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Cognitive behavioural therapy for people with ID who are victims of crime–can it be accessed and does it work?



Cognitive behavioural therapy for people with ID who are victims of crime – can it be accessed and does it work? Abstract The paper examines the research evidence on the use and effectiveness of CBT with people with ID who are victims of crime. There is not a large body of research on the use of CBT with people with ID, and the research that has been conducted within the criminal justice area tends to focus primarily upon accused persons and offenders, rather than victims of crime. There is a dearth of research about the effectiveness of CBT with victims of crime, who may suffer from a number of psychiatric and psychological disorders including anxiety disorder, post-traumatic stress disorder and depression, as well as behavioural difficulties. There are few practitioners who are expert in the dual fields of CBT and victims of crime with ID, and hence it is difficult for service users and their carers to access this form of intervention. In turn, the small number of clinicians working in this field means that few research studies are conducted; when research is conducted, the sample sizes tend to be small and unrepresentative.
Cognitive behavioural therapy for people with ID who
are victims of crime –
can it be accessed and does it work?
Susan Hayes
Associate Professor and Head,
Centre for Behavioural Science, D06
Central Clinical School,
Faculty of Medicine,
University of Sydney,
NSW Australia 2006
5th World Congress of Cognitive and Behavioural Therapies, Barcelona, 11-14 July 2007
Cognitive behavioural therapy for people with ID who are victims of crime –
can it be accessed and does it work?
The paper examines the research evidence on the use and effectiveness of CBT with
people with ID who are victims of crime. There is not a large body of research on the use
of CBT with people with ID, and the research that has been conducted within the criminal
justice area tends to focus primarily upon accused persons and offenders, rather than
victims of crime. There is a dearth of research about the effectiveness of CBT with
victims of crime, who may suffer from a number of psychiatric and psychological
disorders including anxiety disorder, post-traumatic stress disorder and depression, as
well as behavioural difficulties. There are few practitioners who are expert in the dual
fields of CBT and victims of crime with ID, and hence it is difficult for service users and
their carers to access this form of intervention. In turn, the small number of clinicians
working in this field means that few research studies are conducted; when research is
conducted, the sample sizes tend to be small and unrepresentative.
A person with an intellectual disability (ID) is more likely to be a victim of crime, and
also more likely to suffer a psychiatric disorder, compared with the general population.
In summary,
People with ID, especially women, are more likely to be the victims of crime than
their non-disabled counterparts
The high level of vulnerability may be related to social isolation, dependency,
feelings of helplessness and powerlessness, ignorance about violence and
sexuality, and susceptibility to coercion and bribery
People with ID have higher rates of psychiatric conditions than the general
Psychiatric morbidity is hidden in an estimated 50% of cases of victims of crime
with ID
Therefore, the high rate of psychiatric morbidity in people with ID may be partly
a consequence of their high rate of victimisation (Hayes, 2004)
The effect of violence on people with ID is an area in which there is not a large body of
research. Despite the high rate of crime against people with ID, there is comparatively
little known about treating the effects of having been the victim of trauma, neglect or
Victims of crime with ID
A study of 15 people with ID, compared with 77 non-disabled participants, all of whom
had been victims of crime, showed the following (Hayes, 2004):
Sixty per cent showed symptoms of depression (cf. 88% of the non-disabled
group, chi square p<.01)
Forty-seven per cent indicated that they currently or previously had suicidal
ideation (cf. 53%, no difference)
Forty per cent had attempted suicide (cf. 17.3%; chi-square p <.05)
Two-thirds reported symptoms of post traumatic stress disorder (cf. 85.3% of the
non-disabled group; no significant difference)
Sixty per cent indicated symptoms of anxiety disorder (cf. 80%; no significant
One third reported having panic attacks (cf. 41%; no significant difference)
On average, participants in both groups reported three psychiatric disorders
In this small group, one person with ID had been the victim of domestic violence, three
had been victims of non-sexual assaults, eleven had been the victim of one sexual assault
and one had been the victim of two sexual assaults. Clearly some individuals had been
assaulted several times.
The pattern of crime against people with ID differed from that against their non-disabled
counterparts, with the ID group being more likely to be the victims of sexual assault,
whilst the non-disabled group were more likely to be victims of domestic violence or
non-sexual assault.
