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Doing More, Feeling Better: A Behavioural Approach to Helping a Woman Overcome Low Mood and Anxiety

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Title: Doing More, Feeling Better: A Behavioural Approach to Helping a Woman Overcome Low Mood and Anxiety
Language: English
Authors: Stuart, Simon, Graham, Christopher D., Butler, Sarah
Source: British Journal of Learning Disabilities. Dec 2014 42(4):328-335.
Availability: Wiley-Blackwell. 350 Main Street, Malden, MA 02148. Tel: 800-835-6770; Tel: 781-388-8598; Fax: 781-388-8232; e-mail: cs-journals@wiley.com; Web site: http://www.wiley.com/WileyCDA
Peer Reviewed: Y
Page Count: 8
Publication Date: 2014
Document Type: Journal Articles
Reports - Evaluative
Descriptors: Females, Cognitive Restructuring, Behavior Modification, Mild Disabilities, Learning Disabilities, Anxiety, Emotional Response, Intervention, Outcomes of Treatment
DOI: 10.1111/bld.12101
ISSN: 1354-4187
Abstract: A substantial body of literature exists concerning the adaptation of Cognitive Behavioural Therapy for people with learning disabilities. However, it is possible that cognitive approaches have been prioritised at the expense of behavioural techniques that are simpler and more effective. This case conceptualisation considers a behaviourally focused approach to helping a woman with a mild learning disability who was experiencing low mood and anxiety, delivered by a trainee clinical psychologist working within a multidisciplinary team.
Abstractor: As Provided
Entry Date: 2014
Accession Number: EJ1043210
Database: ERIC
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  Value: <anid>AN0098949874;f0401dec.14;2018Jul09.15:06;v2.2.500</anid> <title id="AN0098949874-1">Doing more, feeling better: A behavioural approach to helping a woman overcome low mood and anxiety. </title> <p>Accessible summary: Much has been written about how best to help people with learning disabilities if they feel sad or worried.Often this is about thinking. But it might be better to look at doing instead.This is the story of how we tried to help a lady feel happier, and worry less. Summary: A substantial body of literature exists concerning the adaptation of Cognitive Behavioural Therapy for people with learning disabilities. However, it is possible that cognitive approaches have been prioritised at the expense of behavioural techniques that are simpler and more effective. This case conceptualisation considers a behaviourally focused approach to helping a woman with a mild learning disability who was experiencing low mood and anxiety, delivered by a trainee clinical psychologist working within a multidisciplinary team.</p> <p>anxiety; behavioural therapy; depression; learning disability; Adaptation</p> <p>Adults with learning disabilities, like those without, have varied and sometimes complex emotional lives (Whitehouse et al. [<reflink idref="bib42" id="ref1">42</reflink>] ). Indeed, the nature of common mental‐health problems such as depression and anxiety appears broadly similar for people with learning disabilities and for the general population (MacMahon & Jahoda [<reflink idref="bib28" id="ref2">28</reflink>] ; Perez‐Achiaga et al. [<reflink idref="bib34" id="ref3">34</reflink>] ). However, it is important to consider what differences there may be, particularly in terms of how these might inform treatment approaches.</p> <p>For example, a fundamental element of a cognitive‐behavioural conceptualisation of depression is that certain cognitions about the self in relation to the world lead to low mood, which is maintained by behaviours including rumination, avoidance and withdrawal (Fennell [<reflink idref="bib14" id="ref4">14</reflink>] ). While in a mainstream population it is hypothesised that these cognitions are distorted, Jahoda et al. ([<reflink idref="bib24" id="ref5">24</reflink>] ) argue that certain negative cognitions (e.g. doubts about comparative social skills) may in fact be accurate for a person with a learning disability. Similarly, a cognitive‐behavioural approach to anxiety proposes that an individual's beliefs lead to misinterpretation of situations and associated physiological arousal as threatening; avoidance maintains the anxiety by preventing habituation, or any chance for the cognitions to be disproved (Clark [<reflink idref="bib7" id="ref6">7</reflink>] ). Dagnan & Jahoda ([<reflink idref="bib11" id="ref7">11</reflink>] ) suggest that this conceptualisation also applies to people with learning disabilities, but highlight that social factors may play a major part in anxiety in this population, leading to beliefs about inability and reliance upon other people. Again, while some of these cognitions may be distorted, others may be more valid.