances and overcoming adversity.
Addressing Anxiety States

An event perceived as catastrophic can lead the client to adopt safety-seeking behaviours—
precautions used to avoid or escape situations that are anxiety provoking. To clients who
experience anxiety, these behaviours are logically linked to a perceived threat, though this is
often not the case. The real problem with these safety-seeking behaviours is that they play an
important role in maintaining anxiety disorders (Salkovskis, 1991) because they focus on
negative consequences (like death, illness, or embarrassment) as means of avoiding the distress
or threat at hand. To help the client heal, you need to explore, identify, and change these
behaviours.
As a first step, you can use the cognitive model of panic illustrated in Figure 7.1 below to help the
client understand how anxious feelings, catastrophic thoughts, and problem behaviours are
linked.
Figure 7.1: A Cognitive Model of Panic Attacks
(Permission from Behaviour Research and Therapy, 24, p. 463, D. M. Clark, A Cognitive
Approach to Panic, Copyright 1986, Pergamon Journals Ltd)
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Once the connections between the anxious feelings and the behaviours that result are better
understood by the client you can follow through with this by generating individualised behavioural
experiments to help the client see the harmless causes of his or her feared symptoms. This can
be done within the therapeutic setting. For example, you may encourage the client to breathe
deeply as if he or she were trying to stay calm in an anxious situation. The client may discover
that this actually makes him or her quite dizzy and intensifies anxiety. You can then reassure the
client that nothing bad is going to happen (e.g. he or she is not going to faint) and that the
response—being dizzy—is expected and transient. When the dizziness does, in fact, pass, the
client will see for himself or herself that the feared stimuli were non-threatening.
Additional worksheets provided in Part 3 that will help address anxiety states include:
 Worksheet 15—My Good Thoughts about Me
 Worksheet 17—My Worrying Thoughts about Me
 Worksheet 18—My Worrying Thoughts about Things That Will Happen
 Worksheet 19—My Good Thoughts about Things That Will Happen
Guided Discovery
The final cognitive intervention we will address in this chapter is guided discovery. The rationale
behind this technique is to provide the client an opportunity to learn how to overcome problems
that he or she has not come across before by applying his or her skills to such situations. This
technique can be particularly useful, as it offers the client a real, applicable takeaway from
sessions.
Start by working with the client and support worker to develop a cache of real-life, but fictional
situations the client typically finds him- or herself in. Once this has been established, you will
want to consider a range of emotional states which the client may have experienced in these
settings. For example, you may come up with a list like the following:
 Shopping for groceries—client feels anxious, awkward, and edgy because he or she is
afraid of doing something wrong.
 Travelling on the bus—client feels sad and a little humiliated because he or she thinks
people are looking at him or her funny.
 Walking around in the local area and seeing a couple together—client feels admiring and
envious of the two people together.
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After the list of situations and related emotions has been developed your aim will be to get the
client to shift to healthier ways of expressing and/or experiencing these emotions. This may
include challenging thinking styles, working with core beliefs, addressing anxiety states, or a
variety of other techniques to change the cognitions associated with the feeling. For example, the
client may feel scared in the grocery store because he or she is afraid of making a mistake and
of the possible social consequences involved. You may challenge such thinking and help the
client realise that even if a mistake is made, that doesn’t mean social consequences will
necessarily result.
On the other hand, there are cases where the client should be encouraged to view his or her
emotional reactions as normal and realise that they are feelings everyone experiences from time
to time in day-to-day life. For example, many people have felt the pang of jealousy when seeing
a happy couple together. This is not an uncommon emotional experience. That said, it’s
important to help people with learning disabilities clearly distinguish between grades of emotional
severity and their related, appropriate responses in the home, in public, at work, etc. For
example, you may need to point out that acting out jealous feelings when seeing a happy couple
together is not an appropriate response. Likewise, becoming physically aggressive when
irritated, fleeing a situation when panicked, or staying in bed all day when sad are not appropriate
(or useful) behavioural responses.
By helping the client change his or her thinking style, address cognitive distortions, work through
negative schemas, and develop alternative behaviours in potentially provoking situations, you
offer the client real strategies he or she can use to alter the underlying thoughts that lead to
problems in life. The next step is addressing behaviour. We will turn our attention to this issue in
the next chapter.
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Chapter 8
Specific Behavioural Techniques
Ultimately the purpose of CBT is to change behaviour. While cognitive interventions are an
important step in treatment, behavioural techniques often provide the best results—especially in
people who have learning disabilities.
According to therapists who tested this protocol, the behavioural elements are far
more consistently effective than the cognitive elements. While both are essential
pieces of CBT, for this population it would appear the behavioural elements are
more amenable to short-term intervention.
Here again, there is a broad array of potential interventions to choose from. However, in this
chapter we have provided guidelines for using three specific behavioural techniques to treat
people with learning disabilities: the use of positive reinforcement, graded tasks, and behaviour
experiments. Let’s review each in turn.
Utilising Positive Reinforcement

A lot of conventional treatment paradigms for treating people with learning disabilities use
positive reinforcement. Indeed, the premise is developed from work by Rehm (1977) and
Seligman (1975). There are three key points these researchers raise that are extremely
applicable in this context:
1. It is important to provide people with depression lots of praise, as they tend to focus on
negative aspects of themselves.
2. Helping depressed people identify positive events is an essential step in the healing
process, as they are likely to view all events as negative.
3. Fundamentally, you need to work toward encouraging people who are depressed to be
nice to themselves, as they have likely internalised negative voices and this, in part,
drives the depression.
Therapists who tested this protocol found they used positive emotional
reinforcement often and to great effect. According to one, “This helps a lot to make
the person feel listened to and understood”.
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We encourage you to consider these points and bring plenty of positive reinforcement into the
therapeutic setting. This isn’t only a matter of verbally reinforcing the client. Get the client to
engage in behaviours that are positive. This will reinforce the client’s ability to identify and
participate in positive events in life. One excellent activity is to ask the client to create a list of
positive things he or she might enjoy doing, add these to the client’s WAS, and then ask client to
rate the events based on how much he or she enjoyed doing them. Follow up by discussing the
events in the next session. Encourage the client to add enjoyable events into next week’s
schedule and/or come up with a new list of events to try.
Assigning Graded Tasks

