Important considerations for practitioners
Counsellors' values and attitudes
Counsellors' own views, values and attitudes influence their practice with people with intellectual disability. Individual professionals and agencies have a responsibility to rigorously examine their personal and collective beliefs about intellectual disability, and consider barriers to the inclusion of people with intellectual disabilities as service users and as members of the wider community. The quote below is an honest example of the challenges that many practitioners experience when first engaging with people with intellectual disabilities (Community Living Program, 1995, in O'Connor & Fowkes, 2000, p. 14):
“Looking back on fifteen years of community work I realised that I had come in contact with a number of people with an intellectual disability. I wasn’t conscious at the time that they had an intellectual disability. I thought of them as a bit slow, a bit different. I realise now that as soon as I thought of them as being different I started to detach emotionally, energy wise. They became less human, less real, less visible to me. I didn’t really listen to what they were saying, I didn’t really work to assist their understanding, my communication became a sort of pretend communication. Now it seems to me that this detachment is a common response of people in the community, professionals etc. to people with an intellectual disability.”
Positions of power in the counselling context
Counselling professionals are in a position of power when they work with people with intellectual disability. Being aware of this power imbalance is crucial. In many cases, compliance, miscommunication and challenging behaviour can be avoided or reduced by a conscious and ongoing effort by the practitioner to decrease the power differential between themselves and their clients.
- Language: Avoid using jargon – unnecessary use of professional jargon will only remind the client that they are unequal in the therapeutic relationship.
- Language: Be aware of the different labels of intellectual disability, and use them as little as possible. Most people with intellectual disability do not identify with diagnostic labels or even with having a disability, due to the powerful stigmatisation associated with disability. Often, we use labels for different 'client groups' to meet organisational needs, with little consideration of their effects on the individuals concerned. Keep these labels for discussions with colleagues and staff, rather than for discussions with clients.
- Communication: Take responsibility for communication and make sure that clients know that it is OK to tell you if they don’t know or understand something.
- Blame: Never blame a client for not understanding you. It is the counsellor's responsibility to ensure understanding, and a reflection of their skill as a therapist.
- Understand that through trust and rapport, which may take time, you will hopefully get to a place where it is OK for the client to let you know when they don’t understand something. Until that point, the practitioner must take full responsibility for communicating well and for checking understanding.
Time is a key factor in effective counselling practice with people with intellectual disability. The standard time allowed for practice – to engage, build rapport, create safety, assess and define individual and therapeutic goals – may not be sufficient for many people with intellectual disability. Many agencies struggle to deal with high demands for service and limited staff capacity, however, flexibility in service delivery is highly beneficial (if not essential) for this client group (Brown & Hooper, 2009).
Longer sessions are not necessarily required or advised for clients with intellectual disability, because prolonged concentration can be tiring for many clients. Instead, shorter sessions on a more frequent basis might be helpful. It is also important that counsellors do not expect clients with intellectual disability to develop or move forward at the same rate as other clients. Many people with intellectual disability need more time in counselling sessions to:
- Understand the nature of the task.
- Comprehend the questions being put to them.
- Think about the questions.
- Try to retrieve from memory the relevant information.
- Put this information into words.
- Say these words (or communicate in a way that suits them if they cannot speak) (Milne & Bull, 2006).
- Enlist the support of others to put changes discussed in sessions into practice in the person's real life.
Good practice suggests that counsellors should at least double the time they normally would for the duration of therapy (Brown & Hooper, 2009). In other words, if a counsellor would typically plan to see a person for 6 sessions, they should allow 12 sessions if the client has an intellectual disability. In addition, while adjusting and tailoring materials and activities to suit the client is always part of good clinical practice, it may be more important for clients with intellectual disability.
Working well with family, paid workers and other significant support people
People with intellectual disability are likely to have support from family members, paid workers or other significant people in their lives. Family members and other support people often know the person very well and are best placed to observe changes in their behaviour and well-being. Their opinions and observations should be taken seriously.
Family members, and other support people can often offer useful information and clarification in situations where the client has difficulty providing detailed information. There is evidence to suggest that clients with intellectual disability will best respond to therapy when they have the support of family or paid staff to apply what they have learned with the therapist in real-life settings (Hayes, 2007). This requires the therapist to collaborate with the client’s support people. It may involve allowing support people to accompany the client to sessions, supporting carers to develop the skills and understanding required to create and support change for the client, and helping carers and paid workers to develop helpful attitudes that will allow change to occur (Hayes, 2007).
Carers and supporters can help the therapeutic process by:
- Helping the client to practise the skills learned in sessions and apply the lessons from sessions to the 'real world'
- Observing what has and hasn’t worked well for the client in the 'real world'.
- Creating opportunities for success for the client.
- Helping the client to recognise and celebrate positive change.
- Learning new ways of understanding and interacting with the client to support positive relationships.
- Teaching others (e.g. teachers, friends, workmates) ways they can support the client to maintain positive change.