</p> <p>As this very brief outline suggests, a cognitive‐behavioural approach to depression and anxiety does have explanatory value for people with learning disabilities. However, an idiographic formulation and Cognitive Behavioural Therapy (CBT) treatment plan for a person with a learning disability will require particular consideration of cognitive, psychological and social factors that moderate both their symptoms and their response to those symptoms. For example, while a person with mild cognitive impairment may be able to describe emotions and associated thoughts, they may not have the cognitive capacity to challenge those thoughts as CBT proposes (Willner [<reflink idref="bib44" id="ref8">44</reflink>] ).</p> <p>Evidence for modified or simplified CBT‐based approaches is long‐standing (Cooray & Bakala [<reflink idref="bib8" id="ref9">8</reflink>] ; Pert et al. [<reflink idref="bib35" id="ref10">35</reflink>] ). However, Flynn ([<reflink idref="bib15" id="ref11">15</reflink>] ) cautions that much of this is suboptimal, with many studies having problems with design and outcome measurement. In a review of 25 studies based on cognitive‐behavioural or psychodynamic approaches, Whitehouse et al. ([<reflink idref="bib42" id="ref12">42</reflink>] ) reported 94 adaptations of therapy for people with learning disabilities, many informed by the nine techniques described by Hurley et al. ([<reflink idref="bib22" id="ref13">22</reflink>] ), including simplification, changes in language, and a more activity‐based approach. It is possible that the last of these merits particular consideration. In their critical review of mainstream CBT studies, Longmore & Worrell ([<reflink idref="bib27" id="ref14">27</reflink>] ) advance the view that cognitions might be altered by behavioural interventions alone, arguing that evidence points to it being the behavioural component of CBT that leads to lasting change. While a person with a learning disability may find it difficult to work directly with abstract concepts such as the link between thoughts and emotions (Willner [<reflink idref="bib44" id="ref15">44</reflink>] ), this argument suggests that it is possible to indirectly address cognitions by behavioural change. In attempting to simplify CBT for people with learning disability, a fruitful approach might therefore be to prioritise behaviour.</p> <p>Comparative to other populations, there has been a dearth of research into interventions for common mental‐health problems in people with learning disabilities (Flynn [<reflink idref="bib15" id="ref16">15</reflink>] ; Willner [<reflink idref="bib43" id="ref17">43</reflink>] ). For example, in a comprehensive review aimed at informing clinical practice in Scotland (NES [<reflink idref="bib33" id="ref18">33</reflink>] ), only group CBT with social support was deemed to have sufficient evidence to support its efficacy in treating depression in this population. However, the same review highlights many empirically supported interventions for challenging behaviour in people with a learning disability, each of which has an overt behavioural focus (e.g. applied behavioural analysis, positive behavioural support). Sturmey ([<reflink idref="bib38" id="ref19">38</reflink>] ) offers a consideration of the evidence for behavioural techniques: again, it is notable that there has been very little consideration of common mental‐health problems, especially in people with milder learning disabilities. Given the success of behavioural approaches in other contexts, this would appear to be a key area for further clinical examination and research.</p> <p>This single‐case conceptualisation considers a behaviourally focused approach to the treatment of low mood and anxiety in an outpatient setting, the participant being a 40‐year‐old lady with a mild learning disability. It was hypothesised that the approach would be a timely, effective and acceptable way of helping her.</p> <hd id="AN0098949874-2">The present case</hd> <p>Ms A lives with her adoptive parents in a semi‐rural area of Scotland. She was referred by her GP to a Community Learning Disability Team (CLDT) in relation to anxiety, low mood and possible depression, and treated by a trainee clinical psychologist, under the supervision of a chartered clinical psychologist.