Creative Therapies and Intellectual Disability

There is wide agreement among writers on issues of intellectual disability that there isn’t much agreement on the effectiveness of counselling and psychotherapy with clients who have intellectual disability; the state of the art is “controversial” (Prout, Chard, Nowak-Drabik, & Johnson, 2000; Bhaumik, et al, 2011; WWILD, 2012). Prout et al cited historical reviews of Eysenck (1965) and Levitt (1971, both in Prout et al, 2000) which concluded that treatment with psychotherapy yielded no or minimal benefits when compared to untreated individuals.

Several years later, the meta-analysis of Smith and Glass (1977/1983) yielded the opposite conclusion, pointing to the general effectiveness of psychotherapy. None of these reviews, however, addressed the specific question of effectiveness with those who have intellectual disability. When such reviews began to be conducted, they consistently showed that psychological treatments were not effective, or at least that the question remained unresolved (Butz, Bowling, & Bliss, 2000; Matson, 1984; Prout & Strohmer, 1998).

The Butz, Bowling, & Bliss (2000) study, for example, noted that, despite the fact that there are now many people with intellectual disability living in communities, there has been a lack of scientific inquiry into the usefulness of outpatient psychological treatments. The following reasons for the lack of research are offered:

  1. Diagnostic overshadowing is believed to be occurring, causing the continuing perception among mental health professionals that having intellectual disability accounts for concomitant emotional symptomatology
  2. The mental health field maintains a long-standing assumption that those with intellectual disability are immune to mental illness
  3. Mental health professionals have viewed those with intellectual disability as lacking the ability to understand therapeutic concepts
  4. Funding agencies for mental health and intellectual disability have become dichotomised from regulatory agencies (Butz, et al, 2000).

Many studies have highlighted that the entire body of research literature on the topic of psychotherapeutic efficacy lacks empirical rigour, with studies often being qualitative and descriptive rather than experimental. Beyond that, a diagnosis of intellectual disability has routinely been used as a criterion of exclusion from any investigation. Thus, as Bhaumik et al point out, the current evidence base is “extremely limited” (2011, p 428), and a degree of inference is drawn from the interventions applicable to the general population with mental health problems. The authors argue that, while that inference-drawing may be acceptable for those with mild disability, it is correspondingly less so as the degree of ability (and concomitant communication skill) decreases.

Moreover, with a few exceptions, the investigations have been of poor quality because of inadequate numbers of participants, poor study design, lack of a control group, and/or differing outcome measures. Thus, few meaningful conclusions can be drawn (Bhaumik, et al, 2011). The much-cited study by Prout et al (2000) attempted a large systematic review of a wide range of studies examining the effectiveness of psychotherapy with people who have intellectual disability. They found that a meta-analysis was not possible because, due to the (low-calibre) nature of the studies, too many would have been eliminated, resulting in the analysis being done with only a small number of studies. Ultimately, the researchers were able to identify about 90 studies published between 1968 and 1998 which in some way described results of therapeutic interventions with subjects who had intellectual disability. The studies ranged widely from case studies to experimental designs with control groups. Each study was rated in terms of outcome and general effectiveness by a panel of experts in therapeutic interventions. Overall, the results indicated that psychological treatments with individuals who have intellectual disability yield moderate change and are moderately effective.

In a similar vein to the observations by the Bhaumik investigation, the expert panel on the Prout et al study reported generally having the impression that:

  • The literature is dominated by case studies and single-subject designs
  • Few traditional controlled-comparison studies or clinical trials have been undertaken
  • Interventions have tended to be described vaguely
  • Few of the studies used treatment manuals or protocols to guide the therapists in the treatment
  • Treatment integrity procedures to assess adherence were not often included, resulting in uncertainty as to whether interventions alleged to be from a given theoretical orientation actually followed theory-based strategies.
  • Outcome data were either vaguely described or omitted altogether
  • Conclusions often appeared to be based on weak data

Despite these significant limitations, the expert reviewers did generally feel that the body of literature supported the use of therapeutic interventions with people who have intellectual disability (Prout et al, 2000).

