The experiences of therapists providing psychological treatment for adults with depression and intellectual disabilities as part of a randomised controlled trial

Background: Health professionals were trained to deliver adapted psychological interventions for depression to people with learning disabilities and depression alongside a supporter. Exploring the delivery of psychological interventions can help increase access to therapy. Method: Twenty- seven participants took part in six focus groups, and the data were subject to a Framework Analysis. Results: The structure and focus of the manualised therapies, and the use of specific techniques were perceived as key to service- user engagement. Supporters' involvement was valued by therapists if they had a good relationship and regular contact with the individual they supported. Regular clinical supervision was regarded as vital in understanding their role, assessing progress and delivering the interventions. Conclusions: The findings highlight that health professionals can embrace a focussed therapeutic role and increase access to psychological therapies for people with intellectual disabilities.


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deficits and particular life circumstances of people with learning disabilities (Irvine & Beail, 2017). Guidance regarding best practice in working with people with intellectual disabilities and mental health problems was recently issued in England (National Institute for Clinical Excellence, 2016). However, the lack of trained therapists with the confidence to deliver psychological therapies for problems like depression has proved to be another barrier to treatment for people with intellectual disabilities (Beail, 2016).
Behavioural activation has been found to be as effective as CBT in the treatment of depression in the general population (Richards et al., 2016). Jahoda et al. (2015) conducted a feasibility study of an adapted version of behavioural activation for people with intellectual disabilities, with encouraging results. Behavioural activation focusses on promoting engagement in purposeful activity through exposure to positive environmental contingencies, which is linked with positive behavioural and emotional change.
The manualised approach developed in the feasibility study was subsequently evaluated in a large-scale randomised control trial (Jahoda, Hastings, et al., 2017), comparing the adapted version of behavioural activation (BeatIt) with an active control of Guided Self-Help (StepUp). Guided self-help is also known to be an effective treatment for depression in the general population Cuijpers et al. (2010), and it was chosen as an active control in the trial because it was thought that this psycho-educational approach has a different set of therapeutic ingredients from behavioural activation. It was found that the interventions could be delivered safely, with excellent fidelity (Jahoda, Hastings, et al., 2017). The therapists were also highly rated for the sensitivity they showed and the rapport they built with the individuals they worked with. Both interventions were associated with positive change at 12-month follow-up. The trial included nested qualitative studies concerning views and experiences of the participants with intellectual disabilities , their supporters , therapists and supervisors. This study concerns the therapists' experiences of delivering the BeatIt and StepUp interventions as part of the trial. To increase access to psychological therapies, a range of health professionals working with people who have learning disabilities were trained to deliver the therapies, rather than relying on a narrower group of specialist psychological therapists.
Previous research has suggested that social care staff can be successfully trained to deliver a CBT intervention for depression (McGillivray et al., 2008). Stimpson et al. (2013), explored the experience of day service staff, trained to deliver a group anger management intervention for people with intellectual disabilities, as part of a large-scale cluster randomised control trial. While the staff said they were initially anxious about having the necessary skills to be therapists, they were positive about the focussed nature of the manualised approach and developing new ways of working. While they found the exercises or therapeutic techniques in the manual were engaging for the group participants, some also felt constrained by the manual. Interestingly though, they described themselves as being like a group leader or facilitator, rather than as a therapist.
They placed value on the opportunity to develop more positive relationships with the group members.
A Framework Analysis approach (Ritchie & Spencer, 1994) was used to analyse the therapists' views of delivering the interventions; this is a more structured form of qualitative analysis, which allows for the a priori development of a framework to organise key aspects of the data which are of interest. In this study, there was a focus on the therapists' perceptions of the process of change, therapeutic relationships and barriers and facilitators to change. Therapists' views on training and supervision were also explored, and how they thought the therapies could be adapted to address different service users' needs.

| Participants
All therapists who had worked with at least one participant during the course of the trial were invited to take part in a focus group.

