Malan’s triangles of conflict and person
In order to understand the hidden (unconscious) feelings, the therapist has to identify the defenses and the anxiety, and then draw these to the client’s attention. Then they make links between stages of the conflict, and also between life stages, represented by the second of Malan’s triangles, the “Triangle of the Person” (Figure 14.1). This depicts the origin of the information: the setting in therapy (the transference), and a comment might be, “You feel like this when you are here with me,” and then to the person’s present living environment, “You feel like this towards your friend,” and then the person’s past (usually with parents), “You felt like this towards your mother.”
When working with people who have ID, Alvarez (2012) has suggested that the therapist may need to consider different levels of interpretation. So, for a client who has ID and who is acting in an angry manner towards the therapist, this means changing the location from “you” to “others.” So to extend a reflective comment, “You feel angry …” to make an interpretation, we go on to say, “You feel angry because …” However, it may be that the person with ID may not accept an interpretation with this location, i.e., “You,” as the “You” may be felt as nothing but angry, which they find intolerable and so defend against this. So, for example, it may be better to say, “Part of you feels angry.” However, this may also fail to be accepted, and so Alvarez (2012) suggested using the ideas of Donald Winnicott, and locating the feeling, behavior, or issue in others. So we may say something like, “Isn’t it annoying when people get angry?” People who have ID also have a tendency to act-out in therapy, and sometimes the acting-out may challenge boundaries. In such situations, the interpretation may have to be put on hold and the therapist needs to bring the client back into the reality of the relationship with the therapist rather than the transferred one they are acting into. Here, Alvarez (2012) uses methods of gaining the client’s attention such as saying, “Hey!” or saying the person’s name clearly and firmly.
When working with clients who have ID, the therapist also needs to consider whether the client could retain the interpretation in full or does it need to be delivered in parts? Some therapists prefer to wait until the client is in a state of positive transference. However, Klein (1975) recommended making interpretations when people are at their maximal level of anxiety. As people who have ID have more difficulties in life with their memory, and also are more prone to primitive defenses such as splitting, Beail (1998) suggested, from a pragmatic point of view, that the Kleinian approach is more likely to be effective.
Conclusions
Psychodynamic psychotherapy offers people who have ID an alternative or preferred approach to the treatment of psychological distress and behavioral difficulties. Provision has grown and it can be provided as part of ID mental health service care pathways (Jackson, 2009). The therapeutic frame is virtually the same as that in general psychodynamic practice, but with some flexibility around length of sessions and the negotiated involvement of relatives and carers. The approach needs some adaptation to take account of the client’s developmental needs and communication abilities. Yet Safran and Segal (1990) make the point that innovating to accommodate individual needs in therapy should not mean abandoning the therapeutic model. Instead, the therapist requires a deeper understanding of the model to ensure that innovative or creative strategies remain faithful to the underlying principles of the approach. Jackson and Beail (2013) have shown that this is proving to be the case, so far, for psychodynamic practice with people who have ID. Generally, there is a lack of accounts in the literature of the process of formulation or recontextualization of the client’s communications, and this is clearly an area that needs more attention in the future to assist therapists in training. Evidence is emerging to show that this approach can be effective, but research on the model’s efficacy with people who have ID have yet to be conducted, and such studies would need to make many compromises (Beail, 2010). Research is also emerging to show that recipients who have ID value it and are satisfied with it (Merriman and Beail, 2009; Khan and Beail, 2013).
Key summary points
People who have ID need access to the same range of psychological therapies as everyone else.
The evidence base for psychodynamic psychotherapy with people with ID is outlined; it is in its early days but evidence for effectiveness is emerging.
Theories that have informed the development of psychodynamic psychotherapy with people with ID are elucidated.
Adaptations to psychodynamic psychotherapy that have been made to ensure accessibility are described.
References
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