Are you as a mental health professional aware of the needs of clients with intellectual disabilities? Do you know what generally constitutes “impairment”, “disability”, or “activity limitation”? Would you be aware of special considerations or needs that such a client might have in a counselling context?

There is wide agreement that it is difficult for people with disabilities to get any counselling at all, let alone that which meets their particular needs (WWILD, 2012; Raffensperger, 2010; Haj, 1991). In the past, there has been a general assumption that at least those whose disability was intellectual would not be able to engage in counselling; they were said to lack the cognitive ability and insight to be able to participate meaningfully in the counselling process. Moreover, counsellors have often expressed doubt about their ability to work with this group.

These two situations have combined to mean that people with disabilities (especially intellectual ones) have been excluded from mainstream counselling services. Yet, those living the experience of having disabilities have a greater burden of discrimination, marginalisation, and exclusion from the community and its services than “normal” people. They are more likely to be exploited or become victims of crime, experiencing trauma and necessitating counselling support. Those who acquire their disabilities as adults are particularly vulnerable to trauma (WWILD, 2012; GoodTherapy.org, 2013).

In this article, we explore six important issues counsellors should consider – when working with clients with intellectual disabilities – in order to maximise positive outcomes for clients. These include:

1. Common myths which reduce motivation to engage the counselling process
2. The counsellor-client power imbalance
3. The need to do time differently than with populations without disabilities
4. The need for extra support
5. Processes of trauma, grief, loss, and bereavement
6. Appropriate means of expression and style of counselling.

Common myths which reduce motivation to engage the counselling

As we elaborate on these myths, we challenge you to disidentify from the attitudes you would like to claim, and acknowledge any limiting beliefs you may have been led to adopt.

• Myth 1: People with intellectual disabilities are unable to think. Reality: People labelled intellectually disabled may take more time to come up with an answer. Some are challenged to engage abstract thinking. But they do think (WWILD, 2012). Nartey (2007) reckons that this myth has had much to do with professional disinterest in working with this population; the fear that the client would not be able to think, reasoned the psychoanalyst, meant that he would not be able to form transferences, the basis of psychoanalytic work (Nartey, 2007).
• Myth 2: People with intellectual disability cannot feel. Reality: People with disability have feelings and experience emotions in the same ways as people without intellectual disability.
• Myth 3: People with an intellectual disability do not feel hurt or trauma from exploitation or abuse like persons without disability do. Reality: People with intellectual disabilities feel these things as acutely as any other person.
• Myth 4: People with an intellectual disability are unable to communicate well in a therapeutic environment. Reality: The intellectually disabled can communicate in a number of different mediums if given the opportunity.
• Myth 5: So-called “challenging” behaviours by people with intellectual disabilities are displayed because of their disability. Reality: Although people with intellectual disabilities sometimes engage in unique behaviours, the behaviours labelled “challenging” usually occur because they do not know how to express frustration, anger, or other strong emotions engendered from abuse or trauma. They need help to deal with that (WWILD, 2012).

A counsellor labouring under the illusion of any of these myths perpetuates the stigmatisation and marginalisation of people with intellectual disabilities which is already occurring; this happens partly because of the power imbalance.

The counsellor-client power imbalance

Counsellors are in a position of power when working with people with intellectual disabilities; keenly feeling that power differential can cause clients to miscommunicate, engage in challenging behaviour, or inspire them to be non-compliant. Ways to reduce the power differential, therefore, are crucial with this group. They can include:

• Including power-neutral positions in the environment and allowing the client to choose where to sit
• Avoiding unnecessary use of professional jargon
• Using labels of intellectual disability as little as possible with clients (as most do not identify with diagnostic labels, such as “being disabled”)
• Considering moving the counselling session to a different environment, such as a park or café, or going on a walk
• Making sure that clients know it is ‘ok’ to ask for clarification when they don’t understand something (it is the mental health practitioner’s responsibility to ensure understanding; being able to do so reflects a therapist’s skill) (WWILD, 2012).

