'It's made all of us bond since that course ' - a qualitative study of service users' experiences of a CBT anger management group intervention.

BACKGROUND: People with intellectual disabilities (ID) are rarely asked about their experiences as users of psychological services and little is known about the views of clients with ID who have undergone cognitive behavioural therapy (CBT). This study aimed to gather the views of adults with ID who had recently taken part in a cluster randomised control trial (RCT) of a staff-delivered manualised CBT anger management group intervention. METHOD: A qualitative method, Interpretative Phenomenological Analysis (IPA), was employed and eleven participants were interviewed. The interviews took place after the intervention, within two weeks of the end of the group, to gain an understanding of service users' experiences of participating in a CBT group. RESULTS: IPA of the interview transcripts indicated that the intervention was experienced as effective and enjoyable and a number of themes were identified including: 'the importance of relationships', 'a new me', 'new and improved relationships', 'presenting myself in a positive light' and 'what the group didn't change'. CONCLUSIONS: The results will be discussed in the context of applying group CBT for adults with ID and implications for service development.

Cognitive behavioural anger management intervention for people with intellectual disabilities: costs of intervention and impact on health and social care resource use.

BACKGROUND: Anger and aggression among adults with intellectual disability (ID) are associated with a range of adverse consequences for their well-being and that of their family or staff carers. The aims were to evaluate the effectiveness of an anger management intervention for adults with mild to moderate ID and to evaluate the costs of the intervention and its impact on health and social care resource use. This paper is concerned with the latter aim. METHODS: A cluster-randomised controlled trial was conducted involving day services for adults with ID in Scotland, England and Wales. Incremental costs of delivering the intervention and its impact on subsequent total health and social care package costs were calculated. Full data comparing costs between baseline and follow-up 10 months later were collected for 67 participants in the intervention arm and 62 participants in the control arm. Cost differences between the groups at follow-up, adjusted for baseline levels, were calculated using non-parametric bootstrapping controlling for clustering. RESULTS: The mean hourly excess cost of intervention over treatment as usual was £12.34. A mean adjusted cost difference of £22.46 per person per week in favour of the intervention group was found but this was not statistically significant. CONCLUSIONS: The baseline-adjusted cost difference at follow-up would result in a fairly immediate compensation for the excess costs of intervention, provided the difference is not a statistical artefact. Further research is needed to clarify the extent to which it might represent a real saving in service support costs.

A cluster randomised controlled trial of a manualised cognitive behavioural anger management intervention delivered by supervised lay therapists to people with intellectual disabilities.

BACKGROUND: Anger is a frequent problem for many people with intellectual disabilities, and is often expressed as verbal and/or physical aggression. Cognitive-behaviour therapy (CBT) is the treatment of choice for common mental health problems, but CBT has only recently been adapted for people with intellectual disabilities. Anger is the main psychological presentation in which controlled trials have been used to evaluate CBT interventions for people with intellectual disabilities but these do not include rigorous randomised studies. OBJECTIVES: To evaluate (1) the impact of a staff-delivered manualised CBT anger management intervention on (a) reported anger among people with mild to moderate intellectual disabilities, and (b) anger coping skills, aggression, mental health, quality of life and costs of health and social care; (2) factors that influence outcome; and (3) the experience of service users, lay therapists and service managers. DESIGN: A cluster randomised controlled trial based on 30 day centres (15 intervention and 15 control). Intention-to-treat comparisons of outcomes used a two-level linear regression model to allow for clustering within centres with baseline outcome levels as a covariate. Comparison of cost data used non-parametric bootstrapping. Qualitative analysis used interpretative phenomenological analysis and thematic analysis. SETTING: Recruited day centres had four-plus service users with problem anger who were prepared to participate, two-plus staff willing to be lay therapists, a supportive manager and facilities for group work, and no current anger interventions. PARTICIPANTS: A total of 212 service users with problem anger were recruited. Thirty-three were deemed ineligible (30 could not complete assessments and three withdrew before randomisation). Retention at follow-up was 81%, with 17 withdrawals in each arm. Two to four staff per centre were recruited as lay therapists. Eleven service users, nine lay therapists and eight managers were interviewed. INTERVENTIONS: The manualised intervention comprised 12 weekly 2-hour group sessions supplemented by 'homework'. Lay therapists received training and ongoing supervision from a clinical psychologist. Treatment fidelity, group attendance and resources used in intervention delivery were monitored. MAIN OUTCOME MEASURES: The primary outcome was the service user-rated Provocation Index (PI), a measure of response to hypothetical situations that may provoke anger. Secondary trial outcomes were the key worker-rated PI; the service user- and key worker-rated Profile of Anger Coping Skills (PACS); the service user-rated PACS imaginal provocation test (PACS-IPT), a measure of response to actual situations known to provoke anger; aggression; mental health; self-esteem; quality of life; and health and social care resource use. Assessments were administered before randomisation and at 16 weeks and 10 months after randomisation. RESULTS: Fourteen treatment groups were delivered, each with 12 sessions lasting an average of 114 minutes, with a mean of 4.9 service users and 2.0 lay therapists. The mean hourly cost per service user was £ 25.26. The mean hourly excess cost over treatment as usual was £ 12.34. There was no effect of intervention on the primary outcome - self-rated PI. There was a significant impact on the following secondary outcomes at the 10-month follow-up: key worker-rated PI, self-rated PACS-IPT and self- and key worker-rated PACS. Key workers and home carers reported significantly lower aggression at 16 weeks, but not at 10 months. There was no impact on mental health, self-esteem, quality of life or total cost of health and social care. Service users, key workers and service managers were uniformly positive. CONCLUSIONS: The intervention was effective at changing anger coping skills and staff-rated anger. Impact on self-rated anger was equivocal. With hindsight there are reasons, from an analysis of factors influencing outcomes, to think that self-rated PI was not a well-chosen primary outcome. Widespread implementation of manualised lay therapist-led but psychologist-supervised anger management CBT for people with mild to moderate intellectual disabilities is recommended.

