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Do Video Reviews of Therapy Sessions Help People with Mild Intellectual Disabilities Describe Their Perceptions of Cognitive Behaviour Therapy?

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Title: Do Video Reviews of Therapy Sessions Help People with Mild Intellectual Disabilities Describe Their Perceptions of Cognitive Behaviour Therapy?
Language: English
Authors: Burford, B., Jahoda, A.
Source: Journal of Intellectual Disability Research. Feb 2012 56(2):179-190.
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
Physical Description: PDF
Page Count: 12
Publication Date: 2012
Document Type: Journal Articles
Reports - Research
Descriptors: Video Technology, Mental Retardation, Therapy, Disabilities, Cognitive Restructuring, Perception, Feedback (Response)
DOI: 10.1111/j.1365-2788.2011.01450.x
ISSN: 0964-2633
Abstract: Background: This study examined the potential of a retrospective video reviewing process [Burford Reviewing Process (BRP)] for enabling people with intellectual disabilities to describe their experiences of cognitive behaviour therapy (CBT). It is the first time that the BRP, described in this paper, has been used with people with intellectual disabilities and the aim was to assess the feasibility of the procedure and gain a picture of the information it might yield. Methods: Using the BRP, 12 clients reviewed tapes of their fourth and ninth CBT sessions and six reviewed the fourth session only. All reviews were audio recorded for later verbatim transcriptions of clients' comments. Reviews and transcriptions were conducted by non-clinical researchers. Thematic analysis was applied to the transcripts by a researcher who was not CBT-trained. Results: All clients were able to follow the instructions for the BRP. Three broadly based themes encapsulated their responses--how they felt about themselves, how they felt the therapist was helping and how CBT was helping. A fourth theme referred to comments on issues that were currently troubling clients, which were prompted by watching the video but did not refer to actual events on screen. Conclusions: The BRP seems a feasible approach with this client group and gave insights into their feelings and opinions on CBT. Clinical implications of the results and the potential for further developments are discussed.
Abstractor: As Provided
Number of References: 24
Entry Date: 2012
Accession Number: EJ954164
Database: ERIC
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  Value: <anid>AN0070470161;eul01feb.12;2019Jun04.10:45;v2.2.500</anid> <title id="AN0070470161-1">Do video reviews of therapy sessions help people with mild intellectual disabilities describe their perceptions of cognitive behaviour therapy? </title> <p>Background  This study examined the potential of a retrospective video reviewing process [Burford Reviewing Process (BRP)] for enabling people with intellectual disabilities to describe their experiences of cognitive behaviour therapy (CBT). It is the first time that the BRP, described in this paper, has been used with people with intellectual disabilities and the aim was to assess the feasibility of the procedure and gain a picture of the information it might yield. Methods  Using the BRP, 12 clients reviewed tapes of their fourth and ninth CBT sessions and six reviewed the fourth session only. All reviews were audio recorded for later verbatim transcriptions of clients' comments. Reviews and transcriptions were conducted by non‐clinical researchers. Thematic analysis was applied to the transcripts by a researcher who was not CBT‐trained. Results  All clients were able to follow the instructions for the BRP. Three broadly based themes encapsulated their responses – how they felt about themselves, how they felt the therapist was helping and how CBT was helping. A fourth theme referred to comments on issues that were currently troubling clients, which were prompted by watching the video but did not refer to actual events on screen. Conclusions  The BRP seems a feasible approach with this client group and gave insights into their feelings and opinions on CBT. Clinical implications of the results and the potential for further developments are discussed.</p> <p>Keywords: intellectual disability; learning disability; video reviews; cognitive behaviour therapy</p> <p>This paper examines the use of video reviews to find out clients' impressions of their own therapy sessions, as part of a broader project by [<reflink idref="bib13" id="ref1">13</reflink>] examining how people with intellectual disabilities (IDs) engage in cognitive behavioural therapy (CBT). The study uses a retrospective video reviewing process developed by [<reflink idref="bib5" id="ref2">5</reflink>]) and is the first time it has been carried out with people with IDs. It was run as a small pilot study within the main enquiry to assess its feasibility and potential for helping people with IDs to describe their experiences of CBT.</p> <p>Using film and video in research is no longer a novel approach. It was used extensively in the 1960s and 1970s by researchers in human development and behaviour (e.g. [<reflink idref="bib8" id="ref3">8</reflink>]; [<reflink idref="bib3" id="ref4">3</reflink>]; [<reflink idref="bib21" id="ref5">21</reflink>]; [<reflink idref="bib15" id="ref6">15</reflink>]; [<reflink idref="bib19" id="ref7">19</reflink>]) and is now commonplace in observational studies. The coding of observations is a key element in this type of research, because the validity and reliability of the coding affects the strength of the results ([<reflink idref="bib2" id="ref8">2</reflink>]). It needs to be efficient in extracting pertinent information from the video and is normally piloted beforehand to iron out snags and ensure it does the job adequately. In short, the decision about what to look for is made before observations begin and these are then formalised into a tried and tested coding system. In contrast, the Burford Reviewing Process (BRP) does not use pre‐determined coding to gather information and the observer is the client, not the researcher. The reviews are designed to gain the viewers' impressions about what is happening in the video, what their eye is drawn to and what they think about it. The researcher's task is to provide a structure that helps the viewer to do this, free of any guidance or influence.