Doing time in session with clients with intellectual disabilities

Most mental health helpers avow the importance of allowing the client the time needed to feel comfortable in session, build safety and rapport, come to grips with the problem, and work out appropriate therapeutic goals. People with intellectual disabilitiesmust go through the same process, but needs more time for it. The suggestion is that counsellors should allow double the time they normally would for the total duration of the therapy (Brown & Hooper, 2009).

This allows clients with intellectual disabilities the extra time needed to understand the task and the questions being put to them, to think about the questions, to grab relevant information from memory, and to find words (or another communication medium) to communicate their thoughts and feelings (WWILD, 2012). It is not about making an hour-long session into a two-hour one, however. Such clients may tire easily from the task of concentrating, and may be benefitted more by shorter, more frequent contacts.

Support: a broader issue

Counsellors are sometimes reluctant to take calls from clients in between sessions. With clients with intellectual disabilities, however, support between scheduled session times may be especially beneficial as clients grapple with session issues and come to understandings – or points which need clarification – in their own time, often after a session has finished (Raffensperger, 2010).

Too, while liaising with support people in the client’s life may be useful for counsellors of clients without disabilities, it is essential for those working with disabled ones. Family and friends who are in daily contact with the person are in a position to observe changes in the person’s behaviour and well-being. Such support people can offer useful information and clarification in situations where the client has difficulty providing precise or detailed information.

Hayes (2007) cites research to suggest that clients with intellectual disability have the best therapeutic outcomes when they have the support of family members or paid support workers to apply what they are learning in session to the “real world” outside of therapy. The therapist, then, must collaborate with such support people, allowing carers to come to sessions and facilitating them to develop the skills required to help create and support change in the client. Also, such training can help carers, whether paid or family members, to develop the attitudes which allow change to occur (Hayes, 2007).

As a professional working with a client with intellectual disabilities, you can encourage support people to aid the therapeutic process by:

• Helping the client to apply skills learned in session to the world outside of therapy
• Supplementing the client’s observation about what has and hasn’t worked “in the real world”
• Helping the client to recognise and celebrate positive change
• Enabling more productive and enjoyable relationships by learning new ways of interacting with the client
• Creating opportunities for client success
• Showing others (for instance: friends, teachers, and workmates) how they can support the client to maintain positive change (WWILD, 2012).

Processes of trauma, grief, loss, and bereavement

Trauma

Because so many people with intellectual disabilities have been abused psychologically, emotionally, or physically and thus experience emotional problems or secondary physical mobility disability, learning how to recognise the signs of trauma, grief, and loss in clients with intellectual disabilities is paramount. The indicators which identify whether a person is experiencing depression or other mental health issues are similar to those for the non-disabled population:

• Difficulty getting to sleep or waking early
• Lethargy; more time sleeping
• Restlessness and irritability
• Showing less interest in formerly enjoyed activities
• Losing or gaining weight
• Avoiding other people
• Loss of confidence
• Feelings of guilt or worthlessness (adapted from WWILD, 2012)

Not only depression and anxiety, but also the following symptoms are responses – by both clients with and without intellectual disabilities – to traumatic events:

• Flashbacks, nightmares, intrusive images or thoughts, and reliving the experience
• Hypervigilance
• Problems with memory, attention, concentration, and/or problem-solving ability
• Poor decision-making ability
• Reduced ability to communicate
• Disorientation
• Dissociation
• Blaming themselves or others
• Changes in behaviour, either sudden or gradual
• Anger outbursts, destructiveness, or self-harm
• Physical illness or complaints about aches and pains
• Loss of bladder control
• Seeking reassurance
• Wandering or searching.

People with intellectual disabilities are not different from those without disabilities in needing reassurance and normalisation; a key step in support is to help them understand that such reactions are normal to experience and that they are having them because they have been traumatised, not because they cannot cope (WWILD, 2102).