Cognitive behavioural therapy from the perspective of clients with mild intellectual disabilities: a qualitative investigation of process issues.

BACKGROUND: Clinicians working with clients who have mild intellectual disabilities (IDs) have shown growing enthusiasm for using a cognitive behavioural approach, amid increasing evidence of good treatment outcomes for this client group. However, very little is known about the views and experiences of clients with IDs who have undergone cognitive behavioural therapy. This study aims to explore the perspective of these clients. METHODS: Fifteen participants with borderline to mild IDs and problems of anxiety, depression and anger were interviewed regarding their experience of cognitive behavioural therapy (CBT). Two semi-structured interviews were carried out in the first phase of therapy between session four and session nine. An interpretive phenomenological approach was taken to seek out themes from participants' own personal accounts. RESULTS: Participants valued the opportunity to talk about problems with their therapist and benefitted from therapeutic relationships characterised by warmth, empathy and validation. Participants identified areas of positive change; however, many thought that this may be short lived or not maintained beyond discharge. CONCLUSIONS: The supportive aspects of therapeutic relationships were particularly important to participants undergoing CBT. The clinical implications are considered.

Cognitive behavioural therapy: from face to face interaction to a broader contextual understanding of change.

Cognitive behavioural therapy (CBT) is increasingly used to address the emotional and interpersonal problems of people with ID. There is a limited but promising evidence base supporting this activity. However, these individuals face real and continuing challenges in their lives that have implications for their self and interpersonal perceptions. These adversities have implications for the adaptation of CBT. First, it may mean that characteristically negative perceptions may be more common and may be the result of a complex interaction with a truly aversive environment and should not simply be considered as cognitive distortions. Secondly, clients may have limited control over their everyday lives, with limited opportunity to negotiate change with their informal and formal sources of support. This review suggests that it is important to consider the interpersonal context of therapy both to ensure effective work within sessions and to enable real change in clients' everyday lives. The review draws upon Vygotsky's theory of the zone of proximal development and ecological models of change to consider the challenges of establishing collaborative relationships and the potential to use CBT within a broad psychosocial model. The aim is to offer a helpful framework for practitioners and to identify directions for future research.

General practitioners' attitudes to patients who have learning disabilities.

BACKGROUND: Previous research suggests that the inadequate primary health care received by people with learning disabilities may be the result of general practitioners' (GPs) negative attitudes. Few studies have investigated the evidence for this assumption. This study uses psychological theory to inform an investigation of the attitudes and emotions experienced by GPs when working with learning disabled patients, as assessed by reliable and valid measures. METHOD: A questionnaire comprising an attitude measure and emotion measure was developed and tested for reliability and validity. This was mailed out to a total of 613 GPs registered with three Health Authorities, 310 questionnaires (51%) were returned. RESULTS: GP respondents held positive attitudes to working with patients who have learning disabilities. However, they were less positive about adapting their behaviour. Attitudes varied according to respondents' age and frequency of professional contact with this patient group. There was a strong association between attitudes and emotional experience. Attitudes were unaffected by learning disability training and non-professional contact. CONCLUSIONS: Negative perceptions about working with patients with learning disabilities do not fully explain the inadequate healthcare provided to this group. Other factors may include insufficient awareness of the benefits of adapting the format of a consultation, and the quality of the interface between the GP and the carer accompanying the patient.

Subjective judgements of quality of life: a comparison study between people with intellectual disability and those without disability.