Graded task assignments that expose the client to adverse events which elicit either anxiety or
sadness can be used to help the client confront potentially difficult life problems and develop
resilience in these areas. The key here is to prepare a list of situations of gradually increasing
difficulty, assign these tasks over time, and then ask the client to complete each task and monitor
his or her mood or anxiety while completing the task without running away or engaging in safety
behaviours. Safety behaviours are those behaviours aimed at preventing the feared
consequence from happening. This final point is the essential message you need to
communicate when assigned such exercises. The client must stay with the situation until the
anxiety reduces or the mood improves. The biggest problem with exposure paradigms is that the
client is liable to leave the provoking situation when it reaches its emotional peak. This negative
reinforcement makes it much more difficult for the client to engage in the provoking event the
next time around. This is why you must be particular careful in developing a graded list of tasks
that will take the client through an increasing set of provoking situations.
For these kinds of exercises to be successful a support worker almost always has to be involved
both in the development of the assignments as well in the execution of the tasks. The support
worker should encourage the client to stay with the emotionally loaded situations without
becoming a crutch. This can be a delicate balance and it may be necessary for you to discuss all
of this with the support worker in some detail before the graded task assignments begin.
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Pleasure Predicting Experiments

Pleasure predicting experiments aim to challenge fortune-telling and encourage the client to see
that predictions he or she makes are also excessively biased by emotions. These experiments
also help the client challenge emotional reasoning and encourage the client to stop “buying into”
what his or her mind is telling him or her. To complete these experiments with your client, carry
out the following steps.
 Ask the client to describe activities he or she enjoyed prior to becoming depressed.
 List these activities.
 Ask the client to predict how much he or she believes the said activity would be enjoyable
now, on a scale of 0-100 percent.
 As the client to engage in the activity.
 At follow-up ask the client to rate how much he or she actually enjoyed the activity.
A sample worksheet you could use to facilitate these experiments follows.
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Mastery Pleasure Predicting Sheet
Prospective Retrospective
Time What do you How much do How much did What have you
have planned? you predict you you actually learned from
will enjoy this enjoy this this?
activity? activity?
(0-100%) (0-100%)
Morning Nothing, I will I felt bored and

just see what upset, as my life is
(Specify time)
happens. 30% 10% going nowhere.
Afternoon Going swimming The way I feel is

not always a
(Specify time) 3pm 30% 60% helpful guide about
what to do.
Evening Go and visit my 60% 30% What I predict is

friend Melanie not always
(Specify time) accurate.
7pm
Other Doing nothing does not help, and I need to test out my beliefs rather than assume
Comments, what is going to happen.
Trends,
Conclusions,
etc.
Typically, pleasure-predicting experiments are most effective when the client is at his or her best.
We recommend that you assess the client’s mood and target this kind of behavioural experiment
to be undertaken around this time.
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Designing and Executing Behavioural Experiments

Perhaps the most useful of all behavioural interventions when treating people with learning
disabilities are behavioural experiments. Behavioural experiments help clients test beliefs,
recognise negative thoughts and replace them with more positive ones, and build strategies to
cope with difficulties appropriately. As long as you keep a focus on helping the client recognise
the links between his or her thoughts, feelings, and behaviour, these experiments can also be a
wonderful way to reinforce an understanding of the relationships among the cognitive triad.
One therapist who tested this protocol found behavioural experiments a particularly useful
aspect of treatment for people with learning disabilities. According to her, testing out beliefs
with behavioural experiments gave clients an easy way to recognise some of the contradictory
aspects of their thinking.
We feel the easiest way to illustrate how to use behavioural experiments with people who have
learning disabilities is to provide examples of the kinds of experiments appropriate for this
population. Therefore the rest of this chapter will provide a series of case vignettes you can use
as a guideline when developing your own experiments.
When it is possible and realistic, video feedback may be useful to demonstrate

changes in behaviour. Videos can also help reinforce the belief that a given client is
able to cope with a wide variety of situations.
Case Vignettes That Illustrate Behaviour Experiments
Case Vignette 1
Problem: Doreen has been depressed. She has a low mood, loss of energy, and little motivation.
Her carers complain that she is lazy.
Target cognition: I am lazy and I never do anything to look after myself. (This belief has been
reinforced by people at Doreen’s day centre.)
Alternative perspective:
Doreen: When I do things I begin to feel better.
Prediction: Doreen will progressively avoid activities unless some intervention takes place.
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Experiment: Doreen’s therapist explains that inactivity is a symptom of depression. The