</p> <p>Assessment with the Wechsler Adult Intelligence Scale, 4th Edition (WAIS‐IV; Wechsler [<reflink idref="bib40" id="ref20">40</reflink>] ) and Adaptive Behaviour Assessment System, 2nd Edition (ABAS‐II; Harrison & Oakland [<reflink idref="bib16" id="ref21">16</reflink>] ) had led to the diagnosis of a mild learning disability, with the WAIS‐IV indicating a full‐scale IQ of 67 [95% Confidence Interval (<reflink idref="bib64" id="ref22">64</reflink>, 72)]. At the time of referral, Ms A was overweight but reported no physical‐health concerns other than some dizziness and faintness the previous year, which she said had ceased following the prescription of antihistamines. She worked part‐time in a long‐standing job which she ‘loved’, particularly because it gave opportunities for social contact. Outside work, she said that she did not feel she had any close friends. She described her main hobbies as ‘reading my Kindle’ and watching television, and reported no romantic history. She said that she had struggled with school both academically and socially, had received no formal support, and had no qualifications.</p> <p>Ms A had been adopted as a young child, and no information was available about any constitutional condition that might explain her cognitive impairment. She described a good relationship with her adoptive family.</p> <hd id="AN0098949874-3">Assessment of mood and anxiety</hd> <p>At assessment, Ms A completed the Glasgow Depression Scale (GDS‐LD; Cuthill et al. [<reflink idref="bib9" id="ref23">9</reflink>] ) and Glasgow Anxiety Scale (GAS‐ID; Mindham & Espie [<reflink idref="bib31" id="ref24">31</reflink>] ). These have been reviewed as reliable and valid measures, albeit more descriptive than diagnostic (Hermans & Evenhuis [<reflink idref="bib19" id="ref25">19</reflink>] ; Hermans et al. [<reflink idref="bib20" id="ref26">20</reflink>] ). Pre‐intervention, Ms A scored 21 on the GDS‐LD, indicating that she could be experiencing an episode of depression. She scored 29 on the GAS‐ID, suggesting that she was experiencing symptoms indicative of an anxiety disorder.</p> <p>At initial interview, Ms A described symptoms of low mood including poor sleep, tearfulness, irritability and rumination. She denied suicidal ideation, citing her family and her job as protective factors. She had been using prescribed antidepressant medication at the standard dose for around 6 months: Rai & Kerr ([<reflink idref="bib36" id="ref27">36</reflink>] ) suggest that antidepressants are as effective in people with learning disabilities as in the general population. Ms A reported low self‐confidence and feeling ‘left out’ because other people of her age had relationships and independence. These appeared to be valid observations rather than distorted assumptions (MacMahon & Jahoda [<reflink idref="bib28" id="ref28">28</reflink>] ). She linked her lack of confidence to dissatisfaction with her weight, but added that often she simply felt sad and did not know why. Asking about behavioural concomitants to her emotions enabled a functional analysis of avoidant behaviour and overeating (Fig. [NaN] ).</p> <p>Ms A described frequent worry about her parents’ mortality and her own future, and reported somatic symptoms of anxiety including muscle tension, increased heart rate, overbreathing and slight nausea. She said that although she wanted to live independently, she worried that she would not be able to cope with tasks such as cooking or paying bills, and reported avoiding anything to do with these. While it is possible that some of her negative appraisals of her abilities were accurate, her scores on the Verbal Comprehension and Processing Speed indices of the WAIS‐IV suggested that she might be underestimating her abilities. Further questioning revealed that she had burned herself many years previously while cooking, suggesting a phobic element to her anxiety, maintained by operant avoidance (Butler [<reflink idref="bib6" id="ref29">6</reflink>] ). This is illustrated in Fig. [NaN] , again based on a functional‐analytical approach.</p> <hd id="AN0098949874-4">Problem‐level formulation</hd> <p>The problem‐ and case‐based approach to formulation taken here is informed by Dudley & Kuyken ([<reflink idref="bib13" id="ref30">13</reflink>] ). With regards to Ms A's mood, it appeared that social comparison and associated rumination had led to her experiencing depressive cognitions. It was hypothesised that withdrawal provided a way of avoiding comparison (negatively reinforcing it as a behaviour), while eating chocolate provided a brief sensory pleasure (positively reinforcing it as a behaviour). In the longer term, this had led to a vicious circle of guilt, rumination, prolonged withdrawal and eating several bars of chocolate a day, thereby increasing her weight, further lowering her self‐esteem and depriving her of opportunities to experience alternative rewarding activities. This could theoretically be tested by challenging Ms A's cognitions (Whitehouse et al. [<reflink idref="bib42" id="ref31">42</reflink>] ), but some of these were likely to be accurate (e.g. ‘I am different, I am overweight’). A more useful test of the hypothesis might therefore be to begin altering behaviours; this might also lead to reappraisal of her situation (Biswas & Furniss [<reflink idref="bib1" id="ref32">1</reflink>] ; Longmore & Worrell [<reflink idref="bib27" id="ref33">27</reflink>] ).