</p> <p>[<reflink idref="bib5" id="ref9">5</reflink>]) first used the BRP with parents and carers of children with profound IDs, asking them to indicate the places on videos where they felt the children were aware and involved in communication. Viewers watched the video of their child, or the child in their care, and indicated where they judged the child to be responding in some way. The VCR was paused only long enough to note the time counter for each selection and then the tape carried on playing. No comment was sought during this first viewing. The aim was to obtain a spontaneous reaction to events as they unfolded. Viewers then made their comments on their selections during a second viewing. This procedure was adapted from a segmentation technique described by [<reflink idref="bib4" id="ref10">4</reflink>]) in which viewers watched behavioural sequences of non‐disabled participants on film and indicated when they felt something 'meaningful' had happened. In this way, the researcher can find out what is meaningful to the participants. In [<reflink idref="bib5" id="ref11">5</reflink>]) study, the reviews gave insights into the actions and vocalisations that parents and carers considered communicative. Pre‐determined criteria would have been inappropriate in this study; it would not have given untrammelled insights.</p> <p>Video reviews were used in similar fashion to tap into the intuitive expertise of experienced health visitors and midwives in a study on the development of infants with Rett syndrome ([<reflink idref="bib7" id="ref12">7</reflink>]; [<reflink idref="bib6" id="ref13">6</reflink>]). The health practitioners watched video clips of babies who were later diagnosed with Rett syndrome, a developmental disorder which is difficult to detect in early infancy, and of babies whose development was normal. The practitioners were asked to look for potential signs of developmental problems, which they identified predominantly in the Rett syndrome group. Their comments were often about unexpected, subtle differences, for example, in hand posture, that an experienced practitioner's eye could spot; in contrast, pre‐determined coding would preclude novel, intuitive observations of this nature.</p> <p>The BRP, originally inspired by [<reflink idref="bib4" id="ref14">4</reflink>]) research, was later influenced by [<reflink idref="bib17" id="ref15">17</reflink>]) philosophy of 'tacit knowledge'. This refers to knowledge or expertise that is acquired through experience and of which we are unaware, for example, the health visitor who feels strongly that there is 'something not right' about a baby's development, later to be proved correct, although there are no tangible signs at the time. Another example is of parents who know when their child with profound IDs is unwell days before the appearance of symptoms. The health visitors and parents have been able to observe and assess correctly, yet find it difficult to specify what they have seen. The BRP helps people to bring this 'hidden knowledge' to the surface and share it with others. The present study aims to extend this into a different realm of 'hidden knowledge'– the subjective experiences of clients with IDs in CBT sessions – and to help them describe these experiences.</p> <p>Efforts to adapt CBT for people who have mild IDs and significant emotional problems have been an important clinical innovation. Although the evidence base is embryonic, it has proved encouraging for a range of difficulties, including anger, depression and anxiety ([<reflink idref="bib20" id="ref16">20</reflink>]; [<reflink idref="bib14" id="ref17">14</reflink>]. Moreover, there is broad agreement that people with mild IDs should have access to effective psychological interventions. Perhaps, most research effort has been focused on assessing clients' suitability for CBT ([<reflink idref="bib16" id="ref18">16</reflink>]), and how to make key elements of the interventions more accessible for individuals with cognitive and communicative impairments. There has been a tendency to assume that the ingredients of CBT considered essential in general adult mental health interventions are salient for people with IDs.</p> <p>The BRP has been adopted for the current study because little is known about the sense that people with IDs make of CBT. It is supposed to be a collaborative approach, based on a shared understanding of the therapeutic model, and obtaining insight into clients' own understanding of the sessions could provide a crucial starting point for adapting therapy. This is different from starting with therapists' suggested changes, based on their own expectations and beliefs about clients' understanding of the process. However, as the BRP has not been used before with people who have IDs, the primary aim was to find out if the procedure was viable with this client group and the relevance of the data it produced. In particular, it was hoped to establish if clients with mild IDs could understand and follow the instructions for the video reviews, and then to examine if the procedure yields information about clients' perceptions of CBT sessions.</p> <hd id="AN0070470161-2">Method</hd> <p></p> <hd id="AN0070470161-3">Participants</hd> <p>Thirty video reviews were conducted with 18 clients with mild IDs (nine women and nine men). Clients were recruited over a 15‐month period from a specialist learning disability psychology service in a Scottish city and two more rural services in England. Ethical approval was obtained for the study from the health board ethics committees at each of the sites. These individuals had all been referred with a primary presenting problem of anger, anxiety or depression. The potential participants attended initial screening sessions with the clinical psychologist who went on to carry out the therapy. These sessions did not follow a research protocol but reflected routine clinical practice. The screens helped to ensure that those recruited were sufficiently able to talk about their problems to make them suitable candidates for CBT and that the participants themselves wished to engage in this therapy. The participants' socio‐demographic details are shown in Table 1, and it shows that they obtained a broad range of scores on the Weschler Abbreviated Scale of Intelligence (WASI; [<reflink idref="bib18" id="ref19">18</reflink>]). However, having sufficient expressive and receptive verbal ability to take part in therapy meant that all the participants were able to understand and respond to questions about themselves and their lives. The participants all lived in community settings with different levels of support, and all participants had at least one clinically significant score on one of the self‐report measures of depression, anxiety and anger that were completed. Each participant was given the self‐report measure linked to their reason for referral as part of the study, and the other self‐report measures were administered at the clinicians' discretion.