Education EDF 621 Week 1 Assignment
Br J Learn Disabil. 2021;49:87–99. wileyonlinelibrary.com/journal/bld | 87© 2020 John Wiley & Sons Ltd
Received: 11 December 2019 | Revised: 21 August 2020 | Accepted: 24 August 2020
DOI: 10.1111/bld.12344
O R I G I N A L A R T I C L E
A multiple methods evaluation of a cognitive behavioural therapy group for people with learning disabilities and anxiety
Rengina Giannaki1,2 | Olivia Hewitt1,2
1Learning Disability Services, Berkshire, UK 2Healthcare NHS Foundation Trust, Reading, UK
Correspondence Rengina Giannaki, Psychology Service, Learning Disabilities, 7-9 Cremyll Road, Reading RG1 8NQ, UK. Email: Rengina.Giannaki@oxfordhealth.nhs. uk
Accessible summary • Cognitive Behavioural Therapy (CBT) can help individuals with learning disabilities
and anxiety. • A group was run to help people to manage their anxiety and to feel better. • At the end participants and their supporters fed back their experiences of the
group and filled in questionnaires to measure their anxiety and psychological distress.
• The group seems to reduce people's anxiety. • This report adds to a growing body of existing literature demonstrating some ben-
efits of CBT for people with learning disabilities and anxiety.
Abstract Background: Existing studies show mixed results of the effectiveness of CBT for people with learning disabilities and anxiety. Method: A CBT group was run for people with learning disabilities and anxiety, who attended with a supporter. Qualitative interviews were conducted post-group and analysed using thematic analysis. Standardised questionnaires measuring anxiety, psychological distress and overall functioning were administered at pre- and post- group, and at follow-up. Results: Participants’ anxiety decreased overall post-group, which remained largely at follow-up. The group and the supporters’ involvement was helpful. Both supporters and participants recalled coping strategies that were presented in the group. Three out of four participants found attending a group challenging initially. The supporters seem to have specific expectations about the impact of the group. Conclusions: The results of the study are consistent with the existing, growing body of evidence which supports the use of CBT for people with learning disabilities and anxiety.
K E Y W O R D S
clinical psychology, intellectual disability, learning (intellectual) disabilities, mental health, Psychological therapy, stress
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1 | INTRODUC TION
Mental health issues including anxiety are common in people with learning disabilities (Bowring, Painter, & Hastings, 2019; Cooper et al., 2015; NICE, 2016). Reid, Smiley, and Cooper (2011) found that 3.8% of people with a learning disability have an anxiety disorder with generalised anxiety disorder as the most common (1.7%), and then agoraphobia (0.7%). Physical health issues, sensory impairment, specific syndromes and lower cognitive abilities might be associated with the high rates of anxiety in people with learning disabilities (e.g. Austin, Hunter, Gallagher, & Campbell, 2018; Bowring et al., 2019; Dykens, 2003). Anxiety might impact on the quality of everyday life (Bowring et al., 2019) by hindering the social integration (Totsika & Hastings, 2009) and safety of people with learning disabilities. It might be manifested through self-injurious, aggressive or avoidance behaviours (Stavrakaki, 2002).
NICE (2016) indicates that psychological interventions such as cognitive behavioural therapy (CBT) are effective treatments for anxiety within the general population that CBT should be consid- ered to treat depression in people with mild learning disabilities, and that relaxation therapy and graded exposure should be considered to treat anxiety symptoms.
1.1 | The effectiveness of CBT for anxiety in people with learning disabilities
The existing literature shows mixed results for CBT interventions on anxiety in people with learning disabilities. Dagnan's, Jackson, and Eastlake (2018) systematic review reported positive outcomes of CBT interventions on anxiety for people with learning disabilities, although much of the current literature consists of single case re- ports. Unwin, Tsimopoulou, Kroese, and Azmi (2016) systematically reviewed the literature around the effectiveness of CBT and con- cluded that there is equivocal evidence for improving anxiety with some uncontrolled studies demonstrating some positive results, and with the qualitative data consistently reflecting a positive percep- tion of the treatment. Both authors concluded that the area needs further research.
Some studies show limited or no effectiveness of CBT on anxi- ety. Hassiotis et al. (2013) conducted a randomised control trial to study the effectiveness of a 16-week manualised individual CBT on anxiety and depression. Sixteen adults with mild to moderate learn- ing disabilities were randomly allocated in the CBT group and six- teen in the control group. No statistically significant difference was found. However, the approach of intervention was generalised and not anxiety-focused (Unwin et al., 2016).
Other studies indicate a more promising impact of CBT on anxi- ety. Ghafoori, Ratanasiripong, and Holladay (2010) reported a signif- icant reduction in anxiety, following a 9-week generalised approach of CBT group which included eight participants, but that phobic anx- iety was not reduced. Quantitative analysis showed that the anxi- ety remained roughly decreased at 4-month follow-up but without
statistical significance. However, the participants were young stu- dents which limits the generalisability.
Lindsay (1999) used individual Beck's CBT adapted to anxiety and found that the fifteen participants’ anxiety scores decreased by 35%, which persisted at follow-up. However, the study comprised a brief case report and presented little methodological information (Unwin et al., 2016).
Lindsay et al. (2015) conducted a matched control trial employing a quasi-experimental design. The CBT group involved twelve adults with mild learning disabilities with their supporters. The author developed a CBT manual containing a generalised approach targeting mixed presen- tations, anxiety, depression and anger. Significant decrease in anxiety was found post-group which remained at 6-month follow-up. However, no between group treatment effects on anxiety were reported.
Douglass, Palmer, and O'Connor (2007) studied the effective- ness of a CBT group for anxiety. Outcome measures demonstrated that after a 12-week intervention, two out of six participants noted a significant reduction in anxiety. All group members developed cop- ing strategies. Four participants reported decreased anxiety and all supporters a better understanding of anxiety. The study used both quantitative and qualitative data, but did not present quotes sup- porting the qualitative analysis.
In Marwood and Hewitt’s (2012) study, quantitative data sug- gested that two out of eight participants with mild learning disabil- ities noted a significant decrease of anxiety after a 6-week CBT group. Qualitative data analysis reported positive experiences of attending the group and of supporters’ inclusion. However, the num- ber of participants who noted a decrease of anxiety remains small compared to the total number of participants, though each partici- pant reported finding the group beneficial.
Given the limited existing literature and the ambiguity of results, an evaluation of a CBT intervention seems to be appropriate in de- termining its efficacy on anxiety. According to NICE (2016), further research is needed to evaluate the effectiveness of CBT in people with learning disabilities and anxiety. Due to the limited qualitative data and the limited opportunities that people with learning dis- abilities have to express their views on interventions, a qualitative methodology in addition to a quantitative one could enrich the data and enable the voices of people with learning disabilities to be heard allowing a deeper understanding of participants’ experience in the group. It will also increase insights into helpful components of the intervention and into the process of change (MacMahon et al., 2015).
This study aims to evaluate the effectiveness of a CBT group for adults with learning disabilities who present with anxiety symptoms impacting on their everyday life to the extent that psychological input is sought. A secondary objective is to investigate if the inter- vention will help participants to feel better by reducing their psycho- logical distress.
2 | METHODOLOGY
A service evaluation was carried out using multiple methods.
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2.1 | Participants
The participants who attended the group consisted of four indi- viduals with mild learning disabilities and anxiety symptoms (see Table 1 for demographic information). All of them were presenting with symptoms related to generalised anxiety and specific fears. Each participant was asked to attend the group with a supporter, either family member either carer, who could commit to the group. Previous research reported benefits of supporters’ inclusion by generalising the learned skills in other areas of participants’ life and maintaining long-term treatment effects (e.g. Crossland, Hewitt, & Walden, 2017).
Participants were referred to the psychological service for peo- ple with learning disabilities within the NHS Trust and were assessed for suitability for the group. Inclusion criteria were being over the age of 18 years, presenting with anxiety symptoms, having mild to moderate learning disabilities, being willing to participate in the group, and a supporter's inclusion. No formal, psychiatric diagno- sis of anxiety was required. Exclusion criteria were receiving other psychological therapy during the group or having severe learning disabilities.
All group members gave informed consent both to participate in the group and in its evaluation. They were informed about the ano- nymity of the information they provided. The project was reviewed and registered with the research department of the NHS Trust, which approved it as a service evaluation without warranting review by the research ethics committee.
2.2 | Group content
The group content consisted of basic CBT concepts based on Beck’s (1987) model. The material was developed in the service (see Table 2 for outline of group sessions). Cognitive and behavioural compo- nents were introduced in the group as guided by previous research (e.g. Dagnan et al., 2018; Douglass et al., 2007 for review; NICE Guideline 54, 2016).
Cognitive behavioural therapy is often adapted for use with peo- ple with learning disabilities. Adaptations include using visual aids and prompts, using diary sheets requiring only tick box responses, shorter sessions with slower pace, using concrete examples, re- peating information (Haddock & Jones, 2006). Such adaptions were
included in the present group. Previous research suggests includ- ing supporters improves outcomes (e.g. Douglass et al., 2007). Therefore, each participant was encouraged to bring a supporter to the group to support generalising new skills.
The programme consisted of a 7-week CBT group targeting anx- iety and one follow-up session taking part one month after the last of the 7-week sessions. Two trainee clinical psychologists and two assistant psychologists facilitated the group receiving weekly super- vision by a clinical psychologist.
2.3 | Measures
Three standardised measures were administered by a trainee clini- cal psychologist and an assistant psychologist to the individuals with learning disabilities who attended the group at three time points. A range of measures comprising specific and generic scales were em- ployed in support of the aims of the study. All three detect changes of both anxiety and overall mental health as interventions in an area can lead to changes in several areas of functioning (Roy, Matthews, Clifford, Fowler, & Martin, 2002; Unwin et al., 2016). These meas- ures were chosen for their psychometric properties and were used in previous research (e.g. Douglass et al., 2007). One additional ques- tionnaire, the PTOS-ID, was administered to participants’ supporters at three time points to capture supporters’ perceptions of partici- pants’ level of distress and to identify any discrepancies among par- ticipants’ and supporters’ perception.
The Glasgow Anxiety Scale for people with an Intellectual Disability (GAS-ID; Mindham & Espie, 2003) is a measure designed for people with mild learning disabilities. It has good reliability and internal consistency. The 27-item self-rating scale evaluates the level of anxiety and comprises of cognitive, behavioural and somatic symptoms that the person experiences over the past week. The au- thors suggest a cut-off score of 13 as a threshold value to identify a possible anxiety disorder. Higher score shows higher degree of anxiety. The three-option response format, “never,” “sometimes,” “always”, makes the measure sensitive to changes over time.
The Health of the Nation Brief Outcome Measure for People with Learning Disabilities and Mental Health Needs (HoNOS-LD; Roy et al., 2002) rates the mental health needs and global function- ing for people with all levels of learning disabilities. The 18-item in- strument has good reliability and validity, and can measure changes
TA B L E 1 Demographic data
Pseudonym Age Ethnicity Gender Living situation Diagnosis Supporter's pseudonym and relationship
Alice 21 British-White Female Family home Mild LD, anxiety Sylvia, mother
Colin 56 British-White Male Independent living with support staff
Mild LD psychosis, anxiety
Ivor, paid support worker
Mary 48 British-White Female Supported accommodation
Mild LD, anxiety Jacob, partner
Sally 55 British-White Female Family home Mild LD, anxiety Erica, mother
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over time. The clinician rates each item over the past four weeks according to the level of severity of the problem scoring from 0 to 4. Higher level of wellbeing is indicated by lower total score. The measure can detect changes over time.
The Psychological Therapy Outcome Scale-Intellectual Disabilities (PTOS-ID; Vlissides, Beail, Jackson, Williams, & Golding, 2017) is a 30-item self-rated scale designed to measure anxiety, anger, depres- sion, interpersonal wellbeing and psychological wellbeing in people with mild to moderate learning disabilities. Each item is rated on a 4-point Likert scale anchored by “not at all” to “a lot.” The measure as- sesses two dimensions over the past week: the index of psychological distress and the index of wellbeing. The psychological distress score equals the sum of anxiety, depression and anger scores. Higher score of the psychological distress index indicates higher level of distress. The wellbeing score equals the sum of interpersonal wellbeing and psychological wellbeing. A parallel PTOS-ID form can be completed by supporters and captures supporters’ perception about the distress and wellbeing of the person with a learning disabilities. The measure has high internal consistency of the psychological distress index (α = 0.85) and high reliability of the wellbeing index (α = 0.81). Full evaluation of its psychometric properties has yet to be carried out.
2.4 | Qualitative method
Qualitative data were derived from semi-structured interviews which were conducted post-group in order to obtain group members’ experiences of the group. The interviews were conducted at par- ticipants’ homes, separately for each participant and each supporter. This allowed all group members’ voices to be heard independently and to compare participants’ and their supporters’ experience. A trainee clinical psychologist and two assistant psychologists carried
out the interviews after receiving participants’ and supporters’ writ- ten, informed consent.
The interviews included questions related to the aims of the study: participants’ experience of the group, their interaction with others, group content, what participants learned, helpful and un- helpful things from the group. An interview schedule contained questions which were used in similar studies. A pilot interview took place among the interviewers who provided with feedback to each other. Alongside a discussion with the supervisor ensured the appro- priateness of the questions and of the interview process. The ques- tions were open-ended with prompts, and they were used flexibly as a guide allowing a natural flow of conversation.
The interviews lasted between 13 and 30 min. They were audio recorded using digital voice recorder as explained in the information provided. The recordings were transcribed verbatim by the same interviewers respectively. Identifying information in the transcripts was anonymised.
The transcripts were analysed by the first author using the- matic analysis. Thematic analysis is a method for identifying, an- alysing and reporting patterns (themes) within data. It organises, describes the data and interprets various aspects of the research topic. Six stages of thematic analysis were used in the current study (Braun & Clarke, 2006). The first author was familiarised initially with the data by listening to the audio recordings and reading the transcripts repeatedly; the author created initial codes involving collating and coding quotes (coding); the author looked for similar themes in the transcript and grouped them based on the similarity (searching for themes); the author reflected on the themes, discussed them in the supervision and edited them (re- viewing themes). The fifth stage of “defining and naming themes” was achieved by creating broader superordinate themes of similar themes. The qualitative data were divided into participants’ data and into supporters’ data to ensure that participants’ voice is heard and to achieve a broader understanding of the group members’ experience. The sixth stage included the writing of this report, reflecting, receiving feedback from the supervisor and making choices about the quotes presented.
To ensure credibility, detailed notes were undertaken for all the processes by the first author throughout the study. Regular supervi- sion of the analysis also provided by OH, a clinical psychologist with experience in conducting qualitative research. To ensure validity and trustworthiness, the first author was repeating detailed readings of the verbatim transcript. The first author's role as co-facilitator of the group allowed an early familiarity with the concepts of the group and the establishment of a relationship of trust with the interviewees ensuring validity as well (Shenton, 2004).
2.5 | Attendance and missing data
All four participants completed the group. All measures were completed for all participants at all three time points (pre-, post- intervention and at follow-up). Three out of four participants
TA B L E 2 Group session outline
Week Topic
1 Introduction, creating a safe environment, overview of the programme, supporters’ role
Introducing what anxiety means, anxiety provoking situations, helpful coping skills
2 Identifying emotions. hometask: recording emotions
3 Identifying unhelpful thoughts and their impact on emotions and actions. Setting optional hometask: breathing relaxation
Three weeks Christmas break
4 Recap of first three sessions
5 Identifying body reactions of anxiety
6 Identifying actions. Five senses self-soothing activity
One week break
7 Linking emotions, thoughts and behaviours
8 One month follow-up. Recap of the programme. Completing measures
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completed the measures at 1-month follow-up after the end of the group. Due to Colin's physical health issues, the administration of his follow-up measures took place 2-month post-group. One participant, Mary, joined the group from the fourth group session and she was not administered the HoNOS-LD at pre-group. Alice's interview was not recorded due to technological issues thus her interview is missing.
3 | RESULTS
3.1 | Quantitative results
The group mean and the standard deviation for the three measures are displayed in Table 3. All participants’ pre-group mean score of anxiety for all three measures decreased by nearly half following the intervention. The group mean of anxiety for GAS was 25.25 at intake and 13 post-group. The pre-group mean of distress for PTOS-ID was 25.25 and 13.75 post-group. The mean for three out of four participants on HoNOS-LD was 16.33 initially and 8.25 post-group. The reduced scores remained at follow-up (Figure 1). The group mean of participants’ distress on PTOS-ID as perceived by supporters was 19.5 at intake and became 5.25 at post-group,
which was not maintained at follow-up, where it reverted to base- line levels (Table 3).
Due to the small number of participants, a Reliable Change Analysis (RCI) was carried out for the three time points. This analysis compares each participant's individual scores over time to see if the changes are significant (Table 3).
3.1.1 | Alice
Alice's post-group anxiety score on GAS decreased (RCI = −2.20, p < .05) which remained at follow-up (RCI = −1.69, p < .05) compared to pre-group. Alice's post-group score on HoNOS-LD decreased meaningfully (RCI = −1.88, p < .05), which persisted at follow-up de- spite a slight increase (RCI = −1.61, p < .05).
The Figure 2 shows a significant reduction of distress post- group both on PTOS-ID for Alice (RCI = −2.24, p < .05) and on PTOS-ID completed by her supporter (RCI = −1.36, p < .05). Alice's score of distress on PTOS-ID at follow-up (RCI = −0.46, p < .05) remained at low level though it was slightly equivalent to the post- group score. Alice maintained a meaningful low score on support- er's PTOS-ID at follow-up (RCI = −0.24, p < .05) despite a slight increase.
Measure/Time Alice Colin Mary Sally Mean score
Standard deviation
GAS pre 23 21 23 34 25.25 5.90
GAS post 10 10 18 14 13 3.82
GAS F/U 13 12 15 12 13 1.41
GAS RCI pre-post −2.20* −1.86* −0.84* −3.38*
HoNOS-LD pre 29 8 – 12 16.33 11.15
HoNOS-LD post 8 0 2 23 8.25 10.40
HoNOS-LD F/U 11 14 3 16 11 5.75
HoNOS-LD RCI pre-post
−1.88* −0.71* – 0.98
PTOS Distress pre
41 21 17 22 25.25 10.71
PTOS Distress post
17 18 10 10 13.75 4.34
PTOS Distress F/U
36 22 12 8 14 4.96
PTOS Distress RCI pre-post
−2.24* −0.28* −0.27* −0.47*
Supporter's PTOS Distress pre
20 22 12 8 19.5 12.47
Supporter's PTOS Distress post
3 12 0 6 5.25 5.12
Supporter's PTOS Distress F/U
17 16 30 11 18.5 8.1
Note.: Higher scores indicate increased impairment. Abbreviations: F/U, follow-up; Post, post-intervention; Pre, pre-intervention; RCI, reliable change index. *Statistically significant at α = 0.05.
TA B L E 3 Participants’ pre-post reliable change index (RCI) scores
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3.1.2 | Colin
A RCI analysis demonstrated that Colin's GAS score lowered signifi- cantly post-group (RCI = −1.86, p < .05) and at follow-up (RCI = −1.52, p < .05). Colin's score on HoNOS-LD decreased immediately post- group scoring 0 (RCI = −0.71, p < .05) indicating a meaningful im- provement in his global functioning post-group. Colin's post-group reliable change on HoNOS-LD was not maintained at follow-up showing a decrease of his global functioning (RCI = 0.53) compared to pre-group. This might be attributed to Colin receiving fewer inter- personal interactions post-group or to a physical condition.
A RCI analysis showed a meaningful reduction of distress on the index of distress on PTOS-ID for Colin post-group (RCI = −0.28, p < .05) which was not maintained at follow-up (RCI = 0.09). Colin's score of distress on supporter's PTOS-ID at follow-up was reduced significantly (RCI = −0.80, p < .05) post-group despite a slight in- crease of distress at follow-up compared to post-group (Figure 3).
3.1.3 | Mary
Mary noted a reliable reduction of her anxiety level (RCI = −0.84, p < .05) on GAS at post-group, which decreased further at follow- up (RCI = −1.35, p < .05). Mary did not fill in the HoNOS-LD before the group thus it was not possible to track any change of her overall functioning over time.
Mary's score of distress for PTOS-ID demonstrated reliable change and her level of distress decreased post-group (RCI = −0.27, p < .05) and remained at a lower level at follow-up (RCI = −0.46, p < .05) despite a slight increase. Mary's score on supporter's PTOS-ID noted a reliable change post-group (RCI = −0.96, p < .05) indicating a significant decrease of her distress. Mary showed a high increase of distress on supporter's PTOS-ID at follow-up (RCI = 1.44) which was higher than the pre-group score (Figure 4). This might be because the measure was administered to two different persons. Alongside her partner reported in the interview no improvement for Mary. This might be because Mary joined the group after the other participants and she did not apply the coping strategies outside the group.
3.1.4 | Sally
From the RCI emerged that Sally's anxiety score for GAS de- creased meaningfully post-group (RCI = −3.38, p < .05) which remained almost equivalent at 1-month follow-up (RCI = −3.22, p < .05). Sally's score on HoNOS-LD was increased post-group (RCI = 0.98) indicating an increased impairment in her global func- tioning. There was a slight improvement in her functioning at fol- low-up (RCI = 0.35) compared to the post-group which remained lower than the pre-group (Figure 5). Sally's post-group score on HoNOS-LD was increased showing decreased functioning, possi- bly due to a physical condition that Sally developed whilst attend- ing the group.
Sally's score on PTOS-ID noted a reliable decrease (RCI = −1.12, p < .05) immediately after the intervention showing an improvement of her distress. The post-group reliable change remained at follow-up (RCI = −1.30, p < .05) showing a slight higher level of improvement compared to the intake. Sally's score for supporter's PTOS-ID noted a reliable reduction of distress (RCI = −0.16, p < .05) at post-group but was slightly increased at follow-up (RCI = 0.24) compared to pre- group. This might be due to the ending of the group, which was a positive experience for Sally.
Clinical significance was used to examine the pre- and post- group changes for each participant. Clinical significance is
F I G U R E 1 Participants’ changes for HoNOS-LD, GAS, PTOS-ID index of distress and supporter’s (S/R) PTOS-ID index of distress at pre-, post-group and follow-up. Higher scores on all measures indicate an increase of impairment and vice versa
0 5
10 15 20 25 30
Group's mean scores over time
F I G U R E 2 The graph displays Alice's scores at pre, post and follow-up intervention for the measures GAS, HoNOS-LD, index of distress on PTOS-ID and index of distress on supporters’ (S/R) PTOS-ID. Higher scores indicate increased level of impairment
0 10 20 30 40 50
Alice's scores over time
F I G U R E 3 The graph displays Colin's scores at pre-, post- and follow-up intervention for the measures GAS, HoNOS-LD, index of distress on PTOS-ID and index of distress on supporters’ (S/R) PTOS-ID. Higher scores indicate increased level of impairment
0 5
10 15 20 25
Colin's scores over time
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routinely defined as returning to normal functioning, and occurs when post-intervention scores are more than two standard de- viations above or below the mean score of the pre-intervention sample (Jacobson, Roberts, Berns, & McGlinchey, 1999). Alice's and Colin's post-group improvement on all measures were clini- cally significant. This is supported for Alice by subjective reports. Mary's and Sally's improvement on two measures were clinically significant, which is in line with subjective reports for Sally; how- ever, this is contradicted for Mary by her supporter's subjective reports.
3.2 | Qualitative results
The quotes below indicate text taken directly from the transcripts. The number in brackets indicates the line location within the data. The “P” refers to participants’ and “S” to supporters’ quote.
3.2.1 | Results from participants
Four superordinate themes were identified from the participants’ interviews (Table 4).
Superordinate theme 1: How things were before the group The first superordinate theme described participants’ pre-existing issues and helpful coping skills which were used before starting the group.
All participants identified emotional difficulties, such as fears, frustration and family problems. Mary and Colin expressed concerns around medical appointments. Sally said:
You get headaches. Bad headaches sometimes. (P, 133)
Colin described:
Years ago I used to be a little bit scared of dogs… If we go to the doctor and somebody does not explain me the reason that bothers me.
(P, 52)
All participants described how they coped with anxiety before the group. Mary engaged in helpful activities such as reading and writing. Two participants used physical activity to help them to relax. Collin said:
I use my exercise bike… sometimes I do jogging. And I count up to ten. And I jump up until twenty… it gets out my stress.
(P, 88)
Superordinate theme 2: Participants’ perceived positive and negative aspects of the group This theme considered participants’ positive experience in the group, how they benefited from the group and things they did not like about the group.
All participants held a generally positive view of the group. Two participants enjoyed the group content and activities. Sally found the group “interesting” and said:
it was all good. That was a nice change. I enjoyed it. It was good to do things. I had a nice time.
(P, 171)
Most participants learned helpful coping strategies to manage anx- iety. Two participants found it helpful to talk about their problems in the group. Mary said that she learned:
to talk about my anxiety, the appointment at the hos- pital that I didn't like.. I have to go for that… to talk about to my sister, and feel better…talk about your problems, anxiety it helped me too.
(P, 8)
F I G U R E 4 The graph displays Mary's scores at pre-, post- intervention and follow-up for GAS, HoNOS-LD, index of distress on PTOS-ID and on supporters’ (S/R) PTOS-ID. Higher scores indicate increased level of impairment. Mary's HoNOS score at pre- group is missing
0 5
10 15 20 25 30 35
Mary's scores over time
F I G U R E 5 The graph displays Sally's scores at pre-, post- and follow-up intervention for GAS, HoNOS-LD, index of distress on PTOS-ID and on supporters’ (S/R) PTOS-ID. Higher scores indicate increased level of impairment
0 10 20 30 40
Sally's scores over time
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Two participants described difficulties they experienced in the group. One participant found the room “dark” and the venue too small. Another participant found it difficult initially to be in a group with others.
Superordinate theme 3: Participants’ perceived positive interactions with other group members This theme incorporates participants’ positive experience of inter- acting with other participants, supporters and facilitators.
Sally and Colin enjoyed talking to other group members. Colin described:
I‘ve enjoyed having a chat. And, I‘ve enjoyed explain- ing about myself. I really enjoyed the group.
(P, 16)
Sally liked learning from others and said that it was “nice” to “talk to your friends.” She liked the communication among group members:
[liked] listening and hearing things. Stick to other peo- ple's conversations. Taking in turns. Well done.
(P, 11)
All participants expressed their appreciation about the facilitators describing them as “helpful” and “nice.” For example, Colin said: “I‘ve enjoyed having a chat with them” (P, 38). One participant, Colin, ex- pressed a positive view of his supporter's inclusion: “I really enjoyed it with Ivor in group.” (P, 234).
Superordinate theme 4: Group content This theme reflects topics that were presented in the group, activities that were practised in the group to deal with anxiety and the hometask.
All participants recalled some of the group topics such as feel- ings, behaviours and bodily sensations. Sally recalled that “we talked about heart” and about:
the very happy face on the board. That‘s a good one… It is funny that.
(P, 53)
She also recalled an activity involving writing anxiety provoking thoughts on a picture of a head. She liked the “nice big circle eyes…you could draw it.” (P, 90).
Two participants talked about their positive contribution to the group being a model for others as they presented their pre-existing helpful coping strategies. For example, Sally shared with others what she described as “stretching”:
Looking up to the ceiling, and then looking down. That's good. You have to be careful with your neck…I did it in the anxiety group. It is good Sally because you move and your little fingers as well.
(P, 145)
All participants completed the hometask at least once with their supporters’ help. Most liked the hometask. Sally found it “quite good” although Mary said that she did not find it helpful.
3.2.2 | Results from supporters
Five superordinate themes were identified from the supporters’ in- terviews (Table 5).
Superordinate theme 1: How things were before the group The first theme captures supporters’ account of both participants’ and their own emotional issues, coping skills, positive things in eve- ryday life before the group and expectations about the group.
Most supporters said that the participants were encountering emotional difficulties in their everyday life before starting the group. Jacob said:
Superordinate theme Subordinate theme Endorsed by
1. How things were before the group
Participants’ pre-existing emotional difficulties
Participants’ pre-existing coping skills
Colin, Mary, Sally
2. Perceived positive and negative aspects of the group
Participants’ positive experience in the group
How the group helped participants Participants’ difficulties in the group
Colin, Mary, Sally
3. Participants’ perceived positive interactions with other group members
Participants’ positive experience of interacting with other group members
Colin, Mary, Sally
4. Group content Topics and activities in the group Participants’ presentation of coping
skills Hometask
Colin, Mary, Sally
TA B L E 4 Summary of superordinate and subordinate themes for participants
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Mary gets worried sometimes. She wants me to go always out and get her stuff… (S, 13). When she does things, when she goes somewhere, she always likes somebody with her.
(S, 213)
Sylvia talked about Alice's social withdrawal and Erica about Sally's fears. Most supporters described their own worries. Erica expressed her initial hesitation to attend the group:
I wasn't very keen on going to the group first of all. I couldn't believe that [Sally] would change.
(S, 5)
Superordinate theme 2: What supporters found helpful about the group This theme captures group aspects which supporters perceived as helpful for the participants and themselves, such as the group envi- ronment and content, the hometask, the interactions among group members, practical things.
All supporters described the group as “relaxed,” “interesting” and “friendly” reporting an overall positive experience. For example,
Erica felt “happy”. They appreciated the safe and non-judgemental environment where people felt free to express their views and needs.
All supporters recalled topics from the group and most of them endorsed the group content reporting its positive impact on them- selves, despite materials being targeted to participants. They found the strategies to deal with anxiety and the activities that were prac- tised in the group helpful and enjoyable. Introducing coping strate- gies from the first sessions helped Alice to manage her anxiety as she became familiar with the group, her mother said. Erica found everything was helpful:
it did really sink in all those things for her [Sally]. And she does talk about those things, when she gets home.
(S, 6)
Half of supporters found the hometask which was completed by all participants at least once as helpful. Sylvia recognised that this activity is a “massive help.” Jacob found it “good” and that it “helps me under- stand the feelings what is like.”
Most supporters found the social aspect helpful. Ivor empha- sised the opportunity of making friendships and the usefulness of
Superordinate theme Subordinate theme Endorsed by
1. How things were before the group
Participants’ and supporters’ emotional difficulties in life
Participants’ and supporters’ coping strategies and positive things in life
Supporter's initial hesitation to attend the group
Erica, Jacob, Ivor, Sylvia
2. What supporters found helpful about the group
Supporters’ perceived positive aspects of the group
Supporters’ perceived positive group environment Supporters’ perceived positive group topics and
coping strategies Supporters’ perception about the hometask Social aspects of the group are helpful Others as a source of learning Practical aspects of the group are not an issue
Erica, Jacob, Ivor, Sylvia
3. Supporters’ perceived negative aspects of the group
Participant's initial expectation about the group is not met
Supporters’ perceived negative social aspects of the group
Supporters’ perception about participants’ difficulties in the group and after the termination of the group
Supporter's negative experience about the hometask
Supporter's negative experience about practical aspects of the group
Erica, Jacob, Ivor, Sylvia
4. Supporters’ perceived positive impact of the group on participants and themselves
Supporters’ perceived positive impact of the group on participants’ emotions in the group
Supporters perceive a positive impact of the group on participants which lasts after its termination
Erica, Jacob, Ivor, Sylvia
5. Looking to the future Supporters’ constructive feedback about the group Participant's care plan after the group Supporters’ hopes for the future
Erica, Sylvia, Ivor
TA B L E 5 Summary of themes from supporters’ interviews
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discussions. Most supporters perceived their role as active and helpful. All supporters expressed their appreciation for the facilitators. Sylvia said:
the way you did it passing the bottle and that that helped that helped Alice as well. Alice came out of her shell in the last week… which was good to see what a difference.
(S, 112)
Supporters felt participants benefited from learning through oth- ers’ experiences and skills. Colin got help hearing that “other people have anxieties,” Ivor said. Erica said: “listening to those she [Sally] got confidence from those how to answer questions.” (S, 24). Sylvia said: “it was good to get different perspectives.”
Superordinate theme 3: Supporters’ perceived negative aspects of the group Supporters described negative aspects of the group and members’ difficulties in the group and after the end.
Sylvia felt the facilitators should have been more aware of par- ticipants’ needs before starting the group. Talking about the range of participants’ age Sylvia said:
She [Alice] was running off, she was getting very frus- trated and anxious, but I think that was because Alice was expecting it to be her age range and it wasn't, it was her and two 50 plus year olds and she found that difficult…That was a shame because there was no- body that she could become friends with afterwards.
(S, 7)
Jacob expressed his preference for an individual intervention. Half of supporters expressed their dissatisfaction at one participant's dominance of the conversation. Two participants, Sally and Mary, felt uncertainty about what to say. With regards to the hometask, Erica felt initially “a little bit muddled” on “how to fill those spaces [on the worksheets].” Parking was a “big issue” for one supporter. Jacob said that Mary has not used the coping strategies from the group and that:
She [Mary] still gets worries and stress. Because she came back and then in few days, she is worrying about things again.
(S, 230)
Superordinate theme 4: Supporters’ perceived positive impact of the group on participants and themselves The theme captures supporters’ perception about the positive out- come of the group on participants’ feelings and behaviours in the group and after the end of the group.
Half of supporters talked about participants’ positive feelings and changes in the group over time. Sylvia noticed that Alice became “relaxed” and that she had a “massive difference” at the end with
“fully engagement.” Erica mentioned Sally “found so happy to speak to other people.”
Ivor noticed two participants’ progress: “in a very short space of time, she [Alice] grew to trust the group and enjoyed interacting. I thought that was really impressive.” (S, 10).
Supporters described participants’ feelings and behaviours which lasted after the termination of the group. Erica noticed Sally's “tremendous difference” as she “talks more,” “won't worry about anything” and “feels happier.”
But the happiness she got at the group was really, helped her down there [day centre] really. Because she kept saying I am a nice person, I am strong, I am gonna be all the things that you said at the group, she is taking that on board and repeats that.
(Erica, 11)
Sylvia commented that the “healing process” started early and that the group helped Alice:
definitely one hundred percent… she doesn't get as anxious anymore, she's now started going out more with her friends. She went to the pub last night with a few friends.
(S, 234)
Superordinate theme 5: Looking to the future This theme incorporated suggestions for future groups, plans for on- going psychological support and hopes for the future. Sylvia would prefer the group content to be tailored to each participant's needs:
what’ s the requirement for the individual, what is it that they need from the group, you need to find that out.
(S, 179)
Erica expressed her hope that Sally's progress will last in long-term:
I am hoping now, that we can go forward back to how it used to be one time, when she [Sally] was going to shopping.
(S, 28)
4 | DISCUSSION
This study aimed to evaluate the effectiveness of a 7-week CBT group intervention for adults with learning disabilities and anxiety using a multiple methods design, combining standardised measures with qualitative analysis.
Quantitative results show that the CBT group had an overall positive impact on most participants’ anxiety, distress and global functioning, which was maintained for most at follow-up. This study
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replicated findings that CBT might be helpful for people with learn- ing disabilities and anxiety (Dagnan et al., 2018).
Participants’ mean and individual GAS scores decreased post- group, which remained at follow-up as shown previously (e.g. Lindsay et al., 2015). Participants’ HoNOS-LD scores improved post-group in line with Marwood and Hewitt's study (2012).
All participants’ post-group level of distress decreased, which remained at follow-up despite a slight higher score of distress for most of them, as supported by Crossland et al.'s study (2017). The post-group level of distress on supporter's PTOS-ID for all participants lowered, and the level of distress at follow-up re- mained at low level for three out of four participants despite a slight increase.
The scores of measures are fairly consistent with the qualitative results. The qualitative analysis showed that the group intervention was largely a positive experience for participants who reported get- ting help from the group and from interacting with others, possibly through normalising their own experiences (Marwood & Hewitt, 2012). Based on supporters’ narratives, half participants reported a decrease of anxiety and increase of wellbeing which is supported elsewhere (e.g. Bouvet & Coulet, 2015).
The qualitative data showed that most supporters worried about participants’ wellbeing, as reported elsewhere (e.g. Mansell & Wilson, 2010). Supporters helped participants to manage their initial worries, generalise skills outside the group (e.g. Douglass et al., 2007) and engage with the group (Willner, 2006). Supporters benefited from learning coping strategies for themselves as well, as shown previously (Crossland et al., 2017).
Regarding the group content, participants recalled some anx- iety-related feelings, behaviours and body reactions. Most par- ticipants recalled the skills practised in the group (mindfulness and relaxation skills), in line with similar studies (e.g. Bouvet & Coulet, 2015). Participants presented their own pre-existing coping skills in the group. Using visual aids appears to have aided recollec- tion of the content (Haddock & Jones, 2006).
Some participants recalled anxiety-related situations and be- haviours. This is in line with Tsimopoulou, Stenfert Kroese, Unwin, Azmi, and Jones (2018) study demonstrating that people with a learning disability learned to link activating situations to emo- tions. None of the participants discussed the impact of unhelpful thoughts on anxiety, which is a core concept of cognitive therapy (Beck, 1987), which was found elsewhere (Vereenooghe, Reynolds, Gega, & Langdon, 2015) suggesting that people with learning dis- abilities did not learn to link thoughts to emotions. This might reflect participants’ difficulty in perceiving or recalling abstract concepts. Problems recalling theoretical elements are replicated by other re- search (e.g. Hewitt, Atkisnon-Jones, Gregory, & Hollyman, 2019).
4.1 | Clinical implications
The CBT group had an overall positive impact on participants. The quantitative analysis showed improvement whilst the qualitative
analysis showed that the group was largely beneficial for partici- pants. Current findings have implications for services working with people with learning disabilities.
From the qualitative data, it seems that group aspects that helped achieving positive results are the visual presentation of con- cepts, the presentation of basic CBT concepts such as situations, behaviours, body reactions that are related to anxiety, the practice of skills in and outside the group and modelling participants’ own pre-existing skills to others, all enhanced learning. An environment promoting safety, the social interaction and supporters’ involvement helped too.
Exploring individuals with learning disabilities unhelpful thoughts eliciting anxiety, participants’ and supporters’ initial expectations about the intervention might be helpfully integrated in the assessment session. Setting any unrealistic initial expectations might be of benefit before starting the group. Given the supporters’ self-reported anxiety, additional sessions could focus on supporters’ anxiety, which might enhance participants’ progress over time. Encouraging participants’ regular attendance could enhance participants’ learning.
4.2 | Research implications
This study suggests promising results around the benefits of a CBT group for people with learning disabilities, adding to the growing lit- erature. Use of multiple methods allowed tracking the improvement with regards to anxiety and psychological distress. Standardised measures were used to ensure validity. A qualitative results both from participants and their supporters allowed in depth exploration of what aspects of the group were most helpful for participants. A fol- low-up evaluation helped to identify if the gains remained over time.
However, the results following the intervention should be inter- preted with caution. Supporters reported external factors that may have impacted on measures of anxiety. The first author held the role of group facilitator and interviewer holding possibly biases around the results. A lack of control group limits the reliability of the study. The small sample and large standard error limit the generalisability of the results. The specific cognitive changes linked to participants’ anxiety have not been captured over time. Administering outcomes measures at three time points to the same person with consistency could reduce any errors. Future research should be more rigorous, using more robust methodologies with larger samples of people to ascertain which aspects of CBT are effective and the generalisability of the results.
ACKNOWLEDG EMENTS R.G. would like to thank Iman Hassan, trainee clinical psychologist, Katie Ash and Nerissa Grant, assistant psychologists for their help throughout the process.
DATA AVAIL ABILIT Y S TATEMENT The data that support the findings of this study are available on re- quest from the corresponding author, Rengina Giannaki. The data
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are not publicly available due to their containing information that could compromise the privacy of research participants.
ORCID Rengina Giannaki https://orcid.org/0000-0002-1807-1347 Olivia Hewitt https://orcid.org/0000-0002-6393-2388
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How to cite this article: Giannaki R, Hewitt O. A multiple methods evaluation of a cognitive behavioural therapy group for people with learning disabilities and anxiety. Br J Learn Disabil. 2021;49:87–99. https://doi.org/10.1111/bld.12344
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