therapist shows Doreen and the support worker how to monitor her activity levels by using a
WAS form. Doreen and her support worker start to record what Doreen does over the next three
days and discuss it in the next session.
Results: Doreen realised that she does complete some activities and is, therefore, not as lazy
and disengaged as described.
Reflection: The therapist challenges Doreen’s belief that she does nothing and is lazy. Doreen
looks pleased.
Further work: Doreen feels encouraged and agrees to bring in the WAS for the next session.
The support worker is instructed on how to help Doreen fill out the WAS and encourage her to
keep up with activities. Doreen discovers that she does increasingly more than she thought.
Case Vignette 2
Problem: Adam spends a lot of time in bed or sitting, doing nothing, which he does not like. His
carers say that his quality of life is poor but he does not feel motivated to change. He tends to
mull over things all the time and becomes depressed.
Target cognition: I’m too tired. I should wait do things until I feel better.
Alternative perspective: The therapist challenges Adam’s belief by noting that waiting hasn’t
worked and pointing out that his carers think Adam is not getting the most out of his life.
Therapist: “What do you do when you are down?”
Adam: “I lie on my bed until I feel better.”
Therapist: “But you say that you do not like ‘doing nothing’. So lying in bed doesn’t help you.”
The therapist then engages the client in finding activities he or she likes.
Therapist: “Okay, so I have a list here of going to the shops, speaking to the lollipop lady, going
to the zoo, taking the neighbour’s dog for a walk. Let’s pick one of these…. Hmmm, which one?”
Adam: “Taking the dog for a walk.”
Therapist: “Okay, when do you normally lie on your bed?”
Adam: “In the morning.”
Therapist: “Great. Now, with the help of a friend or carer, can you ask the neighbour if you can
take the dog for a walk tomorrow morning and then come and tell me how it went?”
Adam: “Okay.”
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Predictions: Adam will resist walking the dog when the time comes.
Experiment: Adam’s therapist suggests that Adam do the following with the help of his support
worker:
1. Go to bed if he feels tired or depressed, but fill out his “Worksheet 8—Thoughts and
Feelings Diary” to record how he felt after doing so.
2. If he feels tired or depressed subsequently, he is to resist the urge to go to bed and take
the dog for a walk instead. He can then fill in his “Worksheet 8—Thoughts and Feelings
Diary” again after walking the dog.
Results: Adam got depressed and went to bed the next morning. However, the following day,
with the help of his support worker, he went to walk the dog when he felt tired.
Reflection: Adam felt much better after walking the dog. His carers saw an improvement in his
mood and encouraged him to join in more activities. He did, and when he saw how many more
smiley faces he got he was pleased and said that he liked going out.
Further work: The support worker is advised to help Adam plan his daily activities in advance
(using a WAS). If Adam does at least 50 percent of his daily activities, he gets to do one extra
nice activity that he’s chosen. After each activity, Adam is encouraged to fill in his “Worksheet
8—Thoughts and Feelings Diary”. Therapy continues until Adam’s diary contains a range of
activities Adam is happy with. The support worker is then advised to continue prompting Adam to
find new activities to engage in and review his schedule. Over time Adam gets more and more
smiley faces to help remind him of how much better he feels after doing something.
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Case Vignette 3
Problem: Andrew becomes very anxious and has temper tantrums when his routine changes.
Target Cognition: When things change, I don’t know what is going to happen and I am not going
to have control over anything.
Alternative perspective: Just because something is new doesn’t mean it is bad.
Experiment: The therapist works to help Andrew identify key thoughts about maintaining a
routine. They break down his daily routine in small ways and discuss what may happen following
each change that happens through his day. In session they work through examples of times
when his routine may change unexpectedly and the potential outcomes.
Andrew and his support worker are advised to try out some of these scenarios to see how
Andrew will react. Andrew is asked to record how he feels after each activity is tried.
Results: With the help of his support worker, Andrew tries some of the scenarios. He sticks with
them and is able to reduce his anxiety by exposing himself and using the strategies he
developed with his therapist.
Reflection: Reviewing the diary in the session, Andrew feels encouraged that he is able to deal
with changes in his routine without feels anxious.
Further work: Andrew will continue to discuss how things go for him when he feels anxious at
subsequent sessions.
Case Vignette 4
Problem: Rosy worries about everything. She thinks that she does not have enough money in
the bank and that no one can help her.
Target cognition: If I worry about things, I will be able to prevent negative things from
happening.
Alternative perspective: I don’t have control over events, and worrying will not keep me safe.
Experiment: The therapist helps Rosy to learn how to catch herself worrying as soon as
possible. With the help of her support worker, Rosy and the therapist develop alternative
responses to Rosy’s anxious thoughts. The therapist encourages Rosy to try these out when she
begins to feel worried. Furthermore, the therapist asks Rosy to try to think about why she is
worried and put this into words.
Results and Reflection: With the help of her support worker, Rosy is able to “push out” worrying
thoughts and engage in the alternative activities planned in the session. By doing this she is able
to learn a “process-based” approach to coping with worry, instead of trying to combat individual
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worrisome thoughts. Consequently, Rosy is able to see that worry about things does not affect
the outcome of future events. Furthermore, her support worker helps Rosy keep a diary
regarding why she feels worried.
Further work: The therapist reviews Rosy’s record of why she feels worried in order to identify
key topics and core beliefs that need to be addressed.
Case Vignette 5
Problem: Ambia started work as a trainee receptionist at a day centre for people with learning
disabilities. She was happy with this but very quickly became worried about her performance and
increasingly asks her co-workers for reassurance to the degree that this has affected her
performance.
Target cognition: I will make mistakes and get fired.
Alternative perspective: If I make a mistake I can talk to my manager and he or she will be able
to sort it out for me; I won’t be fired for one mistake.
Predictions: The more I talk to my manager the more confident I feel, and will be able to talk to
my manager if I am worried about something. If I ask for reassurance when I am anxious, it
makes me feel more worried, not less worried.
Experiment: The therapist spends some time finding out what Ambia was worried about in her
workplace. Ambia revealed that she was afraid she would make mistakes and get fired. Ambia
and the therapist worked out examples of situations that made her feel uncertain. They also put
together some flash cards that summarised the bad points about asking her colleagues for
constant reassurance.
The therapist then asked Ambia and her support worker to engage in a role-play in which the
support worker took on the role of Ambia’s supervisor. During the role-play Ambia’s therapist
encouraged her to discuss her fears about making mistakes in front of her supervisor, and they
worked on building up Ambia’s confidence so she could rely on her own skills more.
Results: The role-play helped Ambia deal with similar situations in the workplace. Even though
she initially felt anxious about not seeking reassurance, the flash cards helped her remember the
negative consequences of doing so.
Further work: With the help of her support worker, Ambia was asked to keep positive data logs
to help her remember and focus on things that went well during her workday.
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Case Vignette 6
Problem: Margaret believed that nothing and no one could help her overcome her depression.
However, her therapist managed to persuade her that it was worth trying to engage in therapy to
see if it would help in some way.
Target cognition: Seeking help in talking therapy will not help me overcome depression.
Alternative perspective: If I work with my therapist on my problem, it might help me to feel

