Disability psychotherapy: an innovative approach to trauma-informed care

Disability Psychotherapy provides important evidence-based theory and innovative practice for the field of psychotherapy with people with disabilities. The book begins with Frankish outlining her own life experience and how this has impacted upon her clinical practice. She grew up living on the site of a psychiatric hospital which her parents worked in, which sparked her interest in working with those who have intellectual disabilities. She observed that adults with learning disabilities have often experienced developmental trauma and was able to understand this through the lens of psychoanalysis. She went on to train as a clinical psychologist and now specialises in providing training, services and therapy for people with complex needs using the trauma-informed model she has developed. I initially assumed from the title of the book that it would explore the spectrum of disability. However, despite the book’s focus upon the specialism of intellectual disability, the wider focus on trauma-informed practice could be applied to a range of complex needs and difficulties. It perhaps highlights a need to continue exploring the challenges faced in adapting psychotherapy for the needs of individuals with physical disabilities and chronic illness. Besides potential practical adaptations, there is often a need to process the loss that can be felt as a result of impairment which could be explored using a trauma-informed model.

Disability Psychotherapy dedicates several chapters to psychological theories of emotional development. Frankish outlines the work of key psychoanalytic thinkers such as Bowlby, Winnicott, Bion and Mahler who draw from a range of theories including attachment, emotional development and containment. She adds depth to these theoretical ideas by combining them with her specialist knowledge and clinical experience. For instance, she explains Winnicott’s use of transitional objects and how this not only aids attachment in childhood but is also a useful strategy in managing distress in psychotherapy. She also applies Bion’s ideas of counter-transference to understanding the reactions of staff or carers who may find the impact of trauma too overwhelming. Bion (1962a) also coined the term ‘containment’ which refers to the capacity to manage projection of emotions by processing them consciously and unconsciously before passing them back in a more tolerable form. Containment can therefore aid individuals to feel emotionally supported and develop their own capacity to regulate their emotions.

I found it interesting to relate Frankish’s work with theories about emotional regulation and parental attunement. When an individual is in a state of heightened emotional arousal they can interpret neutral cues as being threatening or critical (Silver 2013). If this misinterpretation is coupled with emotional dysregulation, it hinders their ability to self-soothe when feeling distressed – meaning their state of arousal could remain high, thus perpetuating the situation. Emotional attunement within attachment relationships is important for learning to self-regulate emotions (Howe 2008). These theories are important in psychotherapy with individuals with intellectual disabilities as emotional dysregulation is a feature in pre-individualisation stages of emotional development and the emotional attunement between attachment figures can be adversely affected by trauma.

Margaret Mahler’s work on phases of emotional development provided inspiration for Frankish, who adapted these for use with individuals with intellectual disabilities. This work led to Frankish creating an observational tool for assessing which stage an individual is at based upon their behaviour, with the aim of developing corresponding interventions aimed at emotional and behavioural change. Drawing upon attachment theory, Frankish states ‘the essential ingredient throughout the stages from symbiotic to individualisation is the availability of a reliable and consistent significant other’ (38). However, this can become complicated for children with intellectual disabilities for several reasons: the emotional impact upon the parents on having a child with additional needs, the impact of likely separation due to respite care and hospitalisation, and the potential of reduced attachment-seeking behaviour from the child. Frankish details these reasons, the impact they can have and that without the appropriate input they potentially can result in the child becoming ‘stuck’ at an early stage of emotional development which runs the risk of them becoming ‘arrested’ there (39). However, if the behaviour can be understood within the context of emotional development, then it is possible to design an intervention which supports behavioural change and growth in maturity. There are several chapters explaining the need for comprehensive assessment and describing helpful tools including the ‘house-person-tree test’ (75) and ‘object-relations technique’ (83).

The latter chapters of Disability Psychotherapy are dedicated to implementing a trauma-informed model developed by Frankish by putting theory into practice. She states that ‘experience has shown that people with intellectual disabilities have frequently been traumatised several times, and their early trauma, pre-individuation has interfered with their ability to withstand later traumatic events’ (110). She describes the staff training she devised, including a programme called ‘All Behaviour has Meaning’ which examines ‘behaviour displayed by an individual from a behavioural, cognitive, psychodynamic and systems perspective’ (124). She acknowledges the need for trauma-informed care to start from safe and secure housing, mirroring the hierarchy of needs by Maslow (1968). Frankish’s work demonstrates how individual change can be achieved through disability psychotherapy but also how systemic change within services is possible through trauma-informed care with a focus upon therapeutic relationships. This makes sense on many levels, reinforcing the idea that ‘relational trauma requires relational repair’ (Treisman 2017, 138)

Rebecca Regler
Independent Scholar, Oxford, UK
[email protected]
© 2018 Rebecca Regler
https://doi.org/10.1080/09687599.2018.1471814