The present study investigated the relationship between objective and subjective measures of quality of life (QoL), and in particular, health status and primary care services. Thirty-one people with intellectual disability (ID) were interviewed using a QoL questionnaire. Thirty-one matched controls from the general population filled in a parallel questionnaire. The results in both groups support the findings of many researchers which indicate that satisfaction with aspects of life is generally high (i.e. approximate 75% of maximum possible satisfaction). The present study also confirms previous findings which indicate that satisfaction with aspects of life does not generally correlate with objective circumstances in either group. The importance that people attach to aspects of their lives did not generally correlate with their objective circumstances or their satisfaction with life. However, people with ID attached greater importance to all aspects of their lives than those without disability. This may be linked to their aspirations, preferences and opportunities for choice, and therefore, these factors may be a more meaningful way of considering their QoL. The present findings call into question the use of satisfaction as a general measure of QoL, and also indicate that the use of importance as a mediating variable in understanding satisfaction may not be a solution. The participants with ID had poorer health than the controls, and were significantly less satisfied with their health. Contrary to other findings, the present participants with ID reported that they had received more health checks than the controls over the previous year. Half of these checks had been carried out by 'special' services rather than primary care services.

Assessing the ability of people with a learning disability to give informed consent to treatment.

BACKGROUND: People with a learning disability are increasingly being encouraged to take a more active role in decisions about their psychological and medical treatment, raising complex questions concerning their ability to consent. This study investigates the capacity of people with a learning disability to consent in the context of three treatment vignettes, and the influence of verbal and memory ability on this capacity. METHODS: Measures of verbal ability, memory ability and ability to consent to treatment (ACQ) were administered to 40 people with a learning disability. The ACQ consisted of three vignettes depicting a restraint, psychiatric or surgical intervention. These were followed by questions addressing people's ability to understand the presenting problem; the nature of the proposed intervention; the alternatives, risks and benefits; their involvement in the decision-making process; and their ability to express a clear decision with a rationale for treatment. RESULTS: Five people (12.5%) could be construed as able to consent to all three vignettes; 26 (65%) could be construed as able to consent to at least one. The questions that were most difficult to answer concerned a participants' rights, options and the impact of their choices. Verbal and memory ability both influenced ability to consent. CONCLUSIONS: This study introduces a measure that may enable clinicians to make more systematic assessments of people's capacity to consent. A number of issues surrounding the complex area of consent to treatment are also raised.

Stress, coping, and disturbed eating attitudes in teenage girls.

OBJECTIVE: This study explored the relationship between stressors and disturbed eating attitudes among adolescent females, assessing the moderating role of coping and the mediating influence of poor self-esteem. METHOD: Two hundred eighty-six teenage girls were recruited from local schools, and completed standardized measures of stressors, coping, self-esteem, perfectionism, and disturbed eating attitudes. Regression analyses were used to test for moderating and mediating effects. RESULTS: Stressors and emotion-focused coping were found to be associated with low self-esteem, which in turn was strongly associated with disturbed eating attitudes. Stressors were also directly related to disturbed eating attitudes. DISCUSSION: The findings provide partial support for existing models of the etiology and maintenance of eating psychopathology, but have wider implications for our understanding of the eating disorders and their treatment.

Comparison of a commercial ELISA and an immunoperoxidase monolayer assay to detect antibodies directed against porcine respiratory and reproductive syndrome virus.

A commercially available enzyme-linked immunosorbent assay (ELISA) for the detection of antibodies against porcine respiratory and reproductive syndrome virus (PRRSV) was compared to an immunoperoxidase monolayer assay (IPMA). Serum samples used were collected from pigs experimentally infected with either the American or European antigenic type of PRRSV, and also from piglets born to sows that had been experimentally infected with the European antigenic type of PRRSV. In addition, three sets of European field sera (n = 275, n = 68, n = 349) were tested and evaluated using the IPMA as the gold standard. Results showed that both the IPMA and the ELISA were able to detect antibodies against the two antigenic types of PRRSV. When sera of experimentally infected pigs were tested, the IPMA with homologous antigen detected antibodies 2 to 3 days earlier than the ELISA, and was more sensitive in detecting maternal antibodies. The ELISA was slightly more sensitive for detecting antibodies against the American type than for the European type. When sets of field sera were tested, the relative sensitivity of the ELISA ranged between 0.68 and 0.91, and the relative specificity ranged between 0.75 and 0.97. However, in two of these sets (n = 275, n = 349) we determined that a decrease of the threshold value of ELISA (from 0.4 to 0.3) increased sensitivity without loss of specificity. We concluded that the ELISA is an easy, quick and reliable test to diagnose PRRSV infection in swine herds.

Evaluation of a community care project for people with learning difficulties.

The quality of life and adaptive behaviour of a group of 17 adults with learning difficulties who transferred from a long-stay hospital or hostel into small community-based group homes was assessed before and 1 year after the move. It was found that the increase in adaptive behaviour was largely dependent on structural staff procedures and there was a bias toward achievement in house-bound skills. Subjects had a low level of community presence and few meaningful relationships. Implications for service planning are discussed.