better.
Prediction: If I record my moods and plan some enjoyable activities, I will start to feel better.
Experiment: Margaret’s therapist asked her to rate how depressed she felt on a scale from 0 to
10 (10 being very depressed). The therapist then asked Margaret to talk about her problems for a
few moments and rate how depressed she felt after talking. Next the therapist asked Margaret to
discuss her participation in a singing/music group in some detail. Finally, the therapist asked
Margaret to rate how she felt after talking about the singing group she was a part of.
Results: The therapist was able to show Margaret that she became more depressed when she
thought about her problems but became less depressed when she thought about other things.
They agreed to carry on with more sessions to see how they could apply similar techniques to
other difficulties that Margaret experienced.
Reflection: The therapist then helped Margaret make the mood-thinking link demonstrated by
the experiment. By explaining that she had higher mood ratings when she was thinking about
things she enjoyed and lower ratings when she was thinking about her problems, the therapist
showed Margaret that thinking influenced her feeling.
Further work: Margaret should keep monitoring her moods and building up enjoyable activities.
Case Vignette 7
Problem: Terry believed that he was no good and that he would never achieve anything.
Target cognition: I have a learning disability and I am a failure.
Alternative perspective: I may have a learning disability but that does not make me a failure;
there are some things I can do well.
Prediction: Terry could learn to have more compassion for himself with training.
Experiment: The therapist suggested Terry think about what his close friend, Barry, would say
about Terry when such negative thoughts came up. Terry was instructed to ask himself, “What
would Barry do or say if he were with me now?” The therapist also worked with Terry and his
support worker to put together a “Worksheet 8—Thoughts and Feelings Diary” for Terry. Terry
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was instructed to record both good and bad thoughts he had about himself. Both strategies were
aimed at helping Terry increase his positive thinking, which would act as a reinforcer.
Further work: It might help to add that Terry was encouraged to think about himself in a more
compassionate way by his client and by using flash cards with what Barry would say written on
them. It helped to keep a daily positive data log to remind Terry of some of the good things in his
life.
Results and reflection: It made Terry feel much better to think about what Barry would say
about him, as he knew Barry always found positive things to say. This helped Terry see that
treating himself more kindly was having a positive effect on his mood and better understand the
negative impact of self-criticism.
Case Vignette 8
Problem: Michael split up with his girlfriend (she left him) and he became increasingly withdrawn
and irritable. He did not want to engage in any activities and felt that there was no point in
anything.
Target cognition: My life is useless; there is no point in trying to go out and enjoy myself.
Alternative perspective: It is okay to feel sad when a relationship ends; that doesn’t mean I will
always be sad.
Prediction: I won’t be able to enjoy myself because I am too sad.
Experiment: The therapist found out about some social occasions that were coming up and
asked Michael what he thought about attending them. Michael was sceptical and said no, but in
the end he was persuaded by his support worker to go. Before leaving the session Michael was
also asked to predict how much he would enjoy himself at these events by rating them.
Results: He reported back to the therapist that he had enjoyed going out and had met a few
people he knew from college. When asked to rate his enjoyment it was higher than he had
predicted. He also signed up to go on another outing outside London and started making plans
with his support worker for finding day activities.
Typically, the interventions illustrated in this chapter will have a positive impact on people who
are depressed. As mentioned before, behavioural experiments are particularly important, and we
encourage you to use them throughout the middle sessions of therapy. Doing so may elicit
substantial changes in depressed and anxious clients.
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Chapter 9
Additional Skills
At this stage we have reviewed all of the primary interventions you need to undertake with
depressed and anxious clients who have learning disabilities. The cognitive and behavioural
interventions in the preceding chapters form the core of therapy. However, there are a few
additional skills you may want to help clients with learning disabilities acquire. Many people in
this population benefit from some assertiveness training and developing social skills. In this
chapter we will review these additional skills and provide recommendations about how to
integrate them into therapy. You should not spend undue time on these areas, but each is worth
addressing with most clients who have learning disabilities.
Assertiveness Training
Many people who have learning disabilities find it difficult to speak up for themselves. Those who
do often do so in inappropriate ways. Assertiveness training can benefit many with learning
disabilities, and it may help your attempts to mitigate your client’s anxiety and depression. Lack
of assertiveness can lead to both anxious and depressed states. What’s more, learning to be
assertive will provide the client the confidence he or she needs to use the skills learned in
therapy to better cope with stressful situations.
Any good course in assertiveness starts with an explanation of what assertive communication is,
and the difference between it and aggressive or passive communication. As you are likely aware,
passive communication is when the person’s own feelings and needs are disregarded and the
individual says and does things to please others. People who communicate passively typically
speak in an apologetic manner, and this often results in others disregarding what the individual is
saying. On the other end of the spectrum is aggressive communication. This is when a person
does not take into account other peoples’ feelings and needs and assumes a stance of
dominance. Both of these forms of communication are typically ineffective. Assertiveness lies in
the middle of these two extremes and is defined by a firm explanation of personal needs that
takes into account other peoples’ feelings. The advantage of communicating this way is that you
are more likely to get what you need or desire out of a given situation and you come away from
these scenarios with a more positive feeling about yourself.
Here is an example of each of these forms of communication based on a common scenario.
Situation: A client goes to a doctor who suggests that he or she start taking medication for a
health condition.
88
Passive response: The client agrees to take the medication even though he or she does not
want to and doesn’t understand why it may be needed. The client does not question the doctor’s
decision, as he or she believes that the doctor always knows best.
Aggressive response: The client gets angry about the prescription, thinks that doctor is
useless, and blames him or her for constantly prescribing more medication. The patient walks out
of the consultation, slamming the door behind him or her.
Assertive response: The client lets the doctor know that he or she would prefer not to take
medicines, explains why, and asks for alternative options. The client and the doctor discuss the
situation and the client clearly expresses his or her concerns, worries, and needs while still
listening to and considering the doctor’s professional medical opinion.
To help the client more fully understand the differences between passive, aggressive, and
assertive communication, we recommend you utilise the “Info Sheet 8 - Assertiveness Scale” in
Part 3. It is a good visual that helps illustrate that these forms of communication lie on a
continuous scale and it helps the client identify that assertiveness lies between being passive
and aggressive.
In addition we recommend that you illustrate what each of these forms of communication looks
like. You may do this through role-play or example. Show the client what a person looks like with
each form of communicating (i.e. what body language they are using) and how they sound (i.e.
tone of voice and examples of what may be said).
When undergoing assertiveness training you want to make sure to cover (based on Nezu &
Nezu, 1991):
 Voice intensity (loud vs. quiet)