| The interventions and context
BeatIt (12 sessions) and StepUp (8 sessions BeatIt is a behavioural activation intervention that aims to increase the person's purposeful or meaningful activity in order to improve their mood. A formulation is developed in the first assessment and socialisation phase of therapy. The second phase of therapy involves activity scheduling and tackling barriers to change. An updated formulation booklet is shared at the end of therapy, with guidance about maintaining or building on any progress which has been made.
StepUp is a guided self-help programme aimed at teaching people about depression and ways of helping themselves to feel better. The intervention is structured round four bespoke psycho-educational booklets, dealing with the nature of depression, sleep hygiene, physical exercise and problem solving.
Individuals were recruited if their presentation had a significant depressive component, and they were subsequently screened to establish whether they were clinically depressed, using the DC-LD (Cooper et al., 2003

| Design and procedure
One focus group for each therapy was held in the three regions where the study was conducted (Scotland, England, Wales), with six focus groups in total. The groups were facilitated by two researchers using a semi-structured topic guide and lasted for 60-90 min. Data were audio-recorded and then transcribed verbatim. Written consent was obtained from all participants.

| Data analysis
Using a Framework Analysis approach (Ritchie & Spencer, 1994), transcripts were analysed by three researchers who had expertise in qualitative research (Smith, Huws, and Jahoda). The analysis entailed a series of five interconnected stages of iteratively moving back and forth across the transcripts: stages 1-4 focussed on data management, and the development and refinement of a coding framework.

| RE SULTS
The final framework matrix identified five themes: (1) adapting to the role of a BeatIt/StepUp therapist, (2) delivery of therapy, (3) a future focus, (4) practical challenges and improvement and (5) working with a supporter.
In the quotes shown below, the acronyms BIT and SUT refer to BeatIt and StepUp therapists, respectively, followed by the number given to each person.

| Theme 1. Adapting to the role of a BeatIt or StepUp therapist
3.1.1 | Sub-theme 1.1: Becoming the therapist While some participants with prior experience of delivering psychological therapies felt that taking on the role of 'therapist' was consistent with their previous experience and training, others indicated that they were initially anxious about delivering therapy. In particular, nurses who were BeatIt and StepUp therapists described initial conflicts of expectation in having to engage in work that focussed solely on therapy rather than implementing the range of holistic care usually associated with nursing: I thought it felt a bit surreal, you know, prioritising priorities, you were just there for the one piece of work, it was just so unique (SUT1) Although such preliminary role conflicts were frustrating for some of the nurses, there were also positive aspects associated with having a clearly structured therapy focus to their work: The structure was good to have (…) to not only guide but restrict as well 'cos half the time I would be sitting there going 'oh this is a problem, I'll make a referral to this, I'm not doing it. I'm not a nurse I'm a therapist' and so it was nice to have a very defined role to be within, and a goal that was also quite clear.

| Sub-theme 1.2: Supervision
The therapists highlighted that practice and experience of delivering the interventions was key to developing mastery of the therapeutic approaches: The more you did it the more … it got easier …more flexible … more client focused, it just became quite natural as a process.

(BIT 6)
However, some concerns were expressed by both sets of therapists about lack of flexibility, and repetition was a particular concern raised by some BeatIt therapists. These factors were regarded as barriers to person-centred tailoring of the interventions to individual needs: I thought it was all useful, but I preferred it (manual) as a use it or leave it option, whereas it was prescriptive, and like you said before, I also felt that certain and it always took the same format and we didn't deviate from that so once you got into that after a couple of weeks you got used to the format of it yourself.
You'd relax into it but I also think the client did as well because they started to know exactly what to expect each week even though the topic changed, and I think that was really helpful.

(SUT6)
The structure and predictability were also seen as helping to clarify roles and ensured that the person, the supporter, and the therapist all developed a sense of ownership and control of the therapy process: It provided a sense or predictability for the person for…whoever the supporter was and very early on we were able to identify what our roles were and I … encourage them to take ownership of it and control.
(BIT 1) Having a set number of sessions meant that therapists "kept on track" (SUT6; SUT7) and knew when to end treatment. This was seen as facilitating rather than constraining therapy, ensuring sessions stayed on topic, within time, and that focus was maintained across sessions: It was an eight-session block… and after that it would stop. So I think that was just as important…to focus them… that if you're going to get something out of it you need to really concentrate and be a part of it as well.

(SUT8)
Therapists who had worked with larger numbers of participants felt that their familiarity with the materials helped them to bring the manualised interventions to life for the individuals they engaged with: From the therapy's point of view though, the more you did it the more, I mean if it was rolling on and we were on our sixth client, it got easier and easier and easier, it got far more flexible, it got more client focused, it just became quite natural as a process and enthusiasm and looking at everything else just pops into your head as you mature in it… (BIT3) As the therapists became more aware of their improved competencies in delivering the interventions, the more heightened their confidence became.

| Sub-theme 2.2: Materials and relationships
There were specific criticisms of particular materials and exercises.
For example, some individuals were said to have struggled to engage with BeatIt self-report diaries and others had found materials to be in his attitude'.

(SUT6)
StepUp was seen as providing knowledge and information that people could also use in the future: "It's tools for the future; that's what it's there for, not just those eight weeks".

(SUT8)
It was suggested that the booklets could be used 'proactively' to help people stay emotionally well and to promote people's emotional wellbeing. This appeared to be borne out of the observation that not all of the booklets were relevant to clients' specific difficulties, and there was a value to covering issues like 'A good night's sleep' nonetheless.

(SUT8)
The amount of time a supporter had to give might also be beyond their control, …that person -she basically only had two hours support and that time had to be filled with shopping and things like that; (BIT2) The difficulty of scheduling activities for people who apparently led quite active lives was also raised by some therapists. However, a counterpoint was that some of those who had relatively busy schedules had lost interest in their activities, seemingly because they gained little sense of fulfilment from them: of the sessions, she said that the problem was with the day services and he was getting bored there… The StepUp therapists highlighted that suggested activities in the booklets needed to be affordable, and accessible for people with physical disabilities. When looking at problem solving, it was considered important that people's goals were achievable and realistic, and there was concern about the potential to 'set up people Therapists preferred supporters who knew the person well, and spent time with them daily, rather than someone who was supporting them for the purpose of therapy alone. The best supporter was viewed as someone who was available to facilitate activities 'outside of hours', and commitment and continuity were identified as being important for successful interventions: It adds complications when the one who was supporting the person had to then pass it onto another organisation to then follow through what homework we'd set. (BIT8) Therapists also felt it was important for supporters who worked in services to share session content with their colleagues.

| Sub-theme 5.2: Challenging aspects
In contrast, supporter negativity could impact upon the person's engagement. For example, one BeatIt therapist reported that: You could tell from the offset that the support worker thought that it was not any use at all. "Why are we here? Why have we got to do that?" And I think my client picked up on that, didn't engage, didn't do any of the homework that he was supposed to do.
In some instances, therapists felt that the presence of the supporter impeded and restricted the therapeutic relationship and communication. This was influenced by the nature of the relationship with the supporter. For example: There was one boy who was 17 or 18 and we were doing things on relationships and his mum was sitting there and… he was embarrassed and didn't want to speak in front of his mum.
This therapist went onto suggest that one way to allow people to address topics in confidence with the therapist would be set aside part of the session to talk with the therapist on their own, without the supporter.
There were occasions when the supporter changed midprogramme and did not know what the therapy was about: "when you were turning up and the supporter didn't know who you were and what this was meant to be, that's what caused the problems".
Therapists felt that supporters in the StepUp intervention would have benefitted from an initial session to explain the nature of the therapy and their role in the process. Therapists delivering both interventions found that some supporters were unaware, at the outset, of the level of commitment that was required of them: My supporters weren't aware that they would be required to give support outside [of the sessions]. (BIT9)

