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Significant therapy events: An interpretative phenomenological analysis of psychotherapy with clients with intellectual disabilities

Wills, Sarah

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Sarah Wills


Background: Gradually, over the years, the type of treatments provided to clients with intellectual disabilities (IDs) has changed, with increasing access to different types of psychotherapy. Given the high prevalence of mental health difficulties of people with IDs, it is key to explore how to make psychotherapy more effective for this client group. There is a growing evidence base of studies investigating the use of psychotherapies for people with IDs, with the level of evidence varying from case studies for less established studies, to small scale randomised controlled trials (RCTs). However, most studies have focused on adapting interventions, and efficacy, rather than exploring the process of psychotherapy, which is in stark contrast to the literature on non-ID populations. Exploring significant events in therapy provides opportunities to gain insight into the therapeutic process; using a video recording of the session to prompt participants’ memory of the session enables such insights to be explored. Research exploring significant therapy events involving clients without IDs has shown there to be a link between significant events in therapy and positive therapy outcomes. However, to date, no significant therapy events research could be found involving clients with IDs.

Aims: To examine client-identified significant events in psychotherapy and to explore the lived experience of psychotherapy with clients with IDs.

Methods: Four therapy dyads of adults with IDs and their therapists were recruited. Semi-structured interviews focused on helpful events in psychotherapy, using videos of particular sessions as a stimulus to help prompt participant recall of that session. A modified version of interpretative phenomenological analysis was used to identify emerging themes.

Results: Five super-ordinate themes were identified that related to the research questions. The first four themes described the process leading up to and surrounding the significant therapy events, comprising of: 1) The Uniqueness of the Therapeutic Relationship; 2) Using Adaptations to Express Emotions; 3) Client Behaviour/Therapist Behaviour; and 4) Hope and Paternalism. The final theme: 5) Meaning Making, depicted how clients and therapists made sense of the identified significant therapy event.

Implications for counselling psychology: This study highlights the need for therapists to work in such a way as to facilitate significant events in therapy with their clients through building a strong therapeutic relationship, making appropriate adaptations to ensure their clients can express themselves, being mindful about instilling hope, and adopting a clientled approach. It may be helpful to have more flexibility within therapeutic contracts to enable clients with IDs to have more sessions in order for a strong therapeutic relationship to be built, as well as providing the space for a client-led approach to foster client independence and moments of insight. Furthermore, therapists could use supervision to reflect on balancing empathising, protecting and helping in order to promote the process of empowerment. Indeed, the use of video-recording sessions could be helpful, not only for therapists to reflect on their practice during supervision, but also as a means of training therapists, working in mainstream psychotherapeutic services, to be able to confidently work with clients with IDs. In addition, the research makes an important contribution by demonstrating the feasibility and importance of undