Understanding the difference between mental health issues and learning disabilities

Definitions matter in mental health. That may seem counterintuitive in a field where labelling is sometimes seen as adding to stigmatisation and exclusion.

Yet understanding exactly what the issue is marks the first step towards personalised treatment strategies that recognise the enormous complexity of mental illness and the uniqueness of every patient.

The same goes for learning disabilities, an area that shares certain characteristics, such as, channels for diagnosis and management, with mental health but is actually something quite different.

Under the amended Mental Health Act 2007 for England and Wales, for example, learning disabilities do not qualify for detention or treatment unless they are associated with “abnormally aggressive or seriously irresponsible conduct”[1].

The fact that 25-40% of people with learning disabilities also have mental health problems[2] only underlines the need to separate out any overlapping conditions and give each the attention it deserves.

What do we mean by learning disabilities?

The term ‘learning disability’encompasses a wide range of states, from the mild to the moderate and severe. Learning disabilities are likewise associated with a broad spectrum of conditions, including autism, Down’s syndrome, Williams syndrome, cerebral palsy, Fragile X syndrome and global development delay, as well as challenging behaviour.

Mencap, which had a number of events and activities planned for this year’s Learning Disability Week between 18 and 24 June[3], describes learning disabilities as reduced intellectual capacity and difficulty with everyday activities such as socialising or household tasks[4].

Notably, these problems are lifelong, different for each person affected, and cannot simply be resolved through treatment.  That distinguishes them immediately from mental health issues, which can affect anyone at any time but the vast majority of which are also amenable to successful therapy[5].

According to the Foundation for People with Learning Disabilities, around 1.5 million people in the UK fall under that definition. It includes some 286,000 children aged 0-17 years with a learning disability[6].

The problems start very early in life, sometimes during pregnancy (e.g., if the mother has a particular illness), sometimes at birth (e.g., through lack of oxygen or head trauma) or shortly afterwards, as a result of childhood illness or seizures. Genetic and hereditary factors may also be involved.

Learning disabilities usually have a permanent effect on intellectual function. Mental health problems, by contrast, often emerge after childhood, may be only temporary, and can change over time.

Delayed diagnosis of learning disabilities and mental health problems

Despite these early origins, it may be some time before learning disabilities are diagnosed, particularly if parents are reluctant to acknowledge that a child’s developmental progress is lagging that of his or her peers. Alternatively, a diagnosis of learning disability may come at birth or never at all.

That learning disabilities can remain unrecognised for years is particularly troubling when we consider their potential impact. Only one in three people with a learning disability in the UK are engaged in some form of education or training, 50,000 adults with a disability are supported by day-care services, and 40% of children with a disability live in poverty. Learning disabilities are also a magnet for bullying and sexual abuse[7].

Getting the right type and level of support is imperative. People with a learning disability may take longer to absorb information, learn new skills or build relationships. All the more reason, then, to have a clear picture from the start of differences between learning disabilities and mental health problems, as well as how these two fields interact.

In children and adolescents, for example, the prevalence rate for diagnosable psychiatric disorder is 36% in those with learning disabilities compared with 8% in those without. At the other end of the scale, dementia prevalence is around 22% among older people with learning disabilities versus 6% in the general over-65 population[8].

Complex interrelationships of mental health diagnoses

Even now, it is important to recognise that too narrow a focus on learning disabilities may lead to mental health issues being overlooked in the same patient[9].

This confusion deepens if healthcare providers or carers put mental health symptoms down to learning disabilities, or if mental-health and learning-disability services are not properly coordinated, with discrete models for managing challenging behaviour.

At the same time, though, it is acknowledged that certain characteristics of learning disabilities aggravate the risk of mental-health issues[10]. These include:

  • Increased susceptibility to physical health problems such as being underweight, or suffering from epilepsy or respiratory disease.
  • A higher incidence of negative life events, such as deprivation, poverty or social hostility.
  • Isolation and loneliness. Nearly one in three young people with learning disabilities spend less than an hour outside their home on a typical Saturday[11].
  • Limited access to resources and skills for coping when things go wrong.

These complex interrelationships make clear that full understanding of learning disabilities as distinct from mental health issues will benefit the diagnosis and treatment of both. Conflating mental health problems and learning disabilities also has political implications, particularly if welfare policy and benefits are shaped by the misperception that learning disabilities can simply be ‘put right’.

Key variables

In both cases, for people with learning disabilities, and for those with mental health issues,  the right approach to supporting patients and managing the daily challenges they face will depend on a number of key variables, such as age, severity, confidence or communication skills.

Only by understanding the particular circumstances and features of learning disabilities, can carers and healthcare professionals tailor their support and therapeutic strategies precisely to each individual, optimising both effectiveness and outcomes.

In some cases, patients may need little more than practical help with filling in a form, accessing healthcare services or using public transport. In others, more formalised interventions such as cognitive behavioural therapy, physiotherapy, psychotherapy or speech and language support may be required.

The overarching objective should be to integrate people with learning disabilities as much as possible into the community, enabling them to neutralise stigmatisation through increased visibility, familiarity and interaction, while leading fulfilled and productive lives – ideally on their own terms.

Without real sensitivity to the nuances of learning disabilities and mental health issues, though, healthcare professionals, families, carers and the general public are at risk of selling everyone short.

 

References:

[1] Mental Health Act 2007. Chapter 12. Retrieved from http://www.legislation.gov.uk/ukpga/2007/12/pdfs/ukpga_20070012_en.pdf.
[2] Learning disability statistics: mental health problems. Foundation for People with Learning Disabilities. Retrieved from https://www.mentalhealth.org.uk/learning-disabilities/help-information/learning-disability-statistics-/187699.
[3] Learning Disability Week 2018. Mencap. Retrieved from https://www.mencap.org.uk/get-involved/learning-disability-week-2018.
[4] What is a learning disability? Mencap. Retrieved from https://www.mencap.org.uk/learning-disability-explained/what-learning-disability.                                                                                
[5] What is a learning disability? Mencap. Retrieved from https://www.mencap.org.uk/learning-disability-explained/what-learning-disability.
[6] Learning disability statistics. Foundation for People with Learning Disabilities. Retrieved from https://www.mentalhealth.org.uk/learning-disabilities/help-information/learning-disability-statistics.
[7] What is a learning disability? Mencap. Retrieved from https://www.mencap.org.uk/learning-disability-explained/what-learning-disability.                
[8] Learning disability statistics. Foundation for People with Learning Disabilities. Retrieved from https://www.mentalhealth.org.uk/learning-disabilities/help-information/learning-disability-statistics
[9] What’s the difference between a learning disability and a mental health problem? Robinson, J. 14 May 2016. Retrieved from https://www.mencap.org.uk/blog/whats-difference-between-learning-disability-and-mental-health-problem.
[10] Ibid.                                                                                                                                                            
[11] Learning disability research and statistics: friendships. Mencap. Retrieved from https://www.mencap.org.uk/learning-disability-explained/research-and-statistics/friendships.

Jill Dawson wins PBS BILD Coach of the Year

Congratulations to Jill Dawson, Lead Speech and Language Therapist at the Huntercombe Group, who received the award for PBS (Positive Behaviour Support) Coach of the Year at the 2018 BILD PBS Leadership Awards which took place during their International Conference in May 2018.

To read more about Positive Behaviour Support please click here.


Join us on 16th June for an information day on Alzheimer’s

Pathfields Lodge will be holding a “Cupcake Day” in support of the Alzheimer’s Society on Saturday 16th June 2018 from 11.00am until 15.00pm.    The day features three free interactive information sessions where our visitors can learn all about how dementia affects a person and what you can do to make a difference.  With an estimated 850,000 people in the UK living with dementia and 24.6 million – 38% of the UK population – who know a family member or close friend living with dementia, we’re hoping that these sessions will be helpful and informative (Alzheimer’s Research UK),

Our interactive sessions will run hourly from 12.00 until 2.00pm and will be run by a Dementia Friend.  Dementia Friends is an Alzheimer’s Society initiative which encourages people to learn a little bit more about what it is like to live with dementia and then turn that understanding into action.  It’s all about learning about the small ways in which you can help dementia sufferers.  Small actions such as telling friends about Dementia Friends, being more patient in a shop queue to campaigning for change, every action counts.  Dementia Friends are all trained and supported by the Alzheimer’s Society

As well as our interactive sessions, we will be raising money for the Alzheimer’s Society through cake-themed games and activities, a raffle and the sale of cupcakes.   Our event is free to members of the general public, anybody that is interested in learning more about dementia, anybody that wants to see what Pathfields Lodge is all about or anybody that likes cupcakes!