</p> <p>1 Demographic characteristics of clients</p> <p> <ephtml> <table><thead valign="bottom"><tr><th><bold>Client variable</bold></th><th><bold>Descriptive statistics</bold></th></tr></thead><tbody valign="top"><tr><td>Age (mean) (years)</td><td>35.8 (SD = 10.1, 21–50)</td></tr><tr><td>Gender</td><td>Male 9, female 9</td></tr><tr><td>WASI IQ scores (mean)</td><td>66.9 (SD = 9.5, 55–79)</td></tr><tr><td>Living situation</td><td>6 living alone with outreach support</td></tr><tr><td>2 living with partner with support</td></tr><tr><td>6 living with parents/families</td></tr><tr><td>1 living in staffed house</td></tr><tr><td>2 living in own accommodation with 24‐h support</td></tr><tr><td>1 unknown</td></tr><tr><td>Referrer</td><td>Self 2</td></tr><tr><td>GP 4</td></tr><tr><td>Psychologist 1</td></tr><tr><td>Psychiatrist 4</td></tr><tr><td>Social worker 2</td></tr><tr><td>Community nurse 2</td></tr><tr><td>Other 3</td></tr><tr><td>Mean self‐report scores on entering therapy</td><td /></tr><tr><td> Glasgow Anxiety Scale (GAS)</td><td>GAS (<italic>n</italic> = 9): 27.8 (16–48, SD = 9.6)</td></tr><tr><td> Glasgow Depression Scale (GDS)</td><td>GDS (<italic>n</italic> = 8): 18.1 (7–35, SD = 8.6)</td></tr><tr><td> Novaco Anger Scale (NAS)</td><td>NAS (<italic>n</italic> = 8): 62.4 (48–80, SD = 11.98)</td></tr><tr><td>Clinical caseness for GAS and GDS = 13</td><td /></tr><tr><td>Clinical caseness for NAS = 60</td><td /></tr></tbody></table> </ephtml> </p> <p>1 WASI, Weschler Abbreviated Scale of Intelligence; GP, general practitioner.</p> <hd id="AN0070470161-4">Design</hd> <p>The reviews were conducted during the 'first phase' of therapy, which focused on engagement and socialising the client into the therapeutic model. This phase is thought to take up to five sessions in non‐disabled populations, but given the cognitive and communicative difficulties of this client group, nine sessions was considered to be a more realistic estimate. Therefore, the two data collection points were sessions 4 and 9, both of which were video recorded for reviewing. Session 4 was chosen because by this stage all initial assessments would have been completed and therapeutic work begun. By session 9, all the participants had finished early work helping them to understand their difficulties using a CBT approach, and were working towards agreed goals for therapeutic change.</p> <p>The therapy sessions were carried out by six clinical psychologists, four women and two men, with considerable experience of using CBT with people who have IDs. All of the therapists had supervised training in CBT as part of their clinical qualification, and had been using this approach with individuals who have an ID for a minimum of 4 years. One of the therapists also had a specific qualification in CBT. A formulation‐driven treatment approach was used and fidelity was assessed by an experienced CBT trainer using the CTS‐Psy ([<reflink idref="bib12" id="ref20">12</reflink>]). Good adherence was obtained, and the findings from Haddock <emph>et al</emph>.'s scale are reported by Jahoda <emph>et al</emph>. (2009a).</p> <p>Twelve clients completed two reviews of CBT sessions (sessions 4 and 9) and six completed one review only (session 4). Two reviews with a blind client used audio recordings for reviewing; all other clients reviewed video recordings. Reasons for completing only single reviews included clients withdrawing from therapy, clients moving away from the area and problems with recording equipment. All reasons for discontinuing were external to the reviews and no client withdrew specifically from the reviews.</p> <hd id="AN0070470161-5">Procedure</hd> <p>There are two essential elements in the BRP which apply to any group of viewers, whether clients, carers or practitioners. First, the relationship between researcher and viewer is a key feature. If a researcher employs the review approach only to extract information and does not engage with the viewer, there is a risk of losing important information. Viewers respond especially well to a relaxed, informal atmosphere. They must be assured that they are not under evaluation, and that they are not being judged on how well they 'perform' or 'see' things, but are valued informants. The reviews should allow us to see the events on screen through the viewer's eyes.</p> <p>Second, it is important that the researcher does not define the event of interest; otherwise, it becomes a test of recognition of the researcher's criteria. Nor should the researcher draw attention to events or prompt viewers who are making no choices; in fact, it is essential that there is no prompting to make a selection under any circumstances. Viewers should be asked to make their selections and comments freely; this is more likely to reveal what <emph>they</emph> consider to be key features and the nature of these features. Furthermore, the researcher should be prepared for the possibility that the viewer will see nothing that he or she considers significant or interesting. A viewer might make no comment on a video in which the researcher sees many occurrences that are significant in his or her eyes. The interesting fact here is that the viewer sees nothing, not that the researcher sees something.</p> <p>Viewers do need to be told how the review session will proceed and why they are watching the video and these instructions need to be carefully formulated and consistently given. Appendix 1 gives details of the instructions for this study. The reviews do require sufficient verbal skills to understand and comply with instructions and to make selections and comment on them. All clients in the present study had the necessary verbal skills and understanding to participate in CBT, but it was not known whether this would be sufficient for participation in review sessions. A further unknown was whether the clients' comments would provide insights into their experience of CBT and whether or not they found it beneficial.</p> <p>Reviews were conducted individually by research assistants uninvolved in the client's CBT. Two intensive training days on the review procedure were held for the research team from all three locations. The video reviews were carried out by four research assistants. Some reviews were conducted in clients' homes, but most were held in the same locations as the clients' CBT sessions, including day services centres and premises used by community teams serving the specialist social and healthcare needs of people with IDs. Videos were reviewed in a quiet room using ordinary domestic televisions and video recorders equipped with a time counter.</p> <p>Review sessions took place within 2 weeks of the therapy sessions. The clients were given time to settle down and to have a chance to see themselves on the video before reviewing a 20‐min portion from the middle of their session. In some cases, the session was short and the reviewed portion included most of the session, excluding the part used in settling down. The two sessions (S4 and S9) were reviewed on separate occasions, with the whole process lasting approximately between 60 and 90 min.</p> <p>Procedure for video reviews:</p> <p>Step 1: The client watched the video recording (or listened to the audio) and told the researcher whenever he or she saw something that caught their interest. The researcher did not prompt the client to make a selection. When the client indicated interest, the researcher paused the recording and noted the time counter to mark the place for later comment. No comment was invited at this stage to avoid 'lines of thought' or a 'storyline' being formed by the first observations. This first viewing captured the client's immediate impressions of what he or she found interesting, free of deliberations.</p> <p>Step 2: The researcher rewound the tape and showed each marked place to the client, replaying that part of the tape as often as he or she requested. The client described why he or she had found that part of the session interesting. When this was completed, the client was given the opportunity to make general comments about the video.</p> <p>At the end of the session, researchers were asked to note anything which might have had an effect on the client's responses, for example, to confirm that a client who made little comment had understood the procedure, or to note distractions and interruptions occurring during the session.</p> <p>All reviews were audio recorded on Sony IC digital recorders for later transcription of clients' comments. These were transcribed verbatim by a research assistant using digital voice editor software. The transcripts were analysed by the first author, who is not a CBT therapist and did not know the identity of the clients or therapists.</p> <hd id="AN0070470161-6">Analysis</hd> <p>The clients' comments were subjected to thematic analysis. Time counter readings were included in the transcripts and used to divide the comments into manageable proportions. The comments at each counter reading were given descriptive tags to summarise what had been said, for example, 'talks about feeling lonely', 'says not feeling so angry now', 'worries about getting into trouble again', 'finds it hard to get up in morning', 'client repeats what was said on screen'. Some counter readings required several tags to cover the variety of comments made about that section of the video.</p> <p>Tags of a similar nature were then grouped together, for example, all comments by a client about how he or she was feeling, to form a broader set of descriptions for each review transcript. This was applied to the transcript in question, to ensure it encapsulated the client's comments. All the descriptive sets were then combined into larger themes that could collectively represent the comments of the whole group. An account of these steps was subjected to the scrutiny of an independent auditor to ensure the analysis was rigorous and gave an accurate picture of the clients' comments ([<reflink idref="bib10" id="ref21">10</reflink>]).</p> <p>A psychotherapist, who was not connected with the study and was not CBT‐trained, conducted an independent audit of 16 transcripts (12 clients). Her analysis produced themes that were complementary to the researcher's, encapsulating her impressions of the clients' comments as 'speaking about their feelings and problems' and 'what was happening in therapy'. The auditor and researcher subsequently discussed the data and the auditor was asked to comment freely on the clients' responses and the appropriateness of the researcher's treatment of the data, in terms of both organisation and decision making, and whether the researcher's themes reflected what clients were saying. The auditor considered the themes a realistic reflection of the transcripts and to broadly cover the clients' comments.</p> <hd id="AN0070470161-7">Results</hd> <p></p> <hd id="AN0070470161-8">Can people with mild intellectual disabilities understand and follow the instructions?</hd> <p>All 18 clients followed instructions to watch the video and tell the researcher when they saw something of interest. The number of places on the video that clients selected for comment ranged from 0–18 (see Table 2), but number is not an indication of the session's value – one client who made only two brief comments identified sections of the video that were emotionally potent. Length of comment varied from a few words to several pages, including some lengthy and informative post‐viewing comments. The one client who made no comment at all was reported to have understood what was required and enjoyed watching the video.</p> <p>2 Number of selections per review</p> <p> <ephtml> <table><thead valign="bottom"><tr><th><bold>Client</bold></th><th><bold>S4 no. of selections</bold></th><th><bold>S9 no. of selections</bold></th><th><bold>Made general comments at end of review</bold></th></tr></thead><tbody valign="top"><tr><td>A</td><td>5</td><td>6</td><td>S4 S9</td></tr><tr><td>B</td><td>7</td><td>1</td><td>S4 S9</td></tr><tr><td>C</td><td>3</td><td>0</td><td>S4 S9</td></tr><tr><td>D</td><td>0</td><td>0</td><td>S9</td></tr><tr><td>E</td><td>2</td><td>0</td><td>S9</td></tr><tr><td>F</td><td>15</td><td>11</td><td>S4</td></tr><tr><td>G</td><td>0</td><td>3</td><td>S4</td></tr><tr><td>H</td><td>0</td><td>0</td><td /></tr><tr><td>I</td><td>4</td><td>2</td><td /></tr><tr><td>J</td><td>4</td><td>5</td><td>S4 S9</td></tr><tr><td>K</td><td>5</td><td>3</td><td /></tr><tr><td>L</td><td>2</td><td>2</td><td>S4</td></tr><tr><td>M</td><td>18</td><td /><td /></tr><tr><td>N</td><td>4</td><td /><td /></tr><tr><td>O</td><td>0</td><td /><td>S4</td></tr><tr><td>P</td><td>3</td><td /><td>S4</td></tr><tr><td>Q</td><td>2</td><td /><td /></tr><tr><td>R</td><td>3</td><td /><td>S4</td></tr></tbody></table> </ephtml> </p> <ulist> <item>2 S4 = CBT session 4.</item> <item>3 S9 = CBT session 9.</item> <item>4 Clients M–R – S4 only.</item> <item>5 CBT, cognitive behavioural therapy.</item> </ulist> <p>Two clients became uncomfortable and upset when watching the video (e.g. discussion in video of difficult issues). However, neither wished to stop the reviews and both were able to continue after a pause. Researchers' notes on the sessions give details of interruptions and distractions encountered during reviews: emotional upset (pauses to allow client to settle when becoming upset), interruptions (e.g. client's mobile phone ringing) and technical difficulties with the video (e.g. poor sound). Although sessions had to accommodate clients' emotional responses and cope with distractions, these events do not appear to have been major impediments to carrying out the procedure.</p> <hd id="AN0070470161-9">Does the procedure yield information about the clients' perceptions of cognitive behavioural...</hd> <p></p> <p>• 1</p> <p></p> <ulist> <item> What is the nature of the information that can be obtained from clients?</item> <p></p> </ulist> <p>• 2</p> <p></p> <ulist> <item> Do common themes emerge?</item> </ulist> <hd id="AN0070470161-10">Nature of the information and common themes</hd> <p>Three broadly based themes encapsulate the clients' responses, giving an indication of how they were experiencing CBT: (<reflink idref="bib1" id="ref22">1</reflink>) how they felt about themselves; (<reflink idref="bib2" id="ref23">2</reflink>) how they felt the therapist was helping; and (<reflink idref="bib3" id="ref24">3</reflink>) the way in which therapy was helping. A fourth theme referred to clients' comments on issues not specifically related to the video. Table 3 shows the distribution of thematic responses across the group.