</p> <p>It was hypothesised that Ms A's avoidant behaviour was negatively reinforced by the short‐term reduction in anxiety it provided; however, as Fig. [NaN] suggests, avoidance was leading to a vicious circle and preventing her from experiencing situations that might disconfirm her negative cognitions (Clark [<reflink idref="bib7" id="ref34">7</reflink>] ). This hypothesis could be tested by a programme of graded exposure/desensitisation, and by behavioural experiment (Cooray & Bakala [<reflink idref="bib8" id="ref35">8</reflink>] ; Dagnan [<reflink idref="bib10" id="ref36">10</reflink>] ). It is possible that Ms A's historical dizziness had involved an element of panic: while interoceptive exposure could have been used to test this (Butler [<reflink idref="bib6" id="ref37">6</reflink>] ), it was deemed unnecessary as she was no longer experiencing these symptoms.</p> <hd id="AN0098949874-5">Case‐level formulation</hd> <p>Formulation should be a collaborative process (British Psychological Society [<reflink idref="bib4" id="ref38">4</reflink>] ), and it was important to find a way in which a biopsychosocial consideration of Ms A's problems could be explored and agreed in a manner that she understood. This plain‐language formulation was broadly as follows:</p> <p>Ms A has a mild learning disability, and finds it hard to remember things. This makes her feel different, and not confident.</p> <p>Partly because of this, she has for many years avoided things like cooking, cleaning and dealing with money. While this can make her feel happier in the short term, in the longer term it might be making her worries worse.</p> <p>She has a particular problem with cooking, because she associates it with hurting herself.</p> <p>As she and her parents grow older, she worries more about how she will cope when they die. Thoughts like this are upsetting. They also increase her unhappiness about still living at home, unlike most other people her age.</p> <p>When she is upset, Ms A often notices that her body feels sore and she feels a bit sick. She cannot always explain exactly why she is unhappy.</p> <p>When she feels this way, she tends to go to her bedroom to watch television on her own. To begin with, this feels like an escape from her problems. However, she usually finds herself mulling over them again and feeling worse.</p> <p>To cheer herself up, she might have a bar of chocolate – but she then feels guilty and worries about her weight. She feels even sadder and decides to stay in her room. She might have another bar of chocolate because it makes her feel better for a few moments.</p> <p>Staying in her room means she is not doing anything that might be more enjoyable, such as spending time with other people or trying new activities.</p> <p>Similarly, avoiding things such as cooking or money means she does not have a chance to find out that maybe she can do them. She might even enjoy them!</p> <p>In short, Ms A is caught up in a vicious circle of worry, low mood and inactivity.</p> <p>To emphasise this last point and provide the simplest possible summary, Ms A was provided with a schematic (see Fig. [NaN] ), which she appeared to find particularly helpful. This also facilitated an introduction to how the vicious circle might be weakened or broken.</p> <p>The formulation suggested that key factors maintaining Ms A's difficulties were avoidance and social withdrawal, both negatively reinforced behaviours (Hopko et al. [<reflink idref="bib21" id="ref39">21</reflink>] ). While they had different functions, topographically they were similar, suggesting a unified behavioural treatment approach might be applicable (Brown & Barlow [<reflink idref="bib5" id="ref40">5</reflink>] ), in this case focused on reducing negatively reinforced behaviours.