1. Core questions for CBT and people with learning disabilities. Professor Dave Dagnan Consultant Clinical Psychologist/Clinical Director Cumbria Partnership NHS Foundation Trust

2. Our Philosophy What are we trying to achieve? 1.Access to IAPT or therapy services for people with learning disabilities? 2.What is the right level of reasonable adjustment? -Too complex and it will be hard to maintain -Too minimal and it won’t help anyone

3. Presentation Aims 1.Describe our approach to identification and screening. 2.Describe our initial experience of outcome and training to support adaptation.

4. Numbers of People with a Learning Disability Cumbria population c 500,000 -2.5% population IQ below 70 = 12,500 Only about 20% of adults with learning disabilities are known to learning disability services (about 1750 people), therefore about 10,000 people in community with IQ below 70 not identified as having learning disability. - Presumably receiving services without any adaptation?

5. What does ‘learning disability’ predict for adapting IAPT services? Little prediction in adaptation needed by IQ 65-70, 70-75, 75-80. Can argue adaptations might be considered for those with IQ scores below 85 16% (1 in 6) population IQ (in Cumbria = 77,500) At least 1 in 6 of caseloads in the trust have IQs below 85…. Probably1 in 5 or above. National data also suggests about 16% (1 in 6) people are functionally illiterate and innumerate.

6. Screening tool

9. IAPT outcomes in first 2 years 1.Which people with learning disability used IAPT services? 2.What initial outcomes can we report?

10. Who used First Step services? Data from first two years of operation 27,064 people referred to First Step. 72 identified as people with learning disabilities (all from Trust database) 0. 27% of people referred to First Step were people with learning disabilities Compares to 0.47% prevalence of adults with learning disabilities in Cumbria according to GP data; At the stage of initial contact with First Step, many clients did not report their ethnicity or disability. Only three clients reported themselves to have a learning disability (we found 72!!).

11. Example of outcomes Single referral closed cases: IAPT therapy provided (n=14) Average 9.1 scheduled IAPT sessions (range 4-17) Attended 70.3% of their scheduled sessions IAPT therapy for 8 clients recorded as CBT, for 4 clients counselling, for 2 clients guided self-help Average PHQ9 scores for depression dropped from 17.2 to 11.2 Average GAD7 scores for anxiety dropped from 14.0 to 10.1

12. Outcomes summary People with learning disabilities do use IAPT services, although not fully proportionately to the general population Clients’ learning disabilities generally un-recognised in IAPT data systems (and services?) Patterns of referral sources and primary diagnoses similar to the general population Around half of people with learning disabilities referred into IAPT services do not go on to receive an IAPT service (failure to engage, disengagement, signposting elsewhere) IAPT services can be highly effective for people with learning disabilities

13. Delivering training for IAPT staff Outcomes and curriculum

14. Training Curriculum The training is structured in a modular format such that the training consisted of 4 or 8 modules depending on the duration of the training. 1. Introduction to intellectual disability, epidemiology and impact of literacy and numeracy difficulties in the general population. -2. Stigma and its impact on therapy relationships -3. Introduction to assessment of people with intellectual disabilities -4. Advanced assessment of people with intellectual disabilities -5. Overview of adaptation of therapeutic techniques -6. Specific examples of adaptation; thought diaries -7. Therapy approaches and formulation -8. Overview of local services and discussion of communication and support systems

15. Training for simple adjustments in IAPT Accessible communications for all -Easy read medication guided self-help Allowing extra time, techniques for reading/delivering MDS questionnaires Emphasising less cognitively demanding techniques Emphasising smaller set of techniques Enabling supporters in therapy

16. The therapy confidence scale (Dagnan, et al. The development of a measure of confidence in delivering therapy to people with intellectual disabilities. Clinical Psychology and Psychotherapy, in press)

17. Results Significant difference in confidence between HI and PWP. Significant increase in confidence for both groups maintained at 3 months PWP s

18. Conclusions

19. Conclusions: Key arguments for ensuring accessibility 1.A significant number of people who are not simply identified as having a learning disability will be helped 2.Helping a small number will impact on outcome

20. Conclusions: using screening to trigger adjustments 1.Using the screen to make sure those that can’t engage in high volume assessment are signposted 2.Identifying people who need adjusted pathways 3.Staff training and support to implement adjustments

21. Our Philosophy What are we trying to achieve? 1.Access to IAPT or therapy services for people with learning disabilities? 2.What is the right level of reasonable adjustment? -Too complex and it will be hard to maintain -Too minimal and it won’t help anyone