| DISCUSS ION
The therapists in this study were health professionals and most had previous experience of working therapeutically with people who SMITH eT al.
have intellectual disabilities. Therefore, they had to make a different adjustment from lay therapists in previous research, who had no prior therapeutic experience (Stimpson et al., 2013). The main challenge was adopting the role of a psychological therapist. In particular, the community learning disability nurses reported having initial difficulties engaging in a more focussed and time-limited piece of therapeutic work with individuals. This was at variance with the more holistic approach they would usually take. While concerns were expressed about the more restricted manualised approaches, the therapists generally embraced their new role. They felt that the clear, repeated structure made the therapies more accessible and predictable, and helped service users engage more fully in sessions.
Supervision was also thought to help the therapists adjust to this new way of working and resolve specific difficulties with individual cases. Supervision is known to be important in facilitating the consistent delivery of effective therapy after brief training (Smith, 2011).
There were criticisms of the tasks and materials used with both BeatIt and StepUp, in terms of either being too complex or childlike. However, experience of delivering the therapies and familiarity with the manuals and materials gave the therapists confidence to adapt interventions to individual needs and circumstances. Overall, the tasks and materials were greatly valued, viewed as intrinsically vital to therapy and as a means of encouraging people to talk about themselves and their feelings in a ways that could quickly produce a strong therapeutic alliance.
The involvement of the supporter in sessions when they were positive about the therapy was seen as key to applying what was learned in the therapy sessions to everyday life. The potential importance of involving significant others in therapy sessions is consistent with findings of previous research concerning the delivery of psychological therapies to people with intellectual disabilities (Rose et al., 2005). However, it was also recognised that there were times when it would be beneficial for the person with intellectual disability to speak with the therapist alone. A confiding relationship might allow the person to raise issues they are unable to talk about with family, friends or workers (Pert et al., 2013).
The therapists were aware that the outcomes of BeatIt and StepUp were not confined to what happened in the sessions. When delivering therapies that promote behavioural and lifestyle change, other practical issues, such as money and practical and emotional support may play a vital part. Dagnan (2007) has argued that it is mistaken to view psychological therapies and their impact in a vacuum. One of the key differences between the two therapies was meant to be that StepUp did not have homework tasks. However, therapists in the StepUp focus groups admitted that they had followed-up with on planned life changes made in sessions. In essence, this resulted in greater overlap between the two therapeutic approaches than was intended.
The specific and non-specific components of therapy are

| Clinical implications and future research
The views and experiences of the therapists in this study support the wider trial findings (Jahoda, Hastings, et al., 2017) that it is possible to train and support a range of health professionals to deliver psychological therapies to people with intellectual disabilities and depression. This approach has the potential to increase access to psychological therapies for people with intellectual disabilities. However, the therapists' experiences highlight the need for regular supervision and support to adapt to the role of therapist delivering a psychological intervention. The role of psychological therapist delivering focussed interventions was seen as quite distinct from their usual roles as Community Nurses or Occupational Therapists. It was clear that without this support and guidance many would not have followed the manuals properly.
One of the reasons for this is people usually come to therapy with a more than one particular emotional problem or life difficulty. As Community Nurses or Occupational Therapists, they quite understandably wished to take a more holistic approach. Hence, to embed interventions like BeatIt and StepUp in services for people with intellectual disabilities require more than simply training SMITH eT al.
and supervising therapists. There also has to be a broader commitment by the service to providing therapeutic help for people with intellectual disabilities and depression. Otherwise, people's depressive symptoms may continue to be overshadowed by other difficulties, resulting in a lack of referrals and a loss of confidence in the interventions.
It may be surprising to suggest that thought and effort needs to be given to providing therapeutic help for such a commonly occurring emotional problem as depression. However, the therapists from the Increasing Access to Psychological Therapy (IAPT) services, who are meant to serve the whole population in England, were uncertain that BeatIt could be delivered as part of their routine practice, due to practical constraints they worked under. This highlights the need for mainstream services to be willing to adapt their practices in order to more truly meet the needs of the general population, including those with intellectual disabilities (Chinn & Abraham, 2016).
In addition to the need for research about the implementation of these therapies in routine practice, there may be value in further work trying to obtain more detailed insight into therapists' experiences with delivering the specific therapies, as there are distinct differences between BeatIt and StepUp. Aspects of the manuals have already been clarified and additional information added, based on the observations and insights of the therapists delivering the interventions (Jahoda et al., 2018). However, it remains uncertain whether this would help to determine which therapy would be most suitable for whom. This could be a matter of preference for the individuals with intellectual disability, just as some potential therapists may have a more affinity with BeatIt or StepUp, as a way of working. A distinction could be made between the two therapies, using a stepped care model, whereby higher intensity interventions are required to address increasingly complex mental health problems. BeatIt could be regarded as a higher intensity formulation driven approach and StepUp a more straightforward lower intensity approach. However, the therapists' accounts, of how they brought both approaches to life with individuals presenting with a range of clinical severity and often longstanding depressive symptoms perhaps challenge this stepped care model. This is an issue that deserves further examination in the future research.

| CON CLUS ION
These findings complement the views of individuals with an intellectual disability and their supporters about the delivery of the BeatIt and StepUp therapies as part of the trial Scott et al., 2019). The thoughtfulness shown by the therapists who engaged in this study was consistent with the excellent fidelity ratings they obtained (Jahoda, Hastings, et al., 2017). The insights provided