</p> <hd id="AN0098949874-6">Intervention</hd> <p>Including assessment, Ms A had seven sessions of therapy over 3 months, with the importance of homework emphasised. This was in keeping with the concept of minimum intervention (Jackson [<reflink idref="bib23" id="ref41">23</reflink>] ), with the understanding that the case could be stepped up to the therapist's supervisor if necessary (Dodd et al. [<reflink idref="bib12" id="ref42">12</reflink>] ). Based on the formulation, the intervention was as follows.</p> <hd id="AN0098949874-7">Progressive muscular relaxation</hd> <p>Given Ms A's good verbal abilities, the therapist suggested that she might benefit from daily audio‐based progressive muscular relaxation, in this case the package by White ([<reflink idref="bib41" id="ref43">41</reflink>] ). Ms A stated at each session that she was using the CD most days.</p> <hd id="AN0098949874-8">Simplified behavioural activation</hd> <p>Behavioural activation (BA) is frequently used as part of CBT, but stands on its own as an evidence‐based intervention to improve mood (Kanter et al. [<reflink idref="bib25" id="ref44">25</reflink>] ). Put simply, it aims to replace negatively reinforced behaviours (e.g. avoidance) with ones that are more adaptive and intrinsically rewarding (Hopko et al. [<reflink idref="bib21" id="ref45">21</reflink>] ). There is a lack of evidence concerning BA for people with learning disabilities, although it is assumed to have value (Biswas & Furniss [<reflink idref="bib1" id="ref46">1</reflink>] ; Dodd et al. [<reflink idref="bib12" id="ref47">12</reflink>] ; Mizen & Cooper [<reflink idref="bib32" id="ref48">32</reflink>] ).</p> <p>With Ms A, the aim was to reduce the principles of BA to basic, memorable themes, reinforced through repetition and experience. The first step was to explore the possible benefits of brief exercise – e.g. ‘plan and do’ a 10‐min walk each day – using the simplified vicious‐circle formulation to introduce the idea of altering cognitions through changing behaviour. This was simplified as ‘do more, feel better’ (Hopko et al. [<reflink idref="bib21" id="ref49">21</reflink>] ). Ms A responded enthusiastically to this approach. At the session following its introduction, she stated that she had been out for a walk on 5 days of 12 and added, unprompted, that it was ‘better than watching television’. She was encouraged to increase the number of times she engaged in such behaviour and to identify further rewarding behaviours, such as ‘helping Mum with the housework’ (therapist's suggestion), and ‘sharing my chocolate with the family’ and ‘playing with my nephew’ (Ms A's suggestions). Simple activity‐record sheets were created, enabling her to identify and schedule activities, to note how they made her feel, and to plan what she might do next.</p> <hd id="AN0098949874-9">Considering cognitions, chocolate and confidence</hd> <p>Although BA does not directly target cognitions, it recognises their role in the development and maintenance of depressed mood (Hopko et al. [<reflink idref="bib21" id="ref50">21</reflink>] ). Ms A was given simple psychoeducation about the normality of negative automatic thoughts but was not instructed to directly challenge them. It was suggested that she noticed such thoughts and asked herself, instead of worrying or ruminating, ‘what can I do instead?’ (ibid.)</p> <p>This was also posited as an adaptive way to deal with chocolate cravings, with alternative behaviours including leaving her bedroom and sharing – although Ms A also suggested that if she bought less chocolate in the first place then she would not have as much to eat in her room (changing antecedent rather than behaviour). This was another example of her generating her own solutions: the therapist reinforced these with praise, and suggested to Ms A's parents that they should try to do the same (Dodd et al. [<reflink idref="bib12" id="ref51">12</reflink>] ). The therapist and Ms A agreed that while repeatedly using chocolate to improve mood was maladaptive, it was important to enjoy occasional treats. To this end, the therapist introduced a very basic mindful‐eating technique, with the aim of increasing experiential enjoyment and reducing subsequent consumption cues (Kristeller & Wolever [<reflink idref="bib26" id="ref52">26</reflink>] ).</p> <p>It was hoped that a sequela of the BA approach would be increasing Ms A's confidence and willingness to try new things (Reid et al. [<reflink idref="bib37" id="ref53">37</reflink>] ). This seemed to be the case, and when, serendipitously, a new exercise group was announced in Ms A's locality, she was enthusiastic about joining. She was able to link this directly with the concept of ‘do more, feel better’.