Psychodynamic Therapy and Intellectual Disabilities: Dealing with challenging behaviour

One of the most serious problems facing families and care staff concerns the treatment of extremely behaviourally disturbed individuals with an intellectual disability. Frequently these people are termed "dual-diagnosed" or with "challenging behaviour." The kinds of behaviour which present in this group can be broadly described as extremely aggressive either in their environment, to others (parents, staff, and other residents), to themselves (self-injurious behaviour which in its extreme forms are life threatening), or who are so withdrawn that living with others is unbearable. Treatment is often only possible in closed facilities and with special medication, as the prognosis for community living and social acceptance is extremely poor. In this article some theoretical material on a psychodynamic orientation concerning the diagnosis and treatment of mental illness in this group is presented. Four cases concerning long term treatment are then described--an extremely aggressive young man with a mild intellectual disability, a young man with multiple disabilities whose behaviour is destructive, a very withdrawn young woman with life threatening self-destructive behaviour, and a young autistic man with a broad spectrum of extremely uncontrollable behaviour. Finally, the success and limitations of the approach are discussed.