</p> <p>3 Distribution of themes</p> <p> <ephtml> <table><thead valign="bottom"><tr><th><bold>Client</bold></th><th><bold>Self on video</bold></th><th><bold>Therapist on video</bold></th><th><bold>Therapy process</bold></th><th><bold>Current issues</bold></th></tr><tr><th><bold>S4</bold></th><th><bold>S9</bold></th><th><bold>S4</bold></th><th><bold>S9</bold></th><th><bold>S4</bold></th><th><bold>S9</bold></th><th><bold>S4</bold></th><th><bold>S9</bold></th></tr></thead><tbody valign="top"><tr><td>A</td><td>✓</td><td>✓</td><td>✓</td><td>✓</td><td /><td>✓</td><td /><td /></tr><tr><td>B</td><td>✓</td><td>✓</td><td>✓</td><td>✓</td><td /><td /><td>✓</td><td>✓</td></tr><tr><td>C</td><td>✓</td><td /><td>✓</td><td>✓</td><td /><td>✓</td><td>✓</td><td>✓</td></tr><tr><td>D</td><td /><td /><td /><td /><td /><td /><td /><td /></tr><tr><td>E</td><td>✓</td><td>✓</td><td /><td /><td /><td /><td /><td /></tr><tr><td>F</td><td>✓</td><td>✓</td><td>✓</td><td /><td>✓</td><td>✓</td><td>✓</td><td>✓</td></tr><tr><td>G</td><td>✓</td><td /><td /><td>✓</td><td /><td>✓</td><td>✓</td><td /></tr><tr><td>H</td><td /><td /><td /><td /><td /><td /><td /><td /></tr><tr><td>I</td><td /><td /><td>✓</td><td>✓</td><td>✓</td><td>✓</td><td>✓</td><td>✓</td></tr><tr><td>J</td><td /><td /><td>✓</td><td /><td /><td /><td>✓</td><td>✓</td></tr><tr><td>K</td><td>✓</td><td /><td>✓</td><td>✓</td><td>✓</td><td>✓</td><td>✓</td><td>✓</td></tr><tr><td>L</td><td>✓</td><td>✓</td><td /><td /><td /><td /><td /><td>✓</td></tr><tr><td>M</td><td>✓</td><td /><td>✓</td><td /><td>✓</td><td /><td /><td /></tr><tr><td>N</td><td /><td /><td /><td /><td /><td /><td>✓</td><td /></tr><tr><td>O</td><td>✓</td><td /><td>✓</td><td /><td /><td /><td /><td /></tr><tr><td>P</td><td /><td /><td /><td /><td /><td /><td>✓</td><td /></tr><tr><td>Q</td><td>✓</td><td /><td /><td /><td /><td /><td /><td /></tr><tr><td>R</td><td>✓</td><td /><td /><td /><td /><td /><td /><td /></tr></tbody></table> </ephtml> </p> <ulist> <item>6 Client A, B, C, etc. corresponds to clients in Table 2.</item> <item>7 S4 = CBT session 4.</item> <item>8 S9 = CBT session 9.</item> <item>9 Clients M–R – S4 only.</item> <item>10 CBT, cognitive behavioural therapy.</item> </ulist> <p>To preserve anonymity, information that might identify clients has been removed from their quotes. For the same reason, local accents are reported in standard English.</p> <hd id="AN0070470161-11">Theme A: Self on video</hd> <p>A number of participants expressed interest in how they appeared on the video and how they behaved and what they had said.</p> <p>I can't believe how much I fidgeted and moved around. It shows there must be something wrong.Well, I was watching the tape there and I was watching myself and em, I was all over the place. And we were trying to talk about something and you're trying to get it out and you're all over the place.It was me, with my arms going, moving my hand too much, never been on telly before.</p> <p>Others were pleasantly surprised by how they appeared, or found that the preconceptions they held about themselves were challenged.</p> <p>I actually felt like an adult in there, like a fully mature adult in there.Just thought it was nice to see the way I was talking to T.1Never heard myself say that before. Never done in my life. I've always hurt people and caused grief. I'm seeing a different me.When I was watching it I was thinking is there anything wrong with me or not. People say there is and I say there's not. But when you see that I don't know what to think.Found it upsetting because I looked angry. I moved around, tapping leg, moving hands, on edge as if wanted to just let go. C(arer) says I move my leg and and I'm going, I'm not but I am. I just didn't realise.</p> <hd id="AN0070470161-12">Theme B: Therapist on video</hd> <p>The participants also commented about the therapist. Some talked in general terms about how their therapist's approach was helpful, or just picked up on noteworthy actions.</p> <p>Funny T getting up and down all the time, I think that's hilarious.The way T's talking and helps you understand how you feel. That's good.I've never ever told anybody else. I wanted to talk about that. I feel really, really, really glad with T. It felt really good. I trust T.T was explaining how you could do things and make it calmer for me. And it's a good idea.</p> <p>Others commented on particular points made by the therapist, or tried to interpret what was going through the therapist's mind at a particular stage in the session.</p> <p>What T said about making appointments was interesting. Made the point that I would feel differently if T didn't show up for an appointment, if someone didn't show up to meet me.Like T turned and said you did all the hard work, I've listened to you and you've explained things to me, thing is you did it yourself, all the hard work.T's thinking well, you know, why do you do this? Why this, why does C(lient) have these moods? What's causing the moods? And once or twice I think T's looking a little bit frightened and a little bit apprehensive about whether I'm you know, going to take it out on T. Which I wouldn't. But I think T's thinking, what, what could I sort of, what could I offer C in a situation like this?</p> <hd id="AN0070470161-13">Theme C: Therapy process</hd> <p>A number of the participants' comments concerned the benefits of therapy and, in particular, how their relationship with the therapist had improved over time.</p> <p>I used to get nervous when T's talking to me. Cause I didn't really know what to say at first. Quite open now, but we used, I used to not be able to and I used to go, 'no, no'. I used to not be able to open up and speak to people.I like T's company. T's good to talk to and that's helpful. I come here to get a bit of help, see what happens.I enjoy the sessions with T, they're good. And I felt that T understands how I feel. More or less that I've got feelings.T went through all my anger and everything, wanted to know all what things upset me, what makes me cry. T took that away and breaking it down now into smaller separate, smaller something, you know what I mean. Trying to find out in depth what causes it. Basically T's helping me, I really am finding it's helping.</p> <p>Other participants talked more generally about improvements to their sense of well‐being, as a consequence of therapy.</p> <p>I feel more relaxed now and listen more. I've broken the chain, it had to be broken. I freed myself out of it.It's made a bit of a difference anyway. It's kind of helped me cope with life. Because before T, before I came here I'd actually nobody to talk to really.I find that T's working miracles, I really do. I feel hell of a, hell of a lot better now and touch wood, I haven't had a mood. So obviously something's working.</p> <hd id="AN0070470161-14">Theme D: Issues that currently concern client</hd> <p>This refers to a remark or topic on the video that prompted the client to tell the researcher about issues that were worrying or concerning him or her. Although initially prompted by the video recording, the client's comments go beyond the session to encompass their wider lives. Topics included family problems, difficulties keeping out of trouble, controlling anger, lack of control over life.</p> <p>My Dad's stressed with his job and comes home and upsets Mum, then I get upset and lash out.I got bullied at school and it still haunts me. I'd like to be more confident.</p> <p>In addition, a proportion of remarks were confirmatory – the client confirmed what was said on screen or what was happening, but did not elaborate, for example, 'yes, it was a Friday.'</p> <hd id="AN0070470161-15">What clients retain and find helpful</hd> <p>The responses are rich in information on the clients' point of view about what is happening in CBT. The main benefits they reported are:</p> <p></p> <p>• 1</p> <p></p> <ulist> <item> they can express themselves in sessions;</item> <p></p> </ulist> <p>• 2</p> <p></p> <ulist> <item> they can say how they are feeling;</item> <p></p> </ulist> <p>• 3</p> <p></p> <ulist> <item> they feel they are coping better with problems; and</item> <p></p> </ulist> <p>• 4</p> <p></p> <ulist> <item> they feel understood.</item> </ulist> <p>Review sessions also indicated what clients currently find upsetting and difficult in their lives.</p> <hd id="AN0070470161-16">Conclusions</hd> <p>The clients in this study were able to comply with the task and the nature of their comments on their therapy sessions suggests the video reviews do give insights into clients' perceptions of CBT.</p> <p>Some clients made more comments and were more forthcoming than others, but this is no different from other groups who have participated in video reviews conducted by [<reflink idref="bib7" id="ref25">7</reflink>]). As well as the clients' individual styles of expression, the clinical significance of the CBT sessions selected for review is unlikely to be uniform and there may be little or nothing in some sessions to catch the client's attention. In cases where comment was sparse, the researchers' notes suggest this was the reason rather than the client's misunderstanding of the task. We must also consider the possibility that in some cases the procedure failed to engage the client's interest, although most were reported to enjoy the experience. There are likely to be a number of factors that influence people's engagement in this process, including their level of ability as measured by their IQ score. However, we could discern no relationship at a descriptive level between IQ scores and participants' responses and it is possible that psychological and emotional factors would have a greater impact. In a future study it may be more meaningful to consider the influence of participants' communicative abilities when taking part in the video reviews. In general, the BRP seems to be a viable approach with these clients and is able to capture their interest and engagement and the independent auditor's remarks support this assertion. She observed that the participants managed to express themselves 'clearly, with sincerity and their own kind of wisdom despite limitations in their language skills', and 'how much the researcher gets from just sitting there and listening'.</p> <p>The approach proved amenable to audio recordings, as demonstrated by the blind client, who made comments in keeping with the rest of the group. Other than using a different medium, the reviews with this client required no adaptations from the usual procedure. Whether video or audio is more suitable will depend on the nature of the study, but there appears to be no barrier to using audio.</p> <p>Careful thought needs to be given to who will conduct the reviews. The research assistants in this study were working under the supervision of experienced clinical psychologists and researchers. The central role of the client–researcher relationship and the personal nature of the recordings require sensitivity and empathy. Although the review procedure is a means of gathering data, it is designed to tap into subjective feelings and experiences and those conducting the reviews need to have suitable experience and supervision.</p> <p>The focus of the study was on the feasibility of the procedure. However, the nature of the information obtained from the reviews does give a picture of how clients view CBT and the benefits they feel it gives. The comments from the three themes directly relating to the sessions had a different emphasis, yet each section contained comments indicating that the client felt valued and understood. This is important, as the relevance and effectiveness of talking therapies like CBT to people with IDs is still debated ([<reflink idref="bib20" id="ref26">20</reflink>]). It has been suggested that versions of CBT which emphasise psycho‐educational or behavioural components of treatment could be used with people who have IDs, to compensate for these clients' difficulties with communication and comprehension ([<reflink idref="bib23" id="ref27">23</reflink>]). Yet, the participants' emphasis on developing a therapeutic relationship and being listened to suggests that such didactic approaches may not be what they want.</p> <p>The four themes identified in this pilot study are not definitive, but they do offer a feasible picture of the information the BRP can potentially produce. The study used inductive data analysis in which the themes were driven by data that had been collected verbatim and stemmed from all the comments of all clients. The independent auditor also used an inductive approach, but made a broader analysis which complements but does not contradict the main analysis. In her subsequent appraisal of the main analysis, she considered the four themes gave a realistic picture of the clients' comments.</p> <p>Taking part in the reviews seems a helpful process in itself for participants and has possible therapeutic value. For example, the video review process might be helpful when a client has been difficult to engage in therapy. Perhaps by asking the client to view a session and make comments, therapists could uncover the barriers to engagement and provide insights into the client's views that have been absent during therapy? The method does seem to have good clinical potential, but transforming a research method into a clinical intervention would need careful development.</p> <p>Video recordings of therapy sessions are used widely by psychotherapists to evaluate the progress of clients and to study therapy processes ([<reflink idref="bib9" id="ref28">9</reflink>]) and there is some evidence that reviewing videos as an adjunct to therapy is beneficial. [<reflink idref="bib11" id="ref29">11</reflink>]) asked outpatients in his psychiatric clinic to watch videos of their therapy sessions at home, the majority of whom were reported to find it helpful to their treatment. [<reflink idref="bib1" id="ref30">1</reflink>]) found that getting patients to review videos of their psychotherapy helped them to gain a more realistic and insightful picture of themselves and [<reflink idref="bib22" id="ref31">22</reflink>]) employed video reviewing to assist in family therapy sessions. In Trierweiler <emph>et al</emph>.'s study, family members and their therapist independently reviewed a videotaped therapy session and made unprompted comments on events they found significant. None of these reviews followed the BRP's two‐step procedure, but it is interesting to note the reported benefits in gaining personal insights through retrospective video reviewing.</p> <p>As stated previously, this is a first study using this approach with people who have IDs, and the analyses must be regarded as a tentative first step. It would be interesting to investigate whether such themes were found in future research adopting the same procedure. One of the strengths of this study was that the analyses were carried out by a member of the research team who is a non‐clinician and does not practise CBT. Therefore, her grouping and interpretation of the participants' comments was less likely to have been influenced by a clinical awareness of CBT objectives.</p> <p>Data collection should yield similar data, regardless of the professional background and training of the researchers, provided they follow the review process correctly. However, it is possible that analysis of the data by trained CBT therapists would have yielded different themes – what would have caught their eye in the clients' transcripts and how would their CBT training have affected this? We can surmise that data analysis by different groups of researchers might produce different pictures, influenced by their background and training. Just as viewers will focus on events on the video that are pertinent to their individual experiences, researchers will also focus on points in the transcripts that are salient to their training, experience and expectations. This must be taken into account in further development of this research, but it is not an entirely negative proposition. It poses another interesting layer of research questions – what are the perceptions of different groups of people analysing the same set of clients' transcripts and how might this affect the implementation of findings?</p> <p>In terms of future research, it would also be interesting to have reviews of the same CBT sessions by both client and therapist. If therapists also reviewed the sessions under the same conditions, would it be possible to compare the elements of therapy they regarded as interesting and important and whether they shared similar views about the benefits of therapy?</p> <hd id="AN0070470161-17">Acknowledgements</hd> <p>The authors would like to thank the Chief Scientist's Office at the Scottish Executive for funding this research (CZH/4/181), Carol Pert, Biza Sternfert‐Kroese and Dave Dagnan for their comments and contributions to the manuscript, Mhairi Selkirk for her major role in the reviews and transcripts and Joyce Katsavras for auditing transcripts. Thanks are also due to the universities of Glasgow and Birmingham.</p> <hd id="AN0070470161-18">Appendices</hd> <p></p> <hd id="AN0070470161-19">Appendix 1</hd> <p>Instructions for researchers:</p> <p></p> <ulist> <item> 1 Explain to client that you are going to be showing them part of a video of a therapy session. Make sure that the client feels comfortable, offer them a cup of tea, etc. Ask if they have any questions about what you are going to be doing today.</item> <p></p> <item> 2 Put video on for five minutes. Researcher should busy themselves by adjusting cables etc. so that client can get used to seeing themselves on TV.</item> <p></p> <item> 3 Pause video. Tell client that you are going to put the video on again in a minute and that you would like them to point out when they see anything 'interesting' in the video. Tell the client that you want to find out what is interesting to them, as they are the expert and will be helping you out by letting you know what parts are interesting, and that there are no right or wrong answers. Explain that when the video has finished playing, you are going to go back over the video and talk about the bits that they thought were interesting. Tell the client that when they do see an interesting bit, they should let you know by tapping you on the arm/pressing the pause button/holding up a card (whichever suits the client best). Check understanding with the client, and ask if they have any questions.</item> <p></p> <item> 4 After the excerpt has finished, go back to the parts you have marked. Check with the client that you are at the right bit of the tape, and ask them what they thought was interesting about that particular bit.</item> <p></p> <item> 5 After you have gone through the video, ask the client if there is anything else they would like to talk about to do with the therapy session.</item> <p></p> <item> 6 Thank client for their help.</item> </ulist> <hd id="AN0070470161-20">1</hd> <p>'T' substituted for therapists' names in all examples and in all transcripts.</p> <ref id="AN0070470161-21"> <title> References </title> <blist> <bibl id="bib1" idref="ref22" type="bt">1</bibl> <bibtext> Alpert M. C. (1996) Videotaping psychotherapy. Journal of Psychotherapy Practice and Research 5, 93 – 105.</bibtext> </blist> <blist> <bibl id="bib2" idref="ref8" type="bt">2</bibl> <bibtext> Bakeman R. & Gottman J. M. (1986) Observing Interaction. An Introduction to Sequential Analysis. Cambridge University Press, Cambridge.</bibtext> </blist> <blist> <bibl id="bib3" idref="ref4" type="bt">3</bibl> <bibtext> Birdwhistell R. L. (1970) Kinesics and Context. Essays on Body‐Motion Communication. Penguin Books, Harmondsworth.</bibtext> </blist> <blist> <bibl id="bib4" idref="ref10" type="bt">4</bibl> <bibtext> Buck R. (1981) The evolution and development of emotion expression and communication. In: Developmental Social Psychology (eds S. S. Brehm, S. M. Kassin & F. X. Gibbons), pp. 127 – 51. Oxford University Press, New York.</bibtext> </blist> <blist> <bibl id="bib5" idref="ref2" type="bt">5</bibl> <bibtext> Burford B. 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(1975) Intersubjectivity and the transmission of culture. Bulletin of the British Psychological Society 28, 437 – 46.</bibtext> </blist> <blist> <bibtext> Oathamshaw S. C. & Haddock G. (2006) Do people with intellectual disabilities and psychosis have the cognitive skills required to undertake cognitive behavioural therapy? Journal of Applied Research in Intellectual Disabilities 19, 35 – 46.</bibtext> </blist> <blist> <bibtext> Polanyi M. (1966) The Tacit Dimension. University of Chicago Press, Chicago. With new foreword by A. Sen, 2009.</bibtext> </blist> <blist> <bibtext> Psychological Corporation (1997) The WAIS‐III and WMS‐III Technical Manual. The Psychological Corporation, San Antonio, TX.</bibtext> </blist> <blist> <bibtext> Schaffer H. R. (1977) Early interactive development. In: Studies in Mother‐Infant Interaction (ed. H. R. Schaffer), pp. 3 – 16. Academic Press, London.</bibtext> </blist> <blist> <bibtext> Taylor J. L., Lindsay W. R. & Willner P. 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  Data: Do Video Reviews of Therapy Sessions Help People with Mild Intellectual Disabilities Describe Their Perceptions of Cognitive Behaviour Therapy?
