Ben Webster * was not happy. The 21-year-old, who has a global learning disability, was already ‘hyper vigilant’, in part because he had been assaulted, and he had a history of panic attacks. But latterly, an incident with a security guard at a supermarket had left him feeling he looked ‘suspicious’. As a result, he was becoming increasingly reluctant to leave the house or stay away from home for any length of time.
Webster, who lives in Greenwich, southeast London, had attended a specialist unit in a local mainstream secondary school. But now he was unemployed and spent most of his time unoccupied at the home he shares with his parents and two younger brothers. As well as having problems with reading, writing and fine motor skills, he also displays symptoms of social anxiety – a diagnosis which, in many other parts of the UK, might have proved problematic.
With Webster’s mental health declining, it was clear something needed to be done. It was at this point he was referred to the TLC service, a therapeutic service for Greenwich residents with learning disabilities provided by Oxleas NHS Foundation Trust.
Research shows that mental health problems are more prevalent among people with learning disabilities than in the general population, yet many mainstream services are not geared up to offer them accessible, tailor-made treatment programmes.
A little TLC
Launched in July 2013, the TLC service had received more than 50 referrals by the end of last year. Webster is one of the early success stories, according to team leader Dr Kate Chatters.
Dr Chatters, a clinical psychologist by background, combines her TLC post with another part-time post in the local community learning disability team (CLDT). Though there are good links with other local learning disability and mental health services, she stresses that TLC operates on a stand-alone basis. “I think we are the only team in the country set up this way for people with learning disabilities,” she says.
The name of the service was chosen by service users, adds Dr Chatters. “The initials stand for Talking therapies for people with Learning disabilities and their Carers. We think of ourselves as ‘pathfinders’ and operate under the umbrella of the national Improving Access to Psychological Therapies (IAPT) programme.
“We are a primary care-level, short-term, time-limited service offering therapeutic interventions predominately for people with anxiety or depression – at the ‘mild to moderate’ end of the spectrum.
“We have had very few self-referrals; most come from the mainstream ‘time to talk’ IAPT or CLDT services. We also take referrals from day services and supported living homes.”
Though some service users are seen alone, TLC team members are keen to involve carers in the programmes they devise. This approach is in line with the quality standards on anxiety disorders issued last year by the National Institute for Health and Care Excellence. These ‘recognise’ the important role families and carers have in supporting people with anxiety disorders.
They state: “If appropriate, health, public health and social care professionals should ensure that family members and carers are involved in the decision-making process about assessment, treatment and care.” Indeed, Webster’s mother accompanied her son to every TLC session, the first 10 of which were held weekly before moving to a fortnightly pattern.
Webster’s treatment plan was based on a cognitive behavioural therapy (CBT) approach in which, among other things, clients are given tasks designed to boost their feelings of competence and wellbeing. Key aspects of his plan included:
■ Psycho-education on social anxiety and panic
■ Graded exposure
■ Relaxation techniques
■ Activity scheduling
■ Signposting to Remploy employment support.
Initially, Webster was encouraged to gain confidence by going out locally on an independent basis. A hierarchy was devised that set him gradually more challenging tasks. From first going to the town centre, Webster was encouraged to visit a cinema, then a shopping mall and a football match. The final steps – successfully completed – were to use a train and go into central London.
The team adapted available resources, such as introducing a stress ball to aid progressive muscle relaxation and using a computer to help build an activity diary.
Webster was also given a ‘visual activity thermometer’. This portrayed a worried looking face on a bright red background at the top of the scale (a number 10) accompanied by the word ‘stop!’ in capitals on the right-hand side. As the numbers on the left-hand side of the thermometer fell, the prompts changed to ‘calm down’, ‘relax’ and ‘think about what you really want/something good’.
Finally, at the bottom of the scale a smiling face was accompanied by a number one and a reminder to ‘make yourself happy’. A scrapbook allowed Webster to keep a record of the goals he achieved, and he also received pictures of the activities set by the team.
His progress was regularly assessed using a patient health questionnaire, known as PHQ9, and a generalised anxiety disorder assessment – GAD7. The ratings fell in tandem from being in the low 20s at the onset to below 10 after the 17 sessions were completed.
Dr Chatters explains that Webster now spends more time with his family, helping with household tasks and taking his dogs for walks. He goes out every day and uses relaxation and breathing techniques if he feels anxious – rather than simply leaving the situation as he would have done before treatment.
“He was invited to several interviews and went on a work trial,” says Dr Chatters. “He now has a part-time job at the supermarket that he used to avoid. He also feels more confident in public spaces.
“There is some limited evidence for using the CBT approach with people with learning disabilities, but we have developed a lot of our own resources through innovation and trial and error.
“Half our team has a community learning disability team background and half an IAPT one.” Dr Chatters’ colleagues are: clinical psychologist, Dr Rachel Blundell; psychological wellbeing practitioner, Aysem Mehmet – who was Webster’s therapist – and assistant psychologist Wendy O’Neill.
“We have had some really interesting conversations around melding those two approaches together and finding out what works for this population,” Dr Chatters adds.
* Name has been changed to protect identity
For more information on IAPT visit: www.iapt.nhs.uk
About the author Ian A McMillan is a freelance journal