Whilst crimes against or abuse of people with ID can occur in unfamiliar environments,
much of the abuse occurs in the places where they are meant to be safe, in their place of
residence, in the workplace, or whilst travelling between work and home. The prevalence
of violence in the daily lives of some people with ID is so great that some researchers
have described it as “accepted as a natural part of the daily care for adult person with ID”,
with most of the violence in helping care situations being physical or psychological
(Strand, Benzein and Saveman, 2004).
White, Holland, Marsland and Oakes (2003) maintain that popular explanations of abuse
tend to emphasise the role of the individual, especially the characteristics of the person
with ID which might contribute to them becoming a victim of abuse their “fault” -
rather than the role of the broader context of care. A number of features of care
environments have been identified as promoting abuse of people with ID; on a positive
note, if these factors were changed, there may be greater likelihood of appropriate
recognition of and intervention for psychological and psychiatric symptoms in clients
with ID, and prevention of further abuse.
Drawing on the work of these authors, the factors that have the potential to affect the care
environment positively include:
1. Good management, supervision and accountability; willingness to challenge
abusive staff or clients
2. Support of staff, development of good morale and job satisfaction, staff
3. Staff attitudes and behaviours that are respectful of clients and promote dignity,
within appropriate staff-resident boundaries
4. Staff induction and in-service training in the areas of abuse and protection;
sexuality; intimate care; record keeping (especially of incidents); preventing and
responding to challenging behaviour; supporting client communication; and
coping with anger or stress
5. Power, status and autonomy for both services users and staff; staff culture which
encourages open review and reporting of abuse
6. Contact and interaction with the community outside the service; outside support,
vigilance and monitoring, especially at night and on weekends
7. Service conditions, design and placement that encourage safety, constructive
activity and which do not allow concealment of poor care standards or abusive
If victims of crime with ID are receiving services from service providers which comply
with these good environmental “markers”, the abuse or crime is more likely to have been
recorded, their psychological or psychiatric symptoms are more likely to be noticed, and
staff will be motivated to provide or assist the client to access therapeutic interventions
such as CBT.
The need for treatment for people with ID who have been victims of crime
Given the high rate of victimisation of this group, it is astonishing that relatively little
research and few reports on clinical practice focus upon therapeutic interventions. The
lack of information about the area may be in itself indicative of a tendency to devalue this
group. As Peckham, Howlett and Corbett (2007) point out, ID has been routinely used as
an exclusion criterion for psychotherapy and group interventions for these clients. Other
publications comment on the restriction of services such as psychotherapy for
marginalised groups including people with ID (Department of Health, 2004).
Sequiera and Hollins’ comprehensive review of the clinical effects of sexual abuse on
people with learning disability (2003) nevertheless establishes that victims of crime with
ID suffer the range of symptoms, psychopathology and behavioural difficulties that is
experienced in the general population, including PTSD, depression, loss of self-esteem,
self-destructive tendencies, anger, schizophrenifom psychosis, personality disorder,
dissociative symptoms, self-harm and alcohol abuse. On the basis of clinical experience,
victims also often suffer anxiety disorder and panic attacks.
In about one-third of victims, the symptoms of PTSD are unlikely to resolve even after a
considerable period of time (Kessler, Sonnega, Bromer, Hughes, and Nelson, 1995).
Determining the range and severity of symptoms in both victims and offenders can be
compromised by communication difficulties, especially limitations in the ability to
describe internal subjective experiences.
Ironically, an offender with ID may have a greater likelihood of accessing CBT (and
other forms of therapy) than a victim (Victorian Department of Human Services, 2000) –
amongst the offender group in this service in Victoria (Australia), two-thirds of offender
clients received group or individual CBT from a psychologist. This trend appears to be
similar to service delivery in other nations (Sinclair, Murphy, and Hays, 2007; Taylor,
Novaco, Gillmer and Thorne, 2002). These studies on CBT and offenders are useful,
however, in demonstrating that CBT can be used effectively with people with ID. They
also serve as a useful reminder that many offenders with ID have also been victims of
prior abuse or violence.
Therefore, whilst there is undoubtedly a need for therapeutic interventions with people
with ID who have been victims of crime, there is a need for further investigation of
clinical effects of these traumatic events.