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  Data: <searchLink fieldCode="AR" term="%22Burford%2C+B%2E%22">Burford, B.</searchLink><br /><searchLink fieldCode="AR" term="%22Jahoda%2C+A%2E%22">Jahoda, A.</searchLink>
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  Data: <searchLink fieldCode="SO" term="%22Journal+of+Intellectual+Disability+Research%22"><i>Journal of Intellectual Disability Research</i></searchLink>. Feb 2012 56(2):179-190.
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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: 12
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  Data: 2012
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  Label: Document Type
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  Data: Journal Articles<br />Reports - Research
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  Label: Descriptors
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  Data: <searchLink fieldCode="DE" term="%22Video+Technology%22">Video Technology</searchLink><br /><searchLink fieldCode="DE" term="%22Mental+Retardation%22">Mental Retardation</searchLink><br /><searchLink fieldCode="DE" term="%22Therapy%22">Therapy</searchLink><br /><searchLink fieldCode="DE" term="%22Disabilities%22">Disabilities</searchLink><br /><searchLink fieldCode="DE" term="%22Cognitive+Restructuring%22">Cognitive Restructuring</searchLink><br /><searchLink fieldCode="DE" term="%22Perception%22">Perception</searchLink><br /><searchLink fieldCode="DE" term="%22Feedback+%28Response%29%22">Feedback (Response)</searchLink>
– Name: DOI
  Label: DOI
  Group: ID
  Data: 10.1111/j.1365-2788.2011.01450.x
– Name: ISSN
  Label: ISSN
  Group: ISSN
  Data: 0964-2633
– Name: Abstract
  Label: Abstract
  Group: Ab
  Data: Background: This study examined the potential of a retrospective video reviewing process [Burford Reviewing Process (BRP)] for enabling people with intellectual disabilities to describe their experiences of cognitive behaviour therapy (CBT). It is the first time that the BRP, described in this paper, has been used with people with intellectual disabilities and the aim was to assess the feasibility of the procedure and gain a picture of the information it might yield. Methods: Using the BRP, 12 clients reviewed tapes of their fourth and ninth CBT sessions and six reviewed the fourth session only. All reviews were audio recorded for later verbatim transcriptions of clients' comments. Reviews and transcriptions were conducted by non-clinical researchers. Thematic analysis was applied to the transcripts by a researcher who was not CBT-trained. Results: All clients were able to follow the instructions for the BRP. Three broadly based themes encapsulated their responses--how they felt about themselves, how they felt the therapist was helping and how CBT was helping. A fourth theme referred to comments on issues that were currently troubling clients, which were prompted by watching the video but did not refer to actual events on screen. Conclusions: The BRP seems a feasible approach with this client group and gave insights into their feelings and opinions on CBT. Clinical implications of the results and the potential for further developments are discussed.
– Name: AbstractInfo
  Label: Abstractor
  Group: Ab
  Data: As Provided
– Name: Ref
  Label: Number of References
  Group: RefInfo
  Data: 24
– Name: DateEntry
  Label: Entry Date
  Group: Date
  Data: 2012
– Name: AN
  Label: Accession Number
  Group: ID
  Data: EJ954164
PLink https://search.ebscohost.com/login.aspx?direct=true&site=eds-live&db=eric&AN=EJ954164
RecordInfo BibRecord:
  BibEntity:
    Identifiers:
      – Type: doi
        Value: 10.1111/j.1365-2788.2011.01450.x
    Languages:
      – Text: English
    PhysicalDescription:
      Pagination:
        PageCount: 12
        StartPage: 179
    Subjects:
      – SubjectFull: Video Technology
        Type: general
      – SubjectFull: Mental Retardation
        Type: general
      – SubjectFull: Therapy
        Type: general
      – SubjectFull: Disabilities
        Type: general
      – SubjectFull: Cognitive Restructuring
        Type: general
      – SubjectFull: Perception
        Type: general
      – SubjectFull: Feedback (Response)
        Type: general
    Titles:
      – TitleFull: Do Video Reviews of Therapy Sessions Help People with Mild Intellectual Disabilities Describe Their Perceptions of Cognitive Behaviour Therapy?
        Type: main
  BibRelationships:
    HasContributorRelationships:
      – PersonEntity:
          Name:
            NameFull: Burford, B.
      – PersonEntity:
          Name:
            NameFull: Jahoda, A.
    IsPartOfRelationships:
      – BibEntity:
          Dates:
            – D: 01
              M: 02
              Type: published
              Y: 2012
          Identifiers:
            – Type: issn-print
              Value: 0964-2633
          Numbering:
            – Type: volume
              Value: 56
            – Type: issue
              Value: 2
          Titles:
            – TitleFull: Journal of Intellectual Disability Research
              Type: main
ResultId 1