Counselling an Adult with an Intellectual Impairment

Simone’s Employment Support Worker has arranged for her to receive counselling, with her consent, to assist her day and residential service provider to ascertain the cause of her recent behaviour change. Staff have observed that Simone is increasingly lethargic and withdrawn. An assessment by her GP eliminated any physical cause. The GP noted that while there was no evidence of depression, Simone seemed to be “troubled about something” and referred her to the Counsellor. Despite attempts from staff and Simone’s family to help Simone express her feelings and concerns, Simone continued to quietly deny that there were any problems.

Given that the purpose of the session was to assist Simone to identify her concerns so that her service-provider could then address the issues, no distinct therapeutic approach was used. The core conditions of counselling were applied, for example; empathy, unconditional positive regard, and respect for the client to foster a secure and comfortable counselling environment in which the client could safely explore and express her concerns.

The Counsellor utilised a visual language system to achieve the counselling goals. These communication systems are often used with people with intellectual impairments where their ability to understand pictures exceeds their ability to understand verbal expression. Various formal visual systems exist. The Counsellor chose to use Picture Communication Symbols (PCS) to represent the key questions.

For ease of writing, The Professional Counsellor is abbreviated to C.

Case Information

Simone is a 22 year-old female with a moderate intellectual impairment and spina bifida. She has a visual impairment so appropriate sizing of the PCS was essential. If the symbols were too small, Simone would not benefit from using them as visual prompts and in addition may become increasingly distressed by her inability to clearly identify the symbols. Given Simone’s reported resistance to expressing her concerns, it was important that C did not create conditions that would further increase her anxiety and therefore her unwillingness to disclose.

C visited Simone at her day service so as to conduct the session in a familiar environment in an effort to reduce Simone’s anxiety.

Session Details

The session was scheduled for 60 – 120 minutes. Given Simone’s recent lethargy, C and Employment Support Worker discussed, at the time of scheduling, the option of one 60-minute session and a subsequent 60-minute session, at a later date, if required. Alternatively the option of one two-hour session was also discussed in the event that Simone wished to “get everything off her chest in the one go” and provided that her energy levels allowed this.

Session Summary

Stage 1

Simone had received counselling previously and was aware of the counselling format and her rights as a client. C therefore started with open and simple questions to establish rapport and engender client trust; for example “Laura (the Employment Support Worker) tells me that you are a very good artist. Tell me about your art work”, and “Tell me what you like to do when you’re not working”.

Stage 2

Once Simone appeared to be comfortable with communicating with C, C asked Simone if she knew why Laura had arranged the appointment. Simone accurately indicated the reasons so C then proceeded to introduce Simone to the visual language system.

Stage 3

Each of the following symbols were presented and Simone was asked to identify each emotion.

Simone accurately identified each. C noted that Simone used the word “mad” rather than “angry” and so altered her terminology accordingly so as to work from Simone’s familiar language system.

Stage 4

C then drew a picture of a house and explained to Simone that “We are now going to look at your home (pointing to “house” picture). What makes you happy (pointing to “happy” symbol) at home (pointing again to the “house” picture).”

Simone immediately began identifying what she enjoyed about her home life so it was not necessary for C to use additional prompts or even personal examples such as “I feel happy at home when I’m playing with my dogs”.

Each emotion was progressively targeted in the same way. Simone struggled with identifying “sad” aspects so C prompted her with “See if you can tell me two things (holding up two fingers) that make you sad at home”. As Simone identified the first aspect C had one finger remaining to visually indicate that Simone needed to identify “one more”. Using this prompting process, Simone then proceeded to identify more than two aspects.

Stage 5

C then drew a picture to represent “work” and the process was repeated, with Simone progressively identifying the aspects of her work that elicited the various emotions.

Stage 6

The final stage of the emotion sorting process was to identify Simone’s feelings towards her life in general. C drew a picture to represent “general” with Simone responding to the following questions, “What makes you happy?”, “What makes you mad?”, “What makes you sad?” and “What makes you scared?”. This step was useful in not only identifying additional factors but also in reinforcing issues that were earlier identified.

Stage 7

Simone was asked if she had any additional feelings or thoughts that she wanted to share. She told C that she had “got everything off my chest” and that she felt “happy now”. Simone was required to return to work following the session so C facilitated her through deep breathing and visualisation techniques to clear her mind and restore her energy levels after a lengthy (2-hour) session.


Simone had consented to the release of a report to Laura. The report contained Simone’s responses and a number of subsequent recommendations. Included in these recommendations were the following-:

1. Development and rehearsal of a visual prompt card representing Simone’s “Helpful Hand” so that she can self-manage an appropriate response when something is troubling her. An example of the “Helpful Hand” is shown below:

The Helpful Hand is a laminated card that the client can carry with them at all times and provides direction as to who they can speak to with regards to various lifestyle issues. This also assists the person with an intellectual impairment to maximise their privacy as it directs them to the most suitable person/s to talk with about particular issues.

Each finger on the hand represents a different person that the client can talk to. Pictures, or text, can be used to represent what issues the client can talk to that person about, for example Simone may have “Mum and Dad” on the first finger followed by a symbol representing “anything”. Laura, her Employment Support Worker, may also be on the hand with the “work” symbol following her name. It is important to not put too much information on the hand or it may become confusing for the client and therefore ineffective. A simplified method would simply be to put a name on each finger as people the person can talk to about anything, without distinguishing between the types of issues. Professional persons such as “The Police” and “My Counsellor” can also be included in this way.

2. Implementation of the problem-identification and problem-solving sequence (also known as the “newspaper formula”) to assist Simone to effectively communicate her concerns.

  • Problem-Identification: This involves prompting Simone to sequentially answer each of the following prompts which will enable her to give a thorough explanation of her concern: When, Who, Where, What, and Why.
  • Problem-Solving: Once the issue has been identified the same method can be used for identifying solutions.

Verbal prompting may be sufficient however a visual language system (ie. pictorial representation) could be utilised to further enhance Simone’s understanding. An example is shown below however this could be modified to be more age appropriate.

Key Concepts Used

The goal of counselling in this instance was to simply identify the issues. No formal therapeutic model was therefore utilised as “treatment” of issues was not required. Should Simone’s service-provider pursue counselling to assist Simone to deal with the issues a Cognitive-Behavioural approach would be employed.

The emphasis of the counselling session was on the organisation and expression of the client’s feelings. Given the client’s reported reluctance to share this information with familiar others and the presence of an intellectual impairment, it was important to utilise a method that was easy for the client to understand, non-threatening, and provided concrete prompts to help her to categorise, and hence express, her feelings. The visual language system satisfied this criterion and effectively achieved the counselling goals.

Additional issues associated with providing effective counselling to people with disabilities, as highlighted in the case study, include

  1. The use of familiar language to assist understanding and encourage participative communication exchange (for example “mad” rather than “angry”);
  2. The use of concrete language systems to facilitate the client’s identification and expression of issues (in this case PCS);
  3. The accommodation of attention span and energy levels in scheduling the duration of sessions;
  4. The inability to use the Personality Needs Type Profile and other non-standardised assessments as a source of needs analysis and goal planning; and
  5. The benefits of counselling within a familiar environment to reduce client anxiety.