If you’d like to attend you can contact Michaela Lowe at Pathfields (09133 413 646) or email Nicola, our Dementia Friend direct on NicolaDementiaFriendsChampion@yahoo.com or alternatively just turn up on the day!

Location:

Pathfields Lodge,Station Road, Knuston, Wellingborough, NN29 7EY

 


Moorpark Place celebrates Mental Health Awareness Week

Moorpark Place staff raised awareness of stress for Mental Health Awareness Week 2018, by carrying out a CPD session for staff. The session focussed on the need for being aware of stress and coping strategies for managing time, and organisation which when mismanaged can create a feeling of stress.

The Moorpark Place Psychology Team helped to celebrate the week by holding a stall raising awareness of managing stress. A resident helped to create the poster and information for the stall. During the week the Clinical Psychologist spoke to residents and staff and offered our residents free relaxation packs, which contained a relaxation CD and some bubbles.

 


Eldertree Lodge celebrates International Nurses’ Day

Staff at Eldertree Lodge celebrate International Nurses’ Day 2018 on 12 May.


Managing challenging behaviour with Positive Behaviour Support

Challenging behaviour in mental-health settings takes many forms, and for many reasons. Examples of challenging behaviour may include stereotypical behaviours such as rocking or pacing but may be far more disruptive to both the person and their carers and families. These behaviours would include physical aggression to themselves and others, property damage and verbal abuse..

When thinking about the causes of challenging behaviours, it is important to consider the environment and wider context in which the behaviour occurs as well as the person’s own internal factors such as physical and emotional well-being, mental health and cognitive abilities. As often as not, they are a combination of these factors. Understanding what brings on challenging behaviour is the first step towards anticipating, preventing or de-escalating it in the most humane, effective and non-punitive way possible, and this is the approach championed by Positive Behaviour Support.

A sea change in attitudes to challenging behaviour has been the evolution over the last 30 years or so of Positive Behaviour Support (PBS) strategies. PBS aims to enhance quality of life by encouraging positive behaviour alternatives to challenging behaviour, rather than simply repressing or punishing behaviour through restrictive interventions.

The bedrock of this thinking is acknowledgment that underlying challenging behaviour is functional: it is done by patients with mental health illnesses for a purpose, such as attracting attention, relieving boredom or manoeuvring out of a situation where the instigator feels uncomfortable or distressed.

If challenging behaviour achieves that objective, it is likely to reinforce the behavioural pattern. Addressing the behaviour through restrictive interventions, such as restraint, seclusion, sedation or withdrawal of favoured activities, may stem the challenge in the short term while doing nothing to address root causes, at times even exacerbating the problem.

Concerns about excessive use of restraint and medication in care settings led to initiatives such as the Department of Health’s guidance of April 2014, Positive and Proactive Care: reducing the need for restrictive interventions[1]. This document for health and social care providers came out strongly in favour of Positive Behaviour Therapy as a positive and proactive approach to understanding and managing challenging behaviour.

The Individualised Positive Behaviour Therapy process

The PBS process starts with a basic functional assessment of the individual involved; their personal history; how, when, where and why their challenging behaviour arises; and what the consequences of that behaviour are.

This process is not only person-centred but holistic, looking at every possible factor in an individual’s psychology, needs and environment that might trigger or contribute to incidents of challenging behaviour. It then suggests alternative positive behaviours that can achieve the same objective without presenting a challenge.

Anyone who is dealing with challenging behaviour and is involved in supporting individuals prone to challenging behaviour, including health- and social-care teams, family, carers and service users, should have input into this process. The end result is a personalised, multidisciplinary Positive Behaviour Support plan, which sets out consistent, transparent strategies for identifying, averting and managing challenging behaviour.

The plan includes proactive and reactive strategies to reduce challenging behaviour and improve quality of life. These might encompass changes to the individual’s environment and routine; opportunities to learn new behavioural skills, with an emphasis on coping and repair; de-escalation techniques; and appropriate, ethical responses to minimise risk of harm where behaviour cannot be prevented.

The emphasis is firmly on proactive positive behaviour strategies that redirect challenging into positive behaviour. Once implemented, the plan is monitored and updated to take into account any environmental, circumstantial, emotional or other changes that affect the individual’s propensity for challenging behaviour.

Positive Behaviour Support at Huntercombe

Working with the Centre for the Advancement of Positive Behaviour Support at the British Institute of Learning Disabilities, the Huntercombe Group has been implementing PBS as an integral component of care at its hospitals and centres since April 2017.