Privacy and consent
Involving family members, paid workers or other significant support people in the client's therapy will require careful consideration about issues of privacy and consent. It is important to find an appropriate balance between the clients' right to privacy of their personal information, and the need to share information with others (including family members, support people or other service providers). The benefits of sharing information can include promoting understanding, increasing safety and working together to achieve the client’s goals. Exploring concepts of privacy and consent requires exploring the explicit consequences of what these terms mean and what would happen if they were breached. For example, if they agreed on someone attending their counselling session, what is ok for them to know, what is not ok for them to know, what would it mean if they found out x, y or z?
It is useful to approach confidentiality issues as areas for negotiation (O'Driscoll, 2009). This means discussing confidentiality on a regular basis, exploring what it means, and discussing what kinds of circumstances would break it. It also means having an awareness of the people and relationships in the client's life, both professional and personal, that can help the negotiation process and ethical decision making. Discussing confidentiality directly with family and supporters can help to reach a shared understanding. Ultimately, this will remain the choice of the client, as per anyone else.
Keeping the focus on the client
When the counsellor and the client invite others to be part of a team to support change, it is important for everyone to understand that the client is the focus of the counselling sessions. When powerful family members and significant others are invited to be part of the process, it can be difficult to maintain this focus – particularly when others have their own experiences of the problem. If dominant voices share the experience of the problem, take time to explore whether the problems experienced by the support people are, in fact, experienced by the client.
Building the capacity of the support team
The capacity of families and carers to support therapy and create and support change may vary. It is important to consider the context of the client's support. Who are the significant support people in the client's life? What skills and experiences do they bring to the situation? Do they need help to develop any additional skills or understanding to be able to support the client in therapy? Would working with the supporters and skilling them up to respond to the trauma be a more effective intervention, particularly if the individual has limited communication, or other reasons that may make counselling a less useful intervention.
Be realistic about what can be achieved, and refrain from putting any unnecessary pressure on anyone involved. If the counselling involves working with a parent – who is currently caring for their child, running a household, working and dealing with other issues in their life – that parent's capacity to offer support in counselling may be significantly diminished. Asking them to take on further responsibility may be unrealistic and only set them up for failure.
The capacity of paid support workers can also vary significantly, depending on their level of training, type of supervision, the way they see their role, and the way their role is defined by the organisation they work for. It is important to be aware that paid support work can be a high-stress profession, particularly in organisations that may not have adequate training and supervision of staff (Hatton et al., 1999, in Wilner, & Goodey 2006).
It can be useful to recognise that there may be a distinction between the supportive people in you client's life who have a lasting commitment to the person, who are there 'for the long haul' and those who may be in other roles (such as paid staff) where their support is more likely to be restricted to certain circumstances and less enduring. Understanding this can help you better understand the capacity and limitations of those involved in the persons care.
To develop an understanding of the client's support context, counsellors may need to spend time with the significant support people in client's lives (with the client's permission) to develop an understanding of how the support people see the problem and to understand their capacity to offer support around the therapeutic process.
Duty of care and safety
There are some extra considerations around duty of care to take into account when working with someone with intellectual disability. If the client discloses something that raises a counsellor's concern, the counsellor needs to consider a range of safety, security and ethical issues (MacDonald, 2008; Olver, personal communication, 9 November 2011). Safety and security issues to explore and consider:
- Encourage the client to consider their safety and security. Are they at risk of further victimisation? Do they need a different physical location?
- Discuss relationships regularly. Vulnerability and a lack of understanding around relationships can lead to people putting themselves at risk. Help the client to understand concepts about relationships in concrete terms
- Check back with the client over time to monitor the situation. Don't presume the client can make judgements about safety. Talk through the situation to explore their understanding of their own risk. Talk about consequences or likely outcomes of different decisions.
Ethical issues to explore and consider:
- Inform the client of any obligations that counsellors have to report the information the client has disclosed (taking care not to compromise the safety of yourself or others). Where your obligations are not clear, seek guidance through reflecting with colleagues on the circumstances of the matter and your professional and ethical obligations.
- Name any confidentiality issues.
- If the matter is of a legal nature (for example, the client has disclosed that they have perpetrated or been the victim of a crime), explain that you, as their counsellor, may be called as a witness if the matter proceeds to court.
- If the client has reported that they committed an offence or they are alleged to have committed an offence, reflect on any personal and/or professional values which may limit your capacity to provide effective support. If you are unable to provide support, you need to arrange alternative support options.
- Support the client to clearly describe what occurred. Ask open questions (see the section on 'Narrative interviewing techniques' in this resource). Diarise the exact words that the client uses to describe the incident, preferably at the one sitting. Diarise details such as the time between the event’s occurrence and the time when the client first disclosed the event. Your task here is not to interview the client or interpret their information, but to clearly document the client's account of events at the time of first disclosure (it is possible that the client's capacity to retain or recall this information may reduce as time passes).
- Take extra care around the language used in case notes. While it is always important to take care in case notes, it can be particularly important for clients with intellectual disabilities, as this client group is more likely to have court procedures or need reports for government agencies. Listing the person’s difficulties in case notes can work against them.
- Discuss and clarify the options of reporting or not reporting the incident to the police and the likely course of events associated with each option.
- Support the client to consult a lawyer or specialist agency.
- Support the client to make a complaint to the police if they wish. If the client is not ready to go to the police, remember that, in time, they may change their mind.
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