Grief, loss, and bereavement

Imagine for a moment that you have landed on a strange planet, one in which all the inhabitants – funny-looking though they are – are mathematical geniuses. They practically talk in mathematical formulas and theorems. While you used to do ‘ok’ in school back on Planet Earth in the subject of maths, you are no match for this culture. They quickly size you up and, seeing that you are not equivalently gifted to them in this aspect, begin to call you “retarded”.

Of course, you know that you are regarded on your home planet as a pretty good thinker and that you are normally a quick study, so this intractable characterisation leaves you feeling really anxious and depressed, especially because you will be staying on the planet for some time; you feel a profound sense of grief at how you are thought of. But what happens over time has you even more gobsmacked: you realise that the “natives” of this planet have come to believe that you are anxious, depressed, and grieving because that’s the way you normally are, that it’s part of your “retardation”. They don’t even consider for a moment that you might be reacting to their judgment of you.

For people with intellectual disability, the situation may be similar. The palpable sense of grief and loss can occur simply when the person comes into awareness that they are “different” from others. They may feel anxious and depressed that they cannot communicate or understand things in the way that “normal” people do. These types of losses are many and occur over a very long period of time, prompting some writers to claim that grief and loss are amongst the most significant yet under-acknowledged issues for people with intellectual disability (Riches, 2008). To make matters worse, there is a common assumption that people with intellectual disability are not capable of experiencing grief (Riches, 2008).

Continued negative evaluations of people with intellectual disabilities, by themselves as well as others, make self-esteem and positive self-regard highly difficult to achieve, as the labels “different”, “limited in capacity”, or “dumb” can be a major factor contributing to a sense of loss and the consequent depression. Unfortunately, the resultant behaviours are often seen as “challenging” and as part of the disability, and deeper causes are not considered (Blackman, 2008); thus, they are missed diagnostically, with only the “challenging” behaviour a focus.

Similarly with bereavement, family members and paid carers can wrongly assume that the person with intellectual disabilities is not capable of grieving because they cannot understand death. Compounded by the often-present social isolation, poor physical and mental health, and limited opportunities for appropriate expression of emotion, it is not surprising that intellectually disabled individuals may experience a prolonged anger born of grief (WWILD, 2012).

Because understanding the concept of death can be challenging for those with intellectual disability, it is important that they be able to participate fully in the rituals that take place for the deceased person. The person with intellectual disabilities needs to be able to come to terms with the characteristics of death: namely that it is permanent, that it totally causes the body to stop working, and that it happens to us all (MacHale, McEvoy, & Tierney, 2009). Research has shown that support people and carers are likely to overestimate the intellectually disabled clients’ understanding of death, which makes it harder to identify grieving, with behavioural changes attributed to other causes (MacHale et al, 2009).

You can help a bereaved client with intellectual disabilities to grieve in a healthy way by:

• Making sure that carers and support people know about the client’s loss
• Helping the client access warm, caring, trusting relationships during their time of loss These key supportive relationships can form a solid basis from which to heal
• Aid the client in being able to view the deceased person’s body and to participate in funeral or memorial services or other grief rituals
• Patiently explain, over and over again, about death using methods of communication which work for the client
• Facilitate the client gaining possession of photos or other memorial items of the deceased loved one
• Assist the client to engage in memorial activities such as artwork, memory boxes, or the planting of special trees or shrubs to help the client cope with the loss and provide a positive connection to the person’s memory (Constellation Project Australia, 2010).

All of these strategies work best within an appropriate style of communication, one which allows the client the flexibility to communicate in ways that suit him or her.

Appropriate means of expression and style of counselling

While those with intellectual disability often struggle to tell their stories in a direct, linearly sequenced manner, remembering details and understanding cause-and-effect, they nevertheless have many means of communication at their disposal. We plant here the suggestion that mental health helpers can enhance therapeutic outcomes by allowing as “legitimate” many creative means of expression, in two categories: embodied expression and projected expression.

Embodied expression includes media such as dancing and music, acting, role play, use of masks, and characterisation, embodied games, and whole person movement. Projected expression includes art (e.g., painting and drawing), sand tray work with symbols, written stories and poetry, and drama which expresses the person’s story through an external character.