So far, 21 out of 23 sites have established PBS practitioners to support their services. The programme continues to gain momentum, with four new PBS coaches for the next financial year. Examples of challenging behaviour encountered by Huntercombe staff vary but they often involve self-harm, aggression or, with brain injuries, distress around personal-care needs.

Positive Behaviour Support training programmes to embed PBS in Huntercombe culture have opened up new ways of thinking about challenging behaviour and restrictive practice at multiple levels of support, including psychologists, doctors, occupational therapists, speech and language therapists,  support workers and nurses.

This might be something as straightforward as asking why a door has to be kept shut, or why a toilet is reserved for staff use. Alternatively, it might address more complex issues such as access to mobile phones, tablets and social media.

Positive Behaviour Examples in Huntercombe

One example of PBS being successfully applied in Huntercombe’s Eldertree Lodge facility near Stoke-on-Trent was a 55 year-old patient with a high frequency of challenging behaviour, most of it self-harm. This meant the patient missed out on activities she enjoyed, impacting upon her quality of life.

Based on a functional assessment and information from the DATIX system, which records behaviours of concern, the patient was recommended for a Positive Behaviour Support intervention. The main function of self-harm was identified as ‘attention’. Ward staff said the patient was bored and believed staff were rejecting her or had no time to talk with her.

The PBS plan included communication strategies, to ensure the patient felt ‘looked after’, and a PBS timetable providing alternative means of gaining staff attention, such as hand massages, pampering, one-to-one talk time and additional offsite trips.

Before the intervention, the patient was having an average of 25.8 challenging incidents per week. A DATIX sample during the two months post-intervention showed this frequency reduced to an average 4.6 incidents per week.

The Positive Behaviour Support strategies delivered the patient’s desired outcome of more attention and improved her quality of life by enabling more frequent access to the community, where she started to attend weekly coffee mornings at the local church.

A recent cohort study of PBS outcomes at Eldertree Lodge found there had been a 37% reduction in restraints overall since the PBS programme was implemented. Use of the most restrictive forms of restraint fell by 53%, and of the least restrictive restraints by 37%.

Accentuating the positive

Positive Behaviour Support provides a cohesive framework that can be applied flexibly across a variety of contexts. Accentuating the positive in dealing with challenging behaviour helps people with mental health issues make choices that will benefit both themselves and others.

An additional goal of the PBS programme at The Huntercombe Group is a beneficial impact on workforce wellbeing and practice, including stress levels, competence and staff retention. In specialist brain-injury services, for example, PBS implementation has reduced the frequency of distress-related behaviour that puts undue pressure on staff, such as constant ringing of call bells.  

By ensuring that Huntercombe actively support people through capable environments that allow more choice, control and empowerment, a person’s quality of life improves, removing the need for challenging behaviours to get their needs met.

 

[1] Positive and Proactive Care: reducing the need for restrictive interventions. Department of Health. April 2014. Retrieved from https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/300293/JRA_DoH_Guidance_on_RP_web_accessible.pdf.

 


Dialectical Behaviour Therapy: Building a Life Worth Living

Sometimes efforts to change problematic behaviour, while perfectly valid in themselves, are just not enough for people whose thoughts, emotions and impulses are in a chaotic state.

In fact, these efforts may prove counterproductive if people feel invalidated by too strong an emphasis on the need to change. They have to come to terms with their problematic behaviour, and know it is understood and accepted as a means of coping with challenging circumstances, before they can move on to exploring more positive, socially adapted behaviour. This is where Dialectical Behaviour Therapy (DBT), a form of behavioural therapy, has proven to be one of the most effective treatment programmes applied today.

If the two principles of acceptance and change seem paradoxical, it is precisely this synthesis of apparent opposites that we try to achieve at The Huntercombe Group (THG) by applying the techniques of DBT. Dialectics is about resolving contradictions, or recognising that more than one truth may apply in any given situation. DBT therapy uses this concept to help individuals build a life worth living.

DBT therapy was originally developed by US psychologist Dr Marsha Lineham in the 1980s, as an extension of standard cognitive behavioural therapy (CBT) for individuals who struggled with suicidal thoughts and self-harming behaviours.

Too often with CBT, Dr Lineham and her colleagues found that patients were shutting down or withdrawing from treatment under pressure to enact changes they were not yet ready for. Many patients, who had often come from highly invalidating environments in which emotional vulnerability was dismissed as irrational, were frustrated because they did not believe CBT really recognised the struggles they were going through.

In the years since DBT was introduced, research has shown its effectiveness in treating a wide range of mental-health difficulties, including eating disorders, depression, anxiety, self-harm and as a form of borderline personality disorder treatment.

Across the UK, the presentation of individuals requiring inpatient admission has become more complex, with increased levels of risk and severity of illness. With the ever-increasing evidence base for DBT therapy, Huntercombe believe it to be a robust and comprehensive treatment approach that meets the needs of young people who need inpatient admission. DBT forms a key element of some of Huntercombe’s treatment programmes for young people with our CAMHS hospital in Edinburgh offering an intensive DBT recovery programme.

What is DBT?  

Reconciling acceptance and change

DBT accepts that when patients start treatment, they are doing the best they can for their condition: that intense emotions are normal, and although the patient is doing all they can to manage their difficulties, their behaviours are not helping them.

The long-term goal is a ‘wise mind’ that can balance emotion and reason. This involves patients learning to recognise and respect feelings while responding to them rationally using a range of skills. The wise mind resolves the apparent contradictions between the emotional mind, where feelings control a person’s thoughts, impulses and behaviour; and the reasonable mind, where a person makes decisions based on facts and rational consideration.

Stages and DBT skills 

The therapy is carefully structured and operates on a hierarchical basis, so that the most severe problems are addressed first. Typically people presenting for treatment may have multiple issues that require addressing, sometimes with multiple diagnoses.

The first priority is life-threatening behaviour, followed by any behaviour that interferes with effective treatment, then any behaviour that undermines quality of life. All the while, the patient will be learning new adaptive behaviours.

DBT teaches four main sets of skills to help patients achieve validation, identify and come to terms with the sources of their problems, and find new ways to manage these problems both individually and in their relationships with other people.

Our DBT group facilitators help patients develop new behavioural skills and set homework so that patients can practice their skills in everyday life situations. The four skill modules are:

  • Mindfulness. This is about learning to focus awareness on the present moment, to acknowledge and accept our thoughts and feelings as they occur, and to gain an understanding of our own behaviour.  By reconciling the ‘emotional mind’ and the ‘rational mind’, we can achieve a ‘wise mind’.
  • Distress tolerance. This teaches us how to tolerate challenging feelings, without resorting to harmful coping strategies, when situations are difficult or impossible to change.
  • Emotional regulation. This helps us to understand and manage intense and painful emotions without being overwhelmed by them.
  • Interpersonal effectiveness. This teaches us how to get along with other people, manage conflict within relationships, and be assertive when needed.

According to the standard protocol for DBT therapy, at Huntercombe Edinburgh we run group sessions to teach these new behavioural skills, as well as individual therapy sessions to help patients manage their own emotional responses to difficult situations, maintain their motivation to change, and apply the behavioural skills they are learning in their own lives.

Patients can also ask their DBT therapist or any other member of the DBT team for guidance and support assistance at any time between coaching sessions. Therapists get their own group sessions as well, to consult with other clinicians, reflect on the treatment programme, and improve their own skills.

Parents and Carers

When treating young people, DBT has an additional module for parents and carers called “Walking the Middle Path”. This is a joint patient and parent/carer group which focuses on learning that there is more than one way to see a situation or solve a problem by balancing acceptance and change.

The module emphasises the dialectical view that two opposites can both be true, a perspective that helps patients and their parents to work on changing painful or difficult thoughts and feelings, while accepting themselves as they are in the moment.

By applying DBT techniques and DBT skills across a range of mental challenges, we can steer patients towards a more balanced mindset where they are reconciled with the realities of their condition, its history and the way it manifests, while at the same time looking to the future and the opportunity to change behaviour to their own benefit and that of the broader community.

For more information about DBT at Huntercombe Hospital Edinburgh please click below:

Dialectical Behaviour Therapy at Huntercombe Edinburgh


International Nurses’ Day 2018

Teams across the Huntercombe Group celebrated International Nurses’ Day on 12 May, with cookies on site. We would like to thank all of our amazing staff for the wonderful work they do day in, day out.


Half of Murdostoun patients return home to live independently (April 2018)

We are delighted to share our latest outcomes report for Murdostoun Brain Injury Rehabilitation Centre which shows that our patients make good progress with half our patients being discharged home to live independently. For the full report: Outcomes Murdostoun