Effectiveness of CBT with victims of crime – the research
There are four areas that can be examined for evidence of the effectiveness of CBT:
Non-disabled victims of crime
People with ID who are neither victims nor offenders, but who may have
psychological symptoms or behavioural difficulties that can be treated with CBT
Offenders with ID
Victims of crime with ID
There is compelling evidence that CBT is effective in the treatment of trauma for victims
of crime with no known disability (Foa, Keane and Friedman, 2000). Brief CBT has
been shown to be more effective, particularly for female sexual assault survivors, than an
assessment condition or supportive counselling (all over four 2-hour sessions)
immediately post-treatment and at 3-month follow-up. Early intervention seems to
increase the rate of natural recovery of sexual assault survivors, which clearly would also
reduce the misery of the victim (Foa et al., 2006).
Regarding people with ID who are neither victims nor offenders, there is ample evidence
that CBT can be used effectively, although there are some limitations, for example Verbal
IQ (Willner, Jones, Tams and Green, 2002) and verbal ability generally.
Other factors which affect the individual’s capacity to engage in CBT include (Willner,
Capacity to recognise and label emotions
Ability to link emotions and events
Ability to differentiate between thoughts, feelings and behaviours
Furthermore, the clients who respond best are those whose carers participate in the CBT
programme, assisting the client to apply the principles in real life settings and to practise
the skills after cessation of the group. This is reflected with non-disabled participants
homework compliance has been strongly associated with better CBT outcome (Foa et al.,
2006). These research findings emphasise the point made earlier, concerning the
importance of the environment of the service of which the person with ID is a client. If
the service is willing to locate CBT, allow a worker to accompany the client to the
therapy sessions, and to assist with practice, the outcome will be better for the client.
The CBT technique has also been used with people with ID who are non-victims, in the
treatment of depression (McCabe, McGillivray, and Newton, 2006). In the latter study,
the intervention had a significant impact not only on depression, but also on other
psychosocial variables, self-esteem and frequency of negative thoughts, with the results
being sustained over at least a three month period.
For those people with ID and offending or challenging behaviour, CBT has been
successfully employed in the areas of anger treatment (Willner et al., 2002; Taylor,
Novaco, Gillmer and Thorne, 2002), and sex offending (Sinclair, Murphy, and Hays,
Finally, in treating victims of crime (or survivors) with ID, imagery rehearsal has been
shown to produce significant reductions in distress cause by nightmares (Stenfert Kroese
and Thomas, 2006).
The use of CBT for some selected clients with ID has face validity as an effective
intervention. Some victims of crime report that they dislike counselling which involves
“going over and over” the traumatic event, and express a wish for interventions that are
practical, action-oriented and where they can discern progress. Apart from the lack of
perceived progress with some verbal counselling techniques, participants report that
repetition of aspects of the trauma prevents them from putting the trauma behind them,
and increases their level of distress after each session. CBT would appear to fit the bill as
a technique which would be acceptable to this client group.
Availability of CBT
A major difficulty in implementing CBT or other therapeutic interventions for people
with ID who are victims of crime is the likely time delay in accessing treatment. Ideally,
CBT commences between 2-5 weeks following trauma, and consists of several sessions
(Foa, Zoellner and Feeney, 2006). However, the experience of victimisation of this group
may not be noted for some time, possibly until severe behavioural changes are noticed by
family or service providers. Notification of a possible crime to police may then take
longer, or indeed may not occur at all. If acceptance into a victim counselling programme
is dependent upon the crime being reported, then there is likely to be a significant delay
in implementation of therapy for some or many victims with ID. The longer the delay,
the more likely it is that the symptoms may become chronic and that the victim may
engage in behavioural alterations such as restricting their daily routine and avoiding
reminders of the trauma (Foa, 2006) – that in turn affect their enjoyment of life and begin
to increase the negative thought processes.
A search of the Australian Psychological Society website of psychologists practicing
privately within 100 kms of Sydney, and who were registered with Medicare (a
government funded universal medical care scheme which has recently included
psychological intervention) found that 75% indicated that CBT was one of the range of
therapies that they offered however, none of these practitioners indicated that people
with ID were included in the client groups to whom they offered services. There are, of
course, psychologists who work for government or non-government agencies providing
services for people with ID; clients report that there are waiting lists of up to six months
for an initial appointment, and follow-up appointments occur at a frequency of 2-3 weeks,
usually with a cap of about three months duration. Of 74 clients who have been the
victims of crime and who have been assessed by this author in the past 18 months in
relation to claims for victims compensation from the NSW state government, almost all
of the clients had been referred for some form of therapy prior to being assessed. Not all
of these clients had intellectual disabilities. Only three had participated in CBT.
On the basis of this limited group of clients who have been victims of crime, it appears
that CBT is seldom used, at least by psychologists who are on the NSW Attorney
General’s Victims Services list of approved counsellors.