 When to respond (impulsive vs. appropriate)
 Duration of response (focused vs. lengthy)
 Eye contact
 Body language (threatening vs. appropriate)
 Ability to listen (listening to others vs. talking constantly)
For people with learning disabilities, you may also want to spend some time reviewing situations
where the client would benefit from assertive communication. For example, find out if he or she is
being bullied or teased at times when it is important to express emotions and feelings.
89
The following worksheets in Part 3 will provide additional useful exercises if you choose to
undergo an assertiveness training module with the client:
 Worksheet 22—How to Be More Assertive: Aggressive to Assertive

 Worksheet 23—How to Be More Assertive: Passive to Assertive
 Worksheet 24—How I Can Be More Assertive.
Social Skills Training

Social skills training is particularly helpful for clients who have low self-esteem or are afraid of
negative evaluation by themselves or others. For people with learning disabilities, such negative
views may be the result of having been teased or bullied in the past. Social skills training can be
empowering and help the client overcome these negative perceptions.
Social anxiety arises as people self-monitor their feelings and see themselves as being
negatively evaluated by others (Clark & Wells, 1995). Therefore, the first step in social skills
training is to break this cycle of perpetual self-evaluation and expected negative evaluation by
others. To do this we recommend you help the client focus externally. This will help the person
realise that his or her peers do not necessarily see him or her negatively, and they may actually
feel compassionate and wish to help.
Once this is achieved you should engage in actively helping the client to improve his or her social
skills and encourage the client to engage in social interactions. Social skills training you may
wish to focus on could include:
 Role-plays of social situations
 Behavioural experiments that get the client to engage with people around them
 Reframing thoughts so that clients don’t automatically assume people perceive them
negatively
 Picking up on positive stimuli from the people around them by keep records in positive
data logs
 Working to help the client understand that others may be empathic
It is also worthwhile to spend few minutes in the session addressing social skills, reminding the
client that it is important to develop friendships. Creating a list of friends is a particularly useful
exercise. It may also be useful for you to provide the client with information on community
resources (leisure activities, recreational groups, and social groups) and to encourage him or her
to utilise them.
The following worksheets in Part 3 will facilitate the acquisition of social skills and encourage the
client to develop friendships:
90
 Worksheet 25—Important People in My Life

 Worksheet 26—Things People Like About Me
This concludes the interventions you will need to employ in the middle sessions of therapy. In the
next chapter we will outline the final sessions and explain how to end therapy.
91
Chapter 10
The Final Sessions (15–18)
After fourteen sessions using the techniques described in the previous chapters, you should
begin to see some improvement in the client’s condition. At this point it is time to begin phasing
out therapy. The aim of these final sessions is to:
 Summarise the key points covered in the treatment.

 Go over the main skills and strategies covered.
 Bring the treatment to an end.
 Address and put in place measures for relapse prevention.
Each of these items can loosely be separated into issues addressed while ending treatment and
what happens after treatment. In this chapter we will present information on each of these
phases and help you set the stage for the client to successfully take away what has been learned
in therapy.
Ending Treatment: Steps to Take

It is important to prepare the client for the end of the treatment to avoid issues such as feelings of
rejection or anxiety. This can be done by bringing the treatment to an end in a gradual and
systematic way during the last three or four sessions and reminding the client that the number of
sessions was set and agreed upon at the beginning of therapy and that this time has now come
to an end.
At this time you will want to review and discuss what the client learned in therapy. Ask the client
to list strategies he or she has learned and utilised to cope with depression and anxiety and
discuss ways in which the client can continue to use these techniques to manage future
situations and events.
You will also want to discuss how the client feels about the treatment process and address any
concerns he or she may have. Acknowledging and working through any negative feelings the
client may have about ending treatment is especially important. Talking about the client’s fears
and concerns is useful, as it will help provide a sense of closure, which is very important.
You may also ask the client to reflect on or explore answers to questions such as:
 What do you think you have learned from these sessions?
92
 How do you think therapy has helped you?
 Did you enjoy (and what did you enjoy about) the treatment?
 What have you learned about managing depressive thoughts?
 What have you learned about managing anxiety?
 What strategies do you now have to deal with depression and anxiety? How can you use
these strategies to better manage depression and anxiety?
 In what ways can you continue to improve your depression and anxiety management
skills? Are there specific areas that need improvement?
Therapists testing this protocol found that in some cases proper termination of therapy with
clients who have learning disabilities took several sessions. Client with learning disabilities may
take additional time to adjust to and cope with feelings of sadness at breaking the therapeutic
bond. Termination of therapy should be given longer as needed in each individual case.
After Treatment: Relapse Prevention