</p> <hd id="AN0098949874-10">Approaching anxiety</hd> <p>It was felt that Ms A's anxieties around domestic tasks could be targeted behaviourally using an exposure‐based approach (Cooray & Bakala [<reflink idref="bib8" id="ref54">8</reflink>] ). This could also have the benefit of increasing adaptive skills (Tassé et al. [<reflink idref="bib39" id="ref55">39</reflink>] ). This component of the intervention was facilitated through Occupational Therapy (OT), and an intra‐team referral was therefore made.</p> <hd id="AN0098949874-11">Ending and evaluating</hd> <p>The end of Ms A's clinical‐psychology contact coincided with the end of the therapist's clinical placement, at which point the input was felt to have been beneficial. Ms A described an improvement in mood and a reduction in anxiety, and was enthusiastic about the exercise class and the OT referral. She said that she felt able to continue with the behavioural approach, identifying the key themes as ‘what can I do instead?’ and ‘do more, feel better’. She continued to generate her own ideas for rewarding behaviours, now including spontaneous helping around the house and playing badminton. The GDS‐LD and GAS‐ID were used again at the final session: her score on the former had reduced to 17, and on the latter to 20. While these scores remained above the clinical cut‐off points, it seemed reasonable to assume that they would reduce further if Ms A pursued the programme of relaxation, behavioural activation and exposure via occupational therapy.</p> <hd id="AN0098949874-12">Discussion</hd> <p>Based on the clinical formulation, it was hypothesised that a behaviourally focused approach to treatment would be of value. Self‐report, psychometric outcomes and clinical opinion suggested that this had been the case. However, given time, the therapist would like to have gathered follow‐up measures using the GDS‐LD and GAS‐ID, and to have carried out follow‐up functional analysis. Ideally, he would also have remained involved in a consultative role once direct client contact had finished (McBrien & Candy [<reflink idref="bib29" id="ref56">29</reflink>] ). In Ms A's case, this might have helped provide a balance between skills‐building and exposure, and also to introduce elements of behavioural experiment (McMillan & Lee [<reflink idref="bib30" id="ref57">30</reflink>] ).</p> <p>The authors acknowledge that the brief, individually focused intervention described here is not typical of referrals to clinical psychologists within Learning Disability services. Ms A's learning disability was very mild, and she had a relatively high level of autonomy. We also recognise omissions from the formulation: for instance, the birth of Ms A's nephew might have been a precipitant for some of her social comparison and cognitions around self‐worth, and her adoptive status might have been a predisposing factor. These might have been useful to explore at assessment. Nevertheless, this was timely and efficient input, based on principles of minimal intervention and making use of a multidisciplinary team (Jackson [<reflink idref="bib23" id="ref58">23</reflink>] ). At a time when economic pressures are having a significant effect on health services (Borisch [<reflink idref="bib3" id="ref59">3</reflink>] ), it is incumbent upon clinicians to be efficient without sacrificing effectiveness. An approach such as that outlined here might be an effective way of helping people with a mild learning disability within a stepped‐ or matched‐care structure (Dodd et al. [<reflink idref="bib12" id="ref60">12</reflink>] ; Jackson [<reflink idref="bib23" id="ref61">23</reflink>] ).</p> <p>Much of the literature concerning adaptation of psychotherapy for people with learning disabilities focuses on a cognitive‐behavioural approach, with cognitive elements frequently to the fore (Dagnan & Jahoda [<reflink idref="bib11" id="ref62">11</reflink>] ; Jahoda et al. [<reflink idref="bib24" id="ref63">24</reflink>] ; Willner [<reflink idref="bib44" id="ref64">44</reflink>] ). However, if the effectiveness of CBT is predicated largely on behavioural change (Longmore & Worrell [<reflink idref="bib27" id="ref65">27</reflink>] ), perhaps a shift of balance should be considered. Behavioural treatments have a long and well‐evidenced history in psychological work with people with learning disabilities, but might have become overly synonymous with behavioural symptomatology (e.g. challenging behaviour), particularly in institutional settings, and psychological practitioners may overlook their utility in other areas. The utility of behavioural approaches may prove an important consideration if third‐wave therapies, especially Acceptance and Commitment Therapy (ACT), gain prominence within psychology services for people with learning disabilities (Flynn [<reflink idref="bib15" id="ref66">15</reflink>] ; Hayes et al. [<reflink idref="bib18" id="ref67">18</reflink>] ). Indeed, several elements of the intervention described here – increased engagement with meaningful or valued activities; disengagement from negative thoughts; increased awareness of the present moment – are fundaments of ACT. The authors believe that further investigation of ACT‐based approaches for people with learning disabilities is warranted.