Given that an estimated 60 percent of persons who have intellectual disability also experience severe communication deficits (AIHW, 2008), the literature on counselling this client group consistently refers to the importance of using “creative approaches” (WWILD, 2012, p 60) which allow the client to respond in both verbal and nonverbal ways. In this article, we examine how two of these creative approaches – sand tray therapy and art therapy – can be used to support counselling clients with intellectual disability.

Sand tray therapy

How the therapy works

In the first half of the last century, British paediatrician and child psychiatrist Margaret Lowenfeld utilised sand and water in combination with small toys to help children express “the inexpressible” after reading H.G. Wells’ observation that his two sons would work out family problems playing on the floor with miniature figures (Zhou, 2009). Lowenfeld added miniatures to the shelves of her therapy rooms, and the first child who came to use them took the figurines over to the sandbox, playing with them there. Thus, it was a child who “invented” what Lowenfeld came to call “The World Technique” (Zhou, 2009). In the 1950s, Jungian analyst Dora Kalff (Zhou, 2009) extended the use of the sand tray to adults, realising that the technique allowed not only the expression of fears and anger in children, but also processes of transcendence and individuation (in adults) which she had been studying with Jung. She called it “sandplay” (Zhou, 2009).

Sandplay has been defined as a psychotherapeutic technique which invites clients to arrange miniature figures in a sandbox or sandtray to create a “sandworld” corresponding to various dimensions of their social reality (Dale & Wagner, 2003). It involves the use of one or two sandtrays and any number of small objects or figures from categories including: people, animals, buildings, vehicles, vegetation and other natural objects, and symbolic objects. Using sand and the miniatures gives clients a symbolic way of expressing their feelings and their worldview. Because it does not depend heavily on communicative proficiency, it can be used with a wide range of people with varying verbal and cognitive abilities. It provides a safe way to explore the unconscious, along with overwhelming feelings and life situations. Because it allows the deeper aspects of the psyche to be worked with naturally and in a non-threatening environment, it is highly effective in reducing the emotional causes of difficult behaviours. Sandplay thus helps to strengthen a client’s connection between the inner and outer worlds (Campbell, 2004; WWILD, 2012; Zhou, 2009).

It commonly consists of two central stages, the first involving the construction of the sand picture. Here the perceived need for the counselling session and the specific intentions of the therapist guide the instructions given to the client. Generally, the person is invited to create a sand picture using any of the therapist’s miniatures. While there can be many therapeutic orientations with varying means of interpreting what the client creates, the sandplay pictures are generally considered to be a projection of the child’s internal subjective world and a representation of his or her worldview (Dale & Wagner, 2003). Because they give the client the opportunity to express negative feelings and unconscious memories which impact on their choices, bringing these to consciousness can be the first stage of disempowering them and allowing their release (Campbell, 2004).

The second stage involves sharing a story or narrative about the created sand picture. Here clients can clarify personal meanings and integrate new feelings and insights that may have emerged through the creation of the sand picture. While the issue of whether or not to interpret the scene is strongly debated, many experts on sand play argue that the therapist’s role is to sit quietly beside the client while the picture is created, sketching what is created (or taking photographs) and making notes on any utterances the client makes while doing it. The proponents of this method claim that, in this way, the client is safe and free to explore his/her own meanings, leading naturally to the person’s inbuilt movement toward wholeness (Campbell, 2004; WWILD, 2012).

What the research says

Although sandplay is often presented as a robust assessment and treatment tool, there is little research to show with scientific rigour whether the approach is effective with the population in general, let alone with the much smaller group of those with intellectual disability (Zinni, 1997). Campbell (2004) reviews the use of the technique with various subpopulations, such as those with language and communication difficulties, attention deficits, the culturally different, or those who have experienced trauma. Because of its non-verbal nature, the sandplay process is likely to be useful with clients who have language and communication or cognitive deficits (clients with intellectual disability are probably most similar of those she described to this group). Campbell cites a study which demonstrated the ability of sandplay to improve concentration and peer relations in speech- and language-disordered clients (Carey, 1990, in Campbell, 2004). Those with attention deficits are said to be able to achieve greater kinaesthetic involvement with sand than with mere “talk therapy”, and so were shown to achieve a more concentrated focus, with the sand tray minimising distraction and promoting a focusing effect (Carey, 1990 and Vinturella & James, 1987: both in Campbell, 2004).