Before the client leaves therapy, the two of you, with the help of the support worker, should
develop an overall plan for managing the client’s anxiety and depression on an ongoing basis.
Create a list of problems/situations that the client thinks may cause his or her symptoms to recur.
Then develop a list of cognitive and behavioural strategies to deal with them. We also suggest
you explain how to recognise and identify early signs of relapse to both the client and the support
worker. You may need to review specific parts of this protocol with the client and the support
worker to adequately cover this material. Make sure you identify any support services the client
can take advantage of and who he or she should get in touch with when the strategies learned in
therapy are not adequate.
Before the close of the last session you should provide the client with a handout of the key
points, skills, and strategies that were covered in treatment to help him or her remember the
information as needed in the future. The following materials (found in Part 3) will be useful:
 Worksheet 27—Things I Learned in CBT

 Worksheet 28—Important Things to Remember from My Work with the Therapist
 Resource 4—CBT Certificate
The general goal should be for the client to leave therapy feeling positive about his or her ability
to take what has been learned and use it to successfully cope with depression and anxiety in the
future. The client now has the opportunity to become his or her own therapist.
93
References
Abramson, L., Seligman, M., & Teasdale, J. (1978) Learned helplessness in humans: Critique
and reformulation. Journal of Abnormal Psychology. 87(1), 49-74.
Anderson, G., & Kanzantis, N. (2008) Social Problem-Solving Skills Training for Adults With Mild
Intellectual Disability: A Multiple Case Study. Behaviour Change. 25, 2, 97-108.
Andrews, G., & Jenkins, R. (Eds) (1999) Management of Mental Disorders. (UK Edition). Sydney:
World Health Organisation Collaborating Centre for Mental Health and Substance Abuse.
Azam, K., Sinai, A., Hassiotis, A. (2009) Mental ill-health in adults with learning disabilities.
Psychiatry. 8 (10), 376-381.
Beail, N. (2002) Interrogative suggestibility, memory and intellectual disability. Journal of Applied
Research in Intellectual Disabilities. 15 (2), 129-137.
Beck, A., Rush, A., Shaw, B., & Emery, G. (1979) Cognitive Therapy for Depression. New York:
The Guildford Press.
Bishop, D.V.M. (2003). The Test for Reception of Grammar, version 2 (TROG-2). London:
Psychological Corporation.
Burnip, B. (2002). Communication Skills. In: Porter, L. Educating Young Children with Special
Needs. Australia: SAGE Publications Ltd. 154-173.
Butler, G., Fennell, M., & Hackmann, A. (2008) Cognitive-behavioural therapy for anxiety
disorders: Mastering clinical challenges. Guides to Individualized Evidence-Based Treatment.
Guilford Press, NY.
Clare I. C. H. & Gudjonsson G. H. (1993) Interrogative suggestibility, confabulation, and

acquiescence in people with mild learning disabilities (mental handicap): Implications for
reliability during police interrogations. British Journal of Clinical Psychology 32 (3), 295–301.
Clark, D., & Wells, A. (1995) Social Phobia, Diagnosis, Assessment and Treatment. – Editors. R.
Heimberg, Michael Liebowitz, Debra Hope & Franklin Schneier. The Guildford Press, NY.
Cooper, S., Smiley, E., Morrison, J., Williamson, A., & Allan, L. (2007) Mental ill-health in adults
with intellectual disabilities: prevalence and associated factors. The British Journal of Psychiatry.
190: 27–35.
94
Dagnan, D., Chadwick, P., & Proudlove, J. (2000) Towards an assessment of suitability of people
with mental retardation for cognitive therapy. Cognitive Therapy and Research. 24 (6), 627-636
Deb S, Thomas M, & Bright C. (2001) Mental disorder in adults with intellectual disability.
Prevalence of functional psychiatric illness among a community-based population aged between
16 and 64 years. Journal of Intellectual Disability Research. 45, 495-505.
Department of Health (2001). Valuing People: A New Strategy for Learning Disability in the 21st
Century. 2009. London, The Stationery Office.
Dunn, L., Whetton, L. & Burley, J. (1997) The British Picture Vocabulary Scale – II. Windsor,
NFER.
Esbensen, A., & Benson, B. A. (2007) An evaluation of Beck’s cognitive theory of depression in
adults with intellectual disability. Journal of Intellectual Disability Research. 51, 14-24.
Everington C. & Fulero S. M. (1999) Competence to confess: Measuring understanding and

suggestibility of defendants with mental retardation. Mental Retardation, 37, 212–220.
Gulbenkoglu, H., & Hagiliassis, N. (2006) Anger Management: An Anger Management Training
Package for Individuals with Disabilities. Jessica Kingsley Publishers: London.
Joyce, T., Globe, A., & Moody, C. (2006) Assessment of the component skills for cognitive
therapy in adults with intellectual disability. Journal of Applied Research in Intellectual
Disabilities. 19, 17–23.
Kazantis, N., Deane, F., & Ronan, K. (2000) Homework assignments in cognitive and behavioral
therapy: A meta-analysis. Clinical Psychology: Science and Practice. 7 (2), 189–202
Kazantis, N., Deane, F., & Ronan, K. (2004) Assessing compliance with homework assignments:
Review and recommendations for clinical practice. Journal of Clinical Psychology. 60 (6), 627-
641.
Kazantis, N., Deane, F., & Ronan, K. (2005) Using Homework Assignments in Cognitive
Behaviour Therapy. Routledge, NY.
Kelly, A. (2000) Adults with a Learning Disability. Oxon: Winslow Press Ltd.
Kim, J., Szatmari, P., Bryson, S., Streiner, D., & Wilson, F. (2000) The prevalence of anxiety and
mood problems among children with autism and Asperger Syndrome. Autism. 4, (2) 117–132
95
Kirkland, J. (2005) Cognitive-behaviour formulation for three men with learning disabilities who
experience psychosis: how do we make it make sense? British Journal of Learning Disabilities,
33, 160–165.
Kroese, S., Dagnan, D., & Loumidis, K. (1997) Cognitive-Behaviour Therapy for People with
Learning Disabilities. London: Routledge.
Kuyken, W., Padesky, C., & Dudley, R. (2009) Collaborative Case Conceptualisation: Working
effectively with Clients in Cognitive-Behavioural Therapy. The Guilford Press: NY.
Lasky, G., & Riva, M. (2006) Confidentiality and privileged communication in group
psychotherapy. International Journal of Group Psychotherapy. 56 (4), 455-476.
Linehan, M. (1993) Cognitive-behavioural Treatment of Borderline Personality Disorder. The