Such techniques are often highly beneficial for clients with intellectual disabilities because they do not depend for effectiveness on verbal communication, allowing instead indirect expression. Too, they work with both imagined and factual narratives (Upton, 2009).

If therapists can open themselves to the notion that the client’s story can be told just as validly through art, drama, or music, they can foster not only a closer therapeutic alliance, but also the consequent improved therapy outcomes.

Conclusion

In this article we examined the chief issues for counsellors working with clients with intellectual disabilities, including: popular myths which reduce counsellors’ motivation to engage counselling with this client population; questions of the counsellor-client power imbalance; the need to proceed at a different pace than with non-intellectually disabled clients; the need for extra support; the ongoing issues of under-acknowledged trauma, grief, and loss; and (briefly) the issue of counsellors’ need to accept varying means of expression from the intellectually disabled, who are not always comfortable with direct verbal communication.

In closing, we may speculate about the considerable gains that could accrue for all people with disabilities – whether intellectually or otherwise – if the pervading attitude in the larger society were similar to that of themselves as described in the following quote:

“People with disabilities who consider them-selves successful generally accept their disabilities as one aspect of who they are. They do not define themselves by their disabilities. They recognize that they are not responsible for their disabilities, and they know that they are not inherently impaired. They do not blame others for their situation, nor do they have a sense of entitlement. Instead, they take responsibility for their own happiness and future (Do It, n.d.).

Another may have summed up the entire issue with this one pithy observation:

“God makes each one of us with an ability; society creates the “dis” (Do It., n.d.).

This article was adapted from the upcoming Mental Health Academy CPD course “Counselling Clients with Disabilities: Introduction to the Issues”. The aim of this course is to acquaint you with the issues which surround the counselling of people with disabilities.

References

• Brown, F. J. & Hooper, S. (2009). Acceptance and Commitment Therapy (ACT) with a learning-disabled young person experiencing anxious and obsessive thoughts. Journal of Intellectual Disabilities, 13(3), 195-201.
• The Constellation Project Australia. (2010). Intellectual disability and grief – for professionals [website]. Retrieved on 30 December, 2013, from: hyperlink.
• GoodTherapy.org. (2013). Chronic illness/disability. From the GoodTherapy.org website. Retrieved on 4 December, 2013, from: hyperlink.
• Haj, F. (1991). Problems with counselling the visually handicapped. Future Reflections Winter/Spring, 1991, reprinted from the July, 1990, Braille Monitor. Retrieved on 4 December, 2013, from: hyperlink.
• Hayes, S. (2007).Cognitive behavioural therapy for people with ID who are victims of crime – can it be accessed and does it work? Paper presented at the 5th World Congress of Cognitive and Behavioural Therapies, Barcelona, 11-14 July 2007. Retrieved on 30 December, 2013, from: hyperlink.
• MacHale, R., McEvoy, J. & Tierney, E. (2009). Caregiver perceptions of the understanding of death and need for bereavement support in adults with intellectual disabilities. Journal of Applied Research in Intellectual Disabilities, 22, 574-581.
• Nartey, P. (2007). Ethical issues in counselling and psychotherapy with people with intellectual disability. Counselling, Psychotherapy, and Health, 3(2), 1-12.
• Raffensperger, M. (2010). Brainstorming collaborative solutions: Looking back at problems but moving forward to find collaborative ways to better support the emotional and mental wellbeing of people with an intellectual disability. Talk based on doctoral dissertation given at Disability Support Workers Conference, Melbourne, 2010. Retrieved on 4 December, 2013, from: hyperlink.
• Riches, V. (2008).Unrecognised and unsupported: Grief among people with intellectual disability. Grief Matters, Winter, 48-52.
• WWILD. (2012). How to hear me: A resource kit for counsellors and other professionals working with people with intellectual disabilities. WWILD Sexual Violence Prevention Association Inc: Disability Training Program. Department of Justice and Attorney General Building Capacity for Victims of Crime Services Funding Program. Retrieved on 3 December, 2013, from: hyperlink.