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About this book

The major barrier in the way of competent counselling provision for people with learning disabilities is not the presence of a learning disability, but the lack of understand of the relevance of counselling by potential referrers... Sally Hodges has written for a wide range of professionals who work with people with learning disabilities, and introduces theoretical concepts in an accessible way by using clinical vignettes to illustrate each point.

An introduction to theory and some time spent thinking about different life stages, personal histories, presenting problems and relationship issues will provide an invaluable introduction to the emotional worlds of people with learning disabilities.' - from the Foreword by Sheila Hollins, Professor of Psychiatry of Learning Disability, St George's Hospital Medical School, University of London.

Counselling Adults with Learning Disabilities draws on a psychodynamic framework to bring toegher current ideas and thinking in an approachable and practical way. Through vivid clinical material and case examples, the book creatively illustrates how complex theories can be translated into clinical practice. Common problems are tackled and addressed within a lifespan framework, with attention given to key issues such as:

· bereavement
· abuse
· mental illness
· challenging behabiour
· sexual relationships
· relationships with peers, families and staff.

Additionally, given the increasing importance of evidence-based pratice, the book concludes with a review of the literature in the area of learning disabilities, and its efficacy.

SALLY HODGES is a Consultant Clinical Psychologist at the Tavistock Clinic with their Learning Disabilities Service. Previously she worked for learning disabilities services in Redbridge and Plymouth.

Table of Contents

Introduction

Abstract
Recently I visited a day centre for people with learning disabilities, and was asked to see a young man for counselling. James, I learnt from his keyworker, Sunil, had been given a diagnosis of a terminal brain tumour. Sunil explained that James had come to talk to him in obvious distress wanting to know about the future. Sunil said that he didn’t know what to do, he was not a ‘trained counsellor’, and was not qualified to listen to James. He said ‘I’m not a counsellor, I can’t talk to him about this.’
Sally Hodges, Nancy Sheppard

1. Historical Contexts, Settings and Common Presentations

Abstract
In this chapter I consider the political and historical contexts of people with learning disabilities, and the development of a counselling approach to this client group. The historical context is especially important as this group has traditionally been devalued, and the way in which it is viewed has important implications for the development of a therapeutic relationship with each individual client. Various contexts within which adults with learning disabilities live, work and spend their time are described, with particular emphasis on the way in which psychological distress may be manifest and recognised. These are all contexts within which a counselling approach can be utilised.
Sally Hodges, Nancy Sheppard

2. Theoretical Developments

Abstract
There are three core aspects to the psychodynamic model of counselling. Firstly, we all have aspects of our functioning that we do not have direct access to, parts that we may not understand and that can influence how we feel and behave. These areas of functioning are called the unconscious. A belief in the importance and significance of the unconscious is what makes psychodynamic counselling different from other kinds of talking treatments such as supportive or cognitive therapy. The second aspect is that the unconscious can find a way of expressing itself through the processes of transference and countertransference. Transferences are the processes whereby feelings in the client related to past experiences which have become unconscious are transferred onto the relationship with the counsellor. That is, feelings are drawn into the therapeutic relationship that have a source elsewhere. Countertransferences are the feelings and experiences that are evoked in the counsellor that specifically relate to the relationship with the client. The third aspect to the model is that we all develop a range of defences in order to keep us from developing a more conscious awareness of what our unconscious contains.
Sally Hodges, Nancy Sheppard

3. Assessment and the Beginnings of a Therapeutic Relationship

Abstract
In this chapter we will look at assessment for counselling, and how to utilise psychodynamic ideas in other kinds of assessments. Assessment is a process of information gathering and trying to make sense of something; the Oxford English Dictionary (9th edn, 1997) defines it as ‘to estimate or evaluate the quality of’. Assessment can be an ongoing process, and does not have to be defined as taking place only within the first meetings. If, in our clinical work, we make ongoing efforts to think about our responses to our clients, and their responses to us, we are constantly evaluating or making assessments. This process is different to the more formal assessment for counselling described below.
Sally Hodges, Nancy Sheppard

4. From Infancy to Old Age: Thinking about Life Stages

Abstract
It is not unusual for referrers to be at a loss as to why behavioural or psychological problems have developed for clients at a particular point in time. Similarly it is often the case that everyday events are not considered relevant, meaningful or significant when trying to ascertain what is making a person feel or behave differently. Events that might seem irrelevant to others might in fact hold great importance to the person being assessed or treated. This is particularly true of events that bring into focus issues of loss, difference or absence.
Sally Hodges, Nancy Sheppard

5. Consideration of Specific ‘Presenting Problems’ — How Can a Counselling Approach be of Use?

Abstract
A range of identified or ‘presenting problems’ that are most frequently cited as ‘reasons for referral’ to learning disability mental health services are now considered. This will include a discussion about abuse, particularly the consequences of abuse experienced as a child, loss, bereavement, challenging behaviour, psychiatric diagnosis, and sensory impairments. Talking treatments for challenging behaviours tend to be neglected in favour of medical or behavioural approaches, because they are seen as conditions that have biological aspects. There is, however, a growing body of evidence that counselling can be of use for a wide range of presenting problems. We will start by looking at one of the most common referral reasons, that of abuse.
Sally Hodges, Nancy Sheppard

6. Relationship Issues: Families and Intimate Relationships

Abstract
Relationships with other people have an important role in shaping our personalities, our experiences and how we feel about ourselves. In the past, relatively little attention was paid to the relationships of people with learning disabilities.
Nancy Sheppard

7. Relationship Issues: Friendships and Group Dynamics

Abstract
This chapter will focus on group dynamics and their relevance in understanding the relationships of people with learning disabilities. A group is defined by Barnes et al. (1999) as simply a collection of people who come together with a common aim. Once this boundary is created then the group becomes distinct from the non-group. Groups can have any chosen aim and the dynamics created by groups are evident in all groups, whether formal or informal. The first part of this chapter will explore some of the theories that have had a major influence on the understanding of group dynamics. The second part of the chapter will aim to explore the processes that can occur in the development and running of formal therapeutic groups. Finally, less formal group situations will be considered. Through discussing friendships and relationships that can develop within a group home the chapter will aim to explore how group dynamics can help understand difficulties that people with learning disabilities might experience in such informal relationships.
Nancy Sheppard

8. Working with Care Staff and Organisations

Abstract
The main body of this book has explored how a psychodynamic counselling approach can offer individuals with learning disabilities an opportunity to gain a deeper understanding of their emotional difficulties and to develop emotional maturity. However, individual counselling for people with learning disabilities is a rare resource, not least in the current NHS climate where faceto-face contacts and short ‘episodes of care’ are highly valued and longer-term work is not seen as ‘best value’ (Department of Health, 2001).
Nancy Sheppard

9. Research and Evaluation

Abstract
Counselling can be an expensive resource compared with other treatments such as medical or behavioural approaches. Talking treatments require more time and often more resources, for example, the provision of a consistent protected environment, such as a room set aside specifically for counselling. In order to give open support for working in this way, employers or managers will usually require some evidence that it is an effective use of time and resources. This requirement is even more significant in the climate of increased division between the purchasers and the providers of services. Purchasers have to weigh up how best to spend limited budgets, whilst often remaining at a distance from the ‘hands on’ work. Therefore one important reason for carrying out research is to provide the evidence that one’s intervention is a productive and worthwhile use of limited resources. Evidence-based practice is an integral aspect of Clinical Governance, the process by which service quality is addressed from several perspectives.
Sally Hodges, Nancy Sheppard
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