</p> <p>Gathering evidence is key to improving psychological interventions for people with learning disabilities (Willner [<reflink idref="bib45" id="ref68">45</reflink>] ). While this would ideally take the form of well‐powered randomised control trials, issues of resources, access and ethics make such studies challenging (Hassiotis et al. [<reflink idref="bib17" id="ref69">17</reflink>] ). Individual case‐study‐based approaches therefore have an important role to play, and, although it was not used here, a statistical approach such as time‐series analysis can be applied to examine process change in detail (Borckardt et al. [<reflink idref="bib2" id="ref70">2</reflink>] ). We believe that, despite its limitations, this study shows the value of a behaviourally informed formulation and behaviourally focused intervention, carried out in this case by a junior member of staff under supervision from a clinical psychologist. It is hoped that this suggests a fruitful direction for further clinical research.</p> <hd id="AN0098949874-13">Ethical statement</hd> <p>Written, informed consent for this paper was obtained from Ms A and her parents, and the authors are very grateful to them. Names and some personal details have been changed to ensure anonymity.</p> <hd id="AN0098949874-14">Acknowledgement</hd> <p>Thanks also to Dr Karen McKenzie, Clinical Psychologist, formerly of Edinburgh University.</p> <ref id="AN0098949874-15"> <title>References</title> <blist> <bibl id="bib1" idref="ref32" type="bt">1</bibl> <bibtext>Biswas A.B. & Furniss F.G. ( 2009 ) Life events and mental illness in people with learning disabilities. Psychiatry, 8 : 445 – 7. </bibtext> </blist> <blist> <bibl id="bib2" idref="ref70" type="bt">2</bibl> <bibtext>Borckardt J.J., Nash M.R., Murphy M.D., Moore M., Shaw D. et al. ( 2008 ) Clinical practice as natural laboratory for psychotherapy research. Am Psychol, 63 : 77 – 95. </bibtext> </blist> <blist> <bibl id="bib3" idref="ref59" type="bt">3</bibl> <bibtext>Borisch B. ( 2014 ) Public health in times of austerity. 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( 2005 ) The effectiveness of psychotherapeutic interventions for people with learning disabilities: a critical overview. J Intellect Disabil Res, 49 : 73 – 85. </bibtext> </blist> <blist> <bibl id="bib44" idref="ref8" type="bt">44</bibl> <bibtext>Willner P. ( 2006 ) Readiness for cognitive therapy in people with intellectual disabilities. J Appl Res Intellect Disabil, 19 : 5 – 16. </bibtext> </blist> <blist> <bibl id="bib45" idref="ref68" type="bt">45</bibl> <bibtext>Willner P. ( 2009 ) Psychotherapeutic interventions in learning disability: focus on cognitive behavioural therapy and mental health. Psychiatry, 8 : 416 – 9. </bibtext> </blist> </ref> <p>Graph: Functional analysis of Ms A's behaviour relating to depressed mood.</p> <p>Graph: image%5ft/bld12101-fig-0001-t.gif</p> <p>Graph: Functional analysis of Ms A's behaviour relating to anxiety, incorporating a classically conditioned phobic response.</p> <p>Graph: image%5ft/bld12101-fig-0002-t.gif</p> <p>Graph: Vicious‐circle diagram as presented to Ms A during formulation.</p> <p>Graph: image%5ft/bld12101-fig-0003-t.gif</p> <aug> <p>By Simon Stuart; Christopher D. Graham and Sarah Butler</p> </aug> <nolink nlid="nl1" bibid="bib64" firstref="ref22"></nolink>
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  Label: Title
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  Data: Doing More, Feeling Better: A Behavioural Approach to Helping a Woman Overcome Low Mood and Anxiety
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  Data: <searchLink fieldCode="AR" term="%22Stuart%2C+Simon%22">Stuart, Simon</searchLink><br /><searchLink fieldCode="AR" term="%22Graham%2C+Christopher+D%2E%22">Graham, Christopher D.</searchLink><br /><searchLink fieldCode="AR" term="%22Butler%2C+Sarah%22">Butler, Sarah</searchLink>
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  Data: <searchLink fieldCode="SO" term="%22British+Journal+of+Learning+Disabilities%22"><i>British Journal of Learning Disabilities</i></searchLink>. Dec 2014 42(4):328-335.