Guilford Press: NY.
Lindsay, W.R., Howells, L. & Pitcaithly, D. (1993). Cognitive therapy for depression with
individuals with intellectual disabilities. British Journal of Medical Psychology, 66, 135–141.
Lindsay, W.R., Neilson, C. & Lawrenson, H. (1997). Cognitive-behaviour therapy for anxiety in
people with learning disabilities. In B. Stenfert Kroese, D. Dagnan & K. Loumidis (Eds.),
Cognitive-Behaviour Therapy for People with Learning Disabilities (pp. 124–140). London:
Routledge.
McCabe, M., McGillivray, J., & Newton, D. (2006) Effectiveness of treatment programmes for
depression among adults with mild/moderate intellectual disabilities. Journal of Intellectual
Disability Research, 50 (4), 239-247
McGillivray, J., McCabe, M., & Kershaw, M. (2008) Depression in people with intellectual
disability: An evaluation of a staff-administered treatment program. Research in Developmental
Disabilities, 29, 524-536.
Miller, W.R., and Rollnick, S. (1991) Motivational Interviewing: Preparing People to Change
Addictive Behavior. Guilford Press, NY.
Murdoch, B. (1990) Acquired Speech and Language Disorders – A Neuroanatomical and

Functional Neurological Approach. Chapman & Hall, London.
Myers, B. Pueschel, A., & Siegfied, M. (1991) Psychiatric disorders in persons with Down
Syndrome. Journal of Nervous and Mental Disease. 179, 609–613.
Nezu, C., & Nezu, A. (1991) Assertiveness and Problem-Solving Training for Mildly Mentally
Retarded Persons With Dual Diagnosis. Research in Developmental Disabilities, 12, 371-389.
96
Nezu, C., Nezu, A., Rothenberg, J., DelliCarpini, & Groag, I. (1995) Depression in adults with
mild mental retardation: Are cognitive variables involved? Cognitive Therapy and Research. 19
(2) 227-239.
Peterson, C. and Seligman, M.E.P. (1981). Helplessness and attributional style in depression:
Parts I and II. Tidsskrift for Norsk Psykoilogforening, 18, 3-18, and 53-59.
Prasher, V. (1999) Presentation and management of depression in people with learning

disabilities. Advances in Psychiatric Treatment, 5, 447- 454.
Reed, J (1997) Understanding and assessing depression in people with learning disabilities: A
cognitive-behavioural approach. In B. Stenfert Kroese, D. Dagnan & K. Loumidis (Eds.),
Cognitive-Behaviour Therapy for People with Learning Disabilities (pp. 124–140). London:
Routledge.
Rehm, L (1977) A Self-Control Model of Depression. Behaviour Therapy, 8, 787—804.
Rehm, L. (1981) Behavior Therapy for Depression: Present Status and Future Directions. New
York: Academic Press.
Rose, J., West, C. & Clifford, D. (2000). Group intervention for anger in people with intellectual
disabilities. Research in Developmental Disabilities, 21, 171–181.
Royal College of Psychiatry (2009) Feeling Blue. Available at:

http://www.rcpsych.ac.uk/publications/booksbeyondwords/bbwonlineversions/feelingblue/bluecov
er.aspx. [Accessed at 11 February 2011].
Sams, S., Collins, S., & Reynolds, S (2006) Cognitive therapy abilities in people with learning
disabilities. Journal of Applied Research in Intellectual Disabilities, 19, 1, 25-33.
Salkovskis (1991) The importance of behaviour in the maintenance of anxiety and panic: A
cognitive account. Behavioural Psychotherapy. 19, 6-19.
Schonell, F. (1972) Schonell: Graded Word Reading Test. Oliver & Boyd: Edinburgh.
Seligman, M.E.P. (1975). Helplessness: On Depression, Development, and Death. San

