Best practice principles when working with individuals with intellectual disability and comorbid mental health concerns

Article in review: Man, J. & Kangas, M. (2020). Best practice principles when working with individuals with intellectual disability and comorbid mental health concerns. Qualitative Health Research, DOI: 10.1177/1049732319858226

Summary

This study considered how Australian psychologists utilised and adhered to evidence-based practices (EBP) when working with people with intellectual disabilities. Participating psychologists were found to be aware of clinical practices that were aligned with EBP. Despite the gap in the literature around EBP for this population client group, psychologists adopted a holistic and collaborative approach that was centred on the individuals’ perspectives needs and aspirations.

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Evidence-based practice

Psychologists are trained to deliver care in line with evidence-based practise (EBP) which can be defined as the “integration of best available research with clinical expertise” with client characteristics, culture and preferences. However, adherence to EBP is varied. Studies have found that adherence to EBP was found in only 16% of interventions, with 24% of treatments never or almost never adhering to EBP.
Individual culture and client factors can necessitate flexibility when it comes to working in EBP. For example, one study found that cultural adaptions are frequently (around two-thirds of the time) made when working with diverse populations experiencing depression.
People with intellectual disabilities are thought to be more likely to require mental health services than those without an intellectual disability. There is general consensus that adaptions to EBP are required for people who have an intellectual disability with comorbid mental health concerns. However, the changes to access and implementation that psychologists enact for these patients has not been widely studied.

Participants

A total of 38 practices Australian psychologists provided demographic information and participated in one of eight focus groups. Of the participants:
• 8 males, 30 females
• 20 worked in government disability organisations, 18 in nongovernment
• 66% undergraduate and 34% postgraduate qualifications
• 90% reported five or more years in the field
• 58% reported more than half of their caseload was patients with comorbidity

Themes

Analysis of the transcribed focus groups was assessed to identify the following four key themes and ten subthemes.

Assessment and formulation

• Assessment tools – Which related to environmental, systemic and medical influences that psychologists considered. In practice, this meant liaison with multiple stakeholders and considering many factors and underlying causes for presentation.
• Holistic approach and differential diagnosis – which covered the mainstream and specialised assessment and tools that psychologists used with people with intellectual disabilities, and the point that when specialist assessment resources were unavailable, psychologists tended to adapt mainstream resources.

A systemic approach to intellectual disability care

• Person-centred care – The ways in which psychologists took into account individual (idiosyncratic) factors when working with people with intellectual disabilities. Reasonable amendments were made in a majority of cases. Examples of EBP that psychologists may modify when working with a person with an intellectual disability included adaptations to communication style, changes to the assessment process, duration and environment.
• Collaboration – Psychologists reported commonly working with professionals from other services, disciplines, and the families of the client to deliver the best outcomes possible for the client. Barriers to collaboration with mainstream mental health services were also described.
• Psychoeducation – A need for training and psychoeducation was reported by the psychologists, to address what one described as a situation in which “disability staff don’t understand mental health and health service staff don’t understand disability.”

Clinical reflections

• Clinical experience – A number of participant psychologists mentioned the role of their own clinical experiences in guiding their work and decision making, referring to “a gut feeling”. This was used to compensate when there was a lack of evidence base to guide their work.
• Clinical role – A limited confidence in the mental health diagnosis of patients was expressed, and psychologists felt part of their role was providing psychiatrists with data to inform diagnosis.

Informing Clinical practice

• Legislation and professional guidelines – Participating psychologists described their practice as being informed by workplace guidelines as well as national legislation.
• Evidence-based practice – Psychologists described consulting and adapting research in the absence of specialist literature regarding working with people with intellectual disabilities.
• Professional development – Psychologists described the importance of ongoing informal and formal professional development as a key to delivering best practice.

Further opportunities

Many participants did not view their role as inclusive of mental health diagnosis while other research has also found that psychiatrists conversely report a lack of confidence in mental health assessment and diagnosis within the disability population. The complexity of comorbid presentations is cited as one reason for increased support and training between the involved fields.

Psychologists have been resourceful in compensating for limitations in relation to EBP. This study demonstrates that further investigation into how reasonable adjustments can be made in line with evidence-based best practices when working with people with intellectual disabilities. Continued exploration and improved access to relevant information will help.