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  Label: Availability
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  Data: Wiley-Blackwell. 350 Main Street, Malden, MA 02148. Tel: 800-835-6770; Tel: 781-388-8598; Fax: 781-388-8232; e-mail: cs-journals@wiley.com; Web site: http://www.wiley.com/WileyCDA
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  Data: 8
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  Data: 2014
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  Data: Journal Articles<br />Reports - Evaluative
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  Data: <searchLink fieldCode="DE" term="%22Females%22">Females</searchLink><br /><searchLink fieldCode="DE" term="%22Cognitive+Restructuring%22">Cognitive Restructuring</searchLink><br /><searchLink fieldCode="DE" term="%22Behavior+Modification%22">Behavior Modification</searchLink><br /><searchLink fieldCode="DE" term="%22Mild+Disabilities%22">Mild Disabilities</searchLink><br /><searchLink fieldCode="DE" term="%22Learning+Disabilities%22">Learning Disabilities</searchLink><br /><searchLink fieldCode="DE" term="%22Anxiety%22">Anxiety</searchLink><br /><searchLink fieldCode="DE" term="%22Emotional+Response%22">Emotional Response</searchLink><br /><searchLink fieldCode="DE" term="%22Intervention%22">Intervention</searchLink><br /><searchLink fieldCode="DE" term="%22Outcomes+of+Treatment%22">Outcomes of Treatment</searchLink>
– Name: DOI
  Label: DOI
  Group: ID
  Data: 10.1111/bld.12101
– Name: ISSN
  Label: ISSN
  Group: ISSN
  Data: 1354-4187
– Name: Abstract
  Label: Abstract
  Group: Ab
  Data: A substantial body of literature exists concerning the adaptation of Cognitive Behavioural Therapy for people with learning disabilities. However, it is possible that cognitive approaches have been prioritised at the expense of behavioural techniques that are simpler and more effective. This case conceptualisation considers a behaviourally focused approach to helping a woman with a mild learning disability who was experiencing low mood and anxiety, delivered by a trainee clinical psychologist working within a multidisciplinary team.
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  Data: 2014
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  Data: EJ1043210
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    Identifiers:
      – Type: doi
        Value: 10.1111/bld.12101
    Languages:
      – Text: English
    PhysicalDescription:
      Pagination:
        PageCount: 8
        StartPage: 328
    Subjects:
      – SubjectFull: Females
        Type: general
      – SubjectFull: Cognitive Restructuring
        Type: general
      – SubjectFull: Behavior Modification
        Type: general
      – SubjectFull: Mild Disabilities
        Type: general
      – SubjectFull: Learning Disabilities
        Type: general
      – SubjectFull: Anxiety
        Type: general
      – SubjectFull: Emotional Response
        Type: general
      – SubjectFull: Intervention
        Type: general
      – SubjectFull: Outcomes of Treatment
        Type: general
    Titles:
      – TitleFull: Doing More, Feeling Better: A Behavioural Approach to Helping a Woman Overcome Low Mood and Anxiety
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      – PersonEntity:
          Name:
            NameFull: Stuart, Simon
      – PersonEntity:
          Name:
            NameFull: Graham, Christopher D.
      – PersonEntity:
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            NameFull: Butler, Sarah
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            – D: 01
              M: 12
              Type: published
              Y: 2014
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              Value: 1354-4187
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              Value: 42
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            – TitleFull: British Journal of Learning Disabilities
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