Francisco: W.H. Freeman.
Smiley, E., Cooper, S., Finlayson, J, Jackson, A., Allan, L., Mantry, D., McGrother, C.,
McConnachie, A., & Morrison, J. (2007) Incidence and predictors of mental ill-health in adults
with intellectual disabilities: Prospective study. The British Journal of Psychiatry. 191, 313 - 319.
Stallard, P. (2002) Think Good, Feel Good. Chichester: John Wiley & Sons Ltd.
97
Wechsler, D. (1997) Wechsler adult intelligence scale and Wechsler memory scale technical
manual (3rd Ed.). The Psychological Corporation, San Antonio, TX (1997).
Willner, P., & Goody, R. (2006) Interaction of cognitive distortions and cognitive deficits in the
formulation and treatment of obsessive–compulsive behaviours in a woman with an intellectual
disability. Journal of Applied Research in Intellectual Disabilities. 19, 67–73.
Wilson, R., & Branch, R. (2006) Cognitive Behavioural Therapy for Dummies. Chichester: John
Wiley & Sons Ltd.
Winn & Baron (2009) – Effective Communication. In A. Hassiotis, D. Andrea Baron, I. Hall (Eds),
Intellectual Disability Psychiatry: A practical handbook (pp. 3- 20). Chichester: John Wiley &
Sons Ltd.
World Health Organisation. (1993) The ICD-10 Classification of Mental and Behavioural
Disorders: Diagnostic Criteria for Research. Geneva, WHO.
Young, J., Klosko, J., & Weishaar, M. (2003) Schema Therapy: A Practitioner’s Guide. The
Guildford Press: NY.
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Part III
Accessible CBT material
 Info sheets
 Resources
 Worksheets
99
Information Sheets
Info Sheet 1 Info Sheet 2 Info Sheet 3 Info Sheet 4
Info Sheet 5 Info Sheet 6 Info Sheet 7
Info Sheet 8
100
Resource
s
Resource 3
Resource 1 Resource 2
101
Worksheets
Worksheet 2
Worksheet 1 Worksheet 3
Worksheet 4
Worksheet 8
Worksheet 7
102
Worksheet 9 Worksheet 10 Worksheet 11 Worksheet 12
Worksheet 13
Worksheet 16 Worksheet 17 Worksheet 18 Worksheet 19
103
Worksheet 22
Worksheet 24
Worksheet 26 Worksheet 27 Worksheet 28
104
A Manual of Cognitive Behaviour Therapy for People with Learning Disabilities and Common
Mental Disorders
Therapist Version
This manual provides a step-by-step cognitive behavioural therapy (CBT) approach to
treating common mental disorders in people with mild to moderate learning disabilities. The
treatment describes a three-part protocol for treating anxiety and/or depression and outlines
specific emotional, behavioural, and cognitive techniques that the therapist can use with this
population. Case vignettes and detailed examples are used throughout the manual to
illustrate the process of therapy, from the introduction of CBT and initial assessments to
case conceptualization, treatment planning, intervention, and termination.
The authors also provide expert advice on building collaborative therapeutic relationships
and modifying communication in a therapeutic setting to ensure that CBT is accessible to
people with mild to moderate learning disabilities. An array of accessible material including
worksheets, handouts, therapeutic exercises and homework tasks are provided in the
manual to aid/support clients as they progress through therapy.
The manual offers both theoretical and practical guidance for trained CBT therapists in
becoming more skilled and confident clinicians in modifying and adapting CBT for people
with learning disabilities.
“The CBT manual has been a helpful resource in beginning to bridge some of the communication
difficulties and facilitate more effective communication between therapist and service user. I found
that the manual was flexible in meeting the needs of the individual clients as it broke down the CBT
process i.e. problems, goals, diary keeping, behavioural experiments, positive log etc. It was clear and
concise and designed in way that was both easy to understand and visually stimulating.” Lorna
Vincent, CBT therapist.
“I believe that CBT is a good and user friendly way to use as a tradition. The service users were able
to work in all 3 systems and the manual is an excellent resource both for the therapist and the client. It
provides a visual way of communicating, which is valuable when using guided discovery, for
example.” Matt Broadway-Horner, CBT therapist.
“The therapist showed me different ways of dealing with my emotions. The therapy was really good
because I was able to deal with things that have happened to me and try to build up my confidence
which I never had before.” Participant 09, Randomised Controlled Trial.
“My advice to people, a [CBT] therapist like this one is the best one, because [its] having someone
totally different, sort of teaching you a different way of how to go about life.” Participant 10,
Randomised Controlled Trial.
“I would recommend the therapy because first definitely I could see a lot more confidence in [the
client].” Carer, Randomised Controlled Trial.

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A Manual of Cognitive Behaviour Therapy for People with

Learning Disabilities and Common Mental Disorders

Cover designed by Bastien Cordier

This manual uses pictures from the Photosymbols collection (www.photosymbols.com)

iii About the authors

1 Chapter 1: An Introduction to the Use of CBT in People with Learning Disabilities

15 Chapter 2: Communicating with People Who Have Learning Disabilities in the

23 Chapter 3: The Early Sessions (Sessions 1–4)

44 Chapter 5: The Middle Sessions (Sessions 5–14)

51 Chapter 6: Linking Thoughts, Feelings, and Behaviours

59 Chapter 7: Specific Cognitive Techniques

68 Chapter 8: Specific Behavioural Techniques

78 Chapter 9: Additional Skills

81 Chapter 10: The Final Sessions (15–18)

Part III: Accessible CBT material

About the authors

Depression and Anxiety in People with Learning Disabilities

Behavioural correlates of anxiety disorder include hyperventilation, aggression, increased

Biopsychosocial Influences on the Development and Alteration of Depression and Anxiety

 The cognitive-behavioural model (Beck et al, 1979)

 The self-control model (Rehm 1977, 1981)

 The learned helplessness model (Peterson & Seligman, 1981)

The Cognitive-Behavioural Model of Depression

Core beliefs developed

Events that may trigger

The Self-Control Model of Depression

 Self-monitoring—The individual selectively attends to negative aspects of experience or

 Self-evaluation—The individual constantly evaluates him- or herself using harsh and

 Self-reinforcement—The individual provides him- or herself with insufficient positive

The Learned Helplessness Model of Depression

At present, more work is needed to investigate aetiological

A Brief History of CBT Treatment in People with Learning Disabilities

McCabe et al (2006) and McGillivray et al (2008) reported on group-based CBT treatment

CBT for People with Learning Disabilities

Therapist Characteristics and the Therapeutic Approach

The Importance of Rapport

The Therapeutic Alliance

The Role of the Caretaker/Support Worker

The inclusion of an additional person in sessions represents an interesting challenge to

Understanding People with Learning Disabilities: On the Problems with Vocabulary,

Tips to Help You Understand People with Learning Disabilities

1. If you do not understand what a client says, it is important that you

3. Make sure you listen carefully. Pay special attention to speech

6. Be aware of other things that may affect communication. This could

Client: I couldn’t find my shoes.

Therapist: Tell me what happened.

Client: I put them in the wrong place.

Therapist: How did that make you feel?

Tips to Help People with Learning Disabilities Understand You

2. Think about how to ask questions. Open-ended questions can be more

3. Link your explanation with everyday things. This is especially important if

5. Eliminate distractions. People with learning disabilities have a hard time

Using Picture and Symbols to Communicate

If verbal communication presents a barrier, we encourage you to incorporate pictures or symbols

Focus on Non-verbal Communication

Idiosyncratic Communication Issues Specific to Certain Populations with Learning

 Early/initial phase (sessions 1–4)

 Middle phase (sessions 5–14)

 Final phase (sessions 15–20)