Abuse experiences are particularly tough for clients to acknowledge, let alone verbalise; thus, sandplay is seen to be highly appropriate for abused individuals, a population which includes most clients with intellectual disability. To them it offers a safe place to express through play and symbolic activity the complex emotions related to the abuse (Grubbs, 1994, in Campbell, 2004). One of the few studies conducted in this area used sandplay therapy as an assessment tool with 52 abused and non-abused children. The results showed significant differences in the sandtray constructions between the abused and the non-abused subjects. The differences centred on the content, theme, and approach, reflecting the emotional distress of the abuse (Zinni, 1997).

Because the fields of counselling and psychology consider evidence-based or empirically-supported therapies to be the “gold standard”, limitations on potential scientific research will continue to hamper the demonstration of effectiveness. Rather, it seems for the moment, clinicians using sandplay will have to be content with the wealth of case studies accumulating, which preclude (comparative) conclusions regarding technique effectiveness.

How to best use this therapy with clients who have intellectual disability

In selecting figures for the sandtray, clients normally can choose items to represent themselves. Where some of the client group with intellectual disability have stalled is in picking figurines to represent others in their lives. The problem, according to sandtray therapists, is the tendency of such clients to view things in a concrete, literal way. Therapists can help clients with disability compensate for this tendency by engaging them in conversations about some of the person’s more abstract qualities, such as whether the person is, say, affectionate and cuddly (the client could choose a teddy bear to represent them) or whether the person criticises and “growls” at them a lot (the client could choose a mean-looking dog). The therapist does not choose the object or ascribe their own associations to, say, a family member the client is trying to represent. Rather, the therapist supports the client to understand the person and the client’s relationship to them in less literal, more symbolic terms. When sandplay figurines take on symbolic meaning, the client is connecting to the unconscious, which supports emotional healing and personal development (WWILD, 2012).

Potential enhancements

As noted above, sandtray therapy works in well as an adjunct to many other therapies, although some strong proponents of sandtray therapy might prefer to think of the sandtray work as the main therapy and other approaches as the supplementary ones!

Art therapy

How the therapy works

Art therapy is the therapeutic use of art making, within a professional relationship, by people who experience illness, trauma, or life challenges. It is an established mental health profession and form of expressive therapy that combines traditional psychotherapeutic theories and techniques with an understanding of the psychological aspects of the creative process to enhance the physical, mental, and emotional wellbeing of people of all ages. Some expressive therapies involve the performing arts for expressive purposes, but art therapy generally utilises drawing, painting, sculpture, photography, and other forms of visual art expression. For this reason art therapists are trained to recognise the nonverbal symbols and metaphors that are communicated within the creative process: symbols and metaphors which might be difficult to express in words or in other modalities.

Most definitions of art therapy are said to fall into one of two chief categories. The first involves a belief in the natural healing power of art. This view embraces the idea that the process of making art is therapeutic; this process is sometimes referred to as art as therapy. Art making is seen as an opportunity to be imaginative, genuine, and spontaneous in one’s self-expression, an experience that, over time, can lead to the healing of emotional wounds, transformation, and personal fulfilment.

The second definition of art therapy is based on the notion that art is a means of symbolic communication. This approach, often referred to as art psychotherapy, focuses on the products – drawings, paintings, and other art expressions – as vital communications about issues, emotions, and conflicts. The art image becomes significant in enhancing verbal exchange between the client and the therapist and in achieving insight and growth in cognitive abilities; resolving conflicts; solving problems; and formulating new perceptions that in turn lead to positive changes, growth, and healing.