The paucity of professionals expert in both CBT and intellectual disability is likely to be
paralleled in other countries. Whilst not referring specifically to CBT, the availability of
psychotherapy services for people with ID in England are described as patchy, eclectic,
and often provided by untrained therapists who are not under supervision (Royal College
of Psychiatrists, 2004). A survey of clinical psychologists in the field of learning
disabilities indicated that 35% routinely used CBT (Nagel and Leiper, 1999, as cited in
Willner et al., 2002).
Foa (2006) maintains that non-specialists can be taught how to practise effective CBT,
and gives examples of how short training (she cites four or five day training programmes
for professionals with some prior mental health training and experience) in CBT can
assist professionals to deliver CBT competently. She emphasises the importance of rapid
training, especially where there is a major disaster involving large numbers of victims.
Treatment by counsellors with brief CBT training can be as effective as treatment by
CBT experts (Foa, Hembree, Cahill, Rauch, Riggs, Feeny, and Yadin, 2005).
Furthermore, short interventions over a median of eight sessions were found to produce
positive results.
Whilst CBT appears to be an effective intervention for people with ID in addressing a
number of problems, this technique appears not to be as widely used as would be
expected, partly because of a scarcity of professionals expert in both CBT and ID.
However, Foa and colleagues’ research on brief training in CBT for service providers
with a background in mental health may indicate a way forward for services for people
with ID which can encourage staff to acquire relevant skills and obtain appropriate
supervision. An increase in the numbers of service providers skilled in CBT will in turn
lead to an increase in clinical and research information about the results of CBT with
victims of crime with ID.
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Full-text available
Background Fourteen clients with learning disabilities referred for anger management were randomly assigned to a treatment group and a waiting-list control group. Methods Treatment consisted of nine 2-h group sessions, using brainstorming, role-play and homework. Topics addressed included: the triggers that evoke anger; physiological and behavioural components of anger; behavioural and cognitive strategies to avoid the build-up of anger and for coping with anger-provoking situations; and acceptable ways of displaying anger (assertiveness). The intervention was evaluated using two inventories of anger-provoking situations, which were completed independently by both clients and carers. Results Clients in the treated group improved, on both self- and carer-ratings, relative to their own pre-treatment scores, and to the control group post-treatment. The within-group improvement corresponds to a ‘moderate’ (0.68 SD) effect size, whereas the between-group improvement corresponds to a ‘large’ (1.76 SD) effect size. The degree of improvement during treatment was strongly correlated with Verbal IQ. Clients in the treated group showed further improvement relative to their own pre-treatment scores at 3-month follow-up. Conclusions The treatment was effective in decreasing anger, in this randomized controlled trial of routine clinical practice.
Full-text available
Background Aggressive behaviour has been identified as a significant problem amongst people with intellectual disabilities living in institutional settings. Anger is a key activator of aggressive behaviour, as well as being an important element of clinical distress related to adverse life experiences. There is some evidence for the value of cognitive–behavioural treatments for anger problems with people having intellectual disabilities. No controlled studies of anger treatment involving intellectually disabled offenders living in secure settings have been conducted to date. A pilot study of an elaborated anger treatment protocol for this client population was undertaken, comparing the specialised anger treatment with routine care. Methods Detained men with intellectual disabilities and histories of offending were allocated to specially modified cognitive–behavioural anger treatment (n = 9) or to routine care waiting-list control (n = 10) conditions. Eighteen sessions of individual treatment were delivered over a period of 12 weeks. Treatment outcome was evaluated by participants' self-report of anger intensity to an inventory of provocations and by staff-ratings of the anger attributes of participants' ward behaviour. Results Participants' reported anger intensity was significantly lower following the anger treatment, compared to the routine care wait-list condition. There were largely no treatment condition effects in staff-rated anger. Limited evidence for the effectiveness of anger treatment was provided by the staff ratings of participant behaviour post-treatment. Conclusions Detained offenders with intellectual disabilities can benefit from intensive individual cognitive–behavioural anger treatment. Further research is required to examine the mechanisms for change and their sustainability.
Full-text available
Data were obtained on the general population epidemiology of DSM-III-R posttraumatic stress disorder (PTSD), including information on estimated life-time prevalence, the kinds of traumas most often associated with PTSD, sociodemographic correlates, the comorbidity of PTSD with other lifetime psychiatric disorders, and the duration of an index episode. Modified versions of the DSM-III-R PTSD module from the Diagnostic Interview Schedule and of the Composite International Diagnostic Interview were administered to a representative national sample of 5877 persons aged 15 to 54 years in the part II subsample of the National Comorbidity Survey. The estimated lifetime prevalence of PTSD is 7.8%. Prevalence is elevated among women and the previously married. The traumas most commonly associated with PTSD are combat exposure and witnessing among men and rape and sexual molestation among women. Posttraumatic stress disorder is strongly comorbid with other lifetime DSM-III-R disorders. Survival analysis shows that more than one third of people with an index episode of PTSD fail to recover even after many years. Posttraumatic stress disorder is more prevalent than previously believed, and is often persistent. Progress in estimating age-at-onset distributions, cohort effects, and the conditional probabilities of PTSD from different types of trauma will require future epidemiologic studies to assess PTSD for all lifetime traumas rather than for only a small number of retrospectively reported "most serious" traumas.
Conference Paper
Immediately after experiencing a traumatic event, many people have symptoms of posttraumatic stress disorder (PTSD). If trauma victims restrict their routine and systematically avoid reminders of the incident, symptoms of PTSD are more likely to become chronic. Several clinical studies have shown that programs of cognitive-behavioral therapy (CBT) can be effective in the management of patients with PTSD. Prolonged exposure (PE) therapy-a specific form of exposure therapy-can provide benefits, as can stress inoculation training (SIT) and cognitive therapy (CT). PE is not enhanced by the addition of SIT or CT. PE therapy is a safe treatment that is accepted by patients, and benefits remain apparent after treatment programs have finished. Nonspecialists can be taught to practice effective CBT. For the treatment of large numbers of patients, or for use in centers where CBT has not been routinely employed previously, appropriate training of mental health professionals should be performed. Methods used for the dissemination of CBT to nonspecialists need to be modified to meet the requirements of countries affected by the Asian tsunami. This will entail the use of culturally sensitive materials and the adaptation of training methods to enable large numbers of mental health professionals to be trained together.
Background Sexual abuse has been associated with trauma, low self-esteem, anger, depression and challenging behaviours. This pilot study builds on a small published literature by evaluating a survivors group (SG) for women with an intellectual disability and an educational support group (ESG) for their carers. Method The SG was delivered weekly over 5 months for 20 sessions and the ESG ran concurrently for their seven carers in a separate room within the same community-based building. Participants were helped to build trust and rapport, provided with education about sexual abuse designed for their level of ability, and helped to reprocess the trauma of their sexual abuse. Results Both the SG and the ESG were evaluated using a repeated-measures design (double baseline, mid-treatment, post-treatment and follow up), to see whether there was any improvement in relevant clinical dependent variables associated with the consequences of sexual abuse (i.e. trauma, self-esteem, anger, depression and challenging behaviour). Improvements occurred in sexual knowledge, trauma and depression. Neither self-esteem nor anger improved for most of the SG and challenging behaviour worsened at first before improving. Conclusions The SG seemed to be successful in improving sexual knowledge and in reducing trauma and depression, although challenging behaviours worsened at first before improving. There is a need for more sexual abuse/sexual education groups for men and women with intellectual disabilities.
Background The present paper examines the literature regarding abuse within long-stay hospitals and community-based residences for people with intellectual disabilities. Methods Research and policy developments are reviewed, and concerns regarding the reactive nature of much current guidance are noted, highlighting a need for research and strategies which promote greater protection from the onset of abuse. Results and conclusions It is argued that much current thinking attributes abuse to individual deviancy and culpability; however, a greater recognition of the range of causes of abuse and the circumstances in which abuse flourishes is required if we are to develop a full understanding of preventative strategies. This review is concerned with the significance of environments and cultures in increasing vulnerability to abuse. Seven aspects of environments and cultures which promote vulnerability are outlined, offering insights into the processes by which services may deteriorate and abuse becomes established.
Background Imagery rehearsal therapy for people who suffer from recurring nightmares has been shown to be a successful intervention. Very little research has been conducted on post-traumatic nightmare sufferers with learning disabilities. Method This paper presents two case studies to illustrate the application of an adapted form of imagery rehearsal therapy to adults with learning disabilities. Results Both descriptive cases indicated that the intervention resulted in significant reductions in distress because of nightmares and provided some evidence that these positive results were generalized into waking life. Conclusions As a short and simple method, imagery rehearsal therapy appears to be very suitable for people with learning disabilities.