In practice, art as therapy and art psychotherapy are used together, as both the idea that art making can be a healing process and that art products communicate information relevant to therapy are important. Both help people to increase their capacity to cope with challenges, stress, and traumatic experiences. Art therapists employ this therapy with a wide range of populations in many clinical settings. It can be found in non-clinical settings as well, such as in art studios and workshops that focus on creativity development. Individuals of all ages, couples, families, groups, and communities have benefitted from art therapy services (International Art Therapy Organisation, 2010; WWILD, 2012).

What the research says

There is a growing body of research showing art therapy to be an efficacious intervention capable of expanding the psychotherapeutic possibilities for client groups who are less able to engage with typical talk therapies. Some of the outcomes show that art therapy enables a connection to and processing of feeling states which reach beyond verbal communication. Dr Andrea Gilroy (2007) offers a comprehensive review of all significant research into the efficacy of art therapy. Here is a partial list from her work summarising study outcomes on the client populations most relevant to those with intellectual disability.

Art therapy and intellectual disabilities/learning difficulties

Long-term group and individual studies are shown to improve behaviour difficulties and decrease feelings of helplessness with these client groups. Some research has shown an improved capacity for symbol formation and ability to complete developmental tasks (Fox, 1998; Kuczaj, 1998; Mackenzie, 2000; Stack, 1998; Reese, 1995: in Gilroy, 2007).

Art therapy and abuse and trauma

Some short-term group and individual art therapy studies with abused and traumatised clients have shown a decrease in anxiety, depression, and symptoms of PTSD and improvements in self-esteem (Brooke, 1995; McClelland, 1993; Morgan & Johnson, 1995; Schaverien, 1992 and 1998: in Gilroy, 2007).

Art therapy and addictions

More tolerated by this client group than verbal approaches, art therapy studies with addicts have shown it to be effective in helping clients acknowledge their addictions, facilitate change, and reduce isolation (Dickman, 1996; Francis, 2003; Springham, 1999: in Gilroy, 2007).

Art therapy and depression

Participants in group art therapy showed increased self-esteem and improved relationships (Ponteri, 2001, in Gilroy, 2007), which decreases depression.

Art therapy and personality disorders

Studies of this group showed that highly charged emotional experiences can lose some of their charge through exposure to art therapy, thereby reducing destructive tendencies (Dudley, 2004; Greenwood, 2000; Spring, 2001).

Art therapy and psychotic disorders

Outcome studies demonstrate increased ability to enter and maintain relationships, think symbolically, and develop mature defences. There has been a concomitant reduced need to attend mental health services. Art therapy engages clients in psychological interventions (Killick, 1991, 1995, 1997, 2000; Saotome, 1998; Wood, 1997 and 1999: in Gilroy, 2007).

How to best use this therapy with clients who have intellectual disability

Art therapy for clients with intellectual disability has been evolving over the last quarter century. When therapists started using it with this client group, they tended to focus on the therapeutic value of making art (the first category of art therapy definition, above), but it is now used as a direct therapy to understand emotions, relationships, and the client’s interpretation of their experiences (the second definition, above). It can help make abstract concepts more concrete through the use of pictures. For those with poor verbal ability or communication deficits, it provides a useful, less threatening form of therapy, allowing – as does narrative therapy – the externalisation of problems, feelings, and emotions. This permits both client and therapist to examine and gain insight into the experience the client is having (WWILD, 2012).

Potential enhancements

As with sand tray therapy, some might declare that art therapy is the enhancement: no others need apply. Certainly, it works in well with therapies which are more verbally-oriented, such as narrative therapy or traditional psychotherapy.

© 2014 Mental Health Academy

This article was adapted from Mental Health Academy’s “Counselling Clients with Intellectual Disability: A Look at What Works” CPD course. This course is part of the MHA’s Fostering Ability series. The purpose of the series generally is to build your capacity as a mental health professional to provide high-quality support to this group of people whose needs have been largely misunderstood and under-recognised. The specific aim of this course is to examine which approaches and ways of working may be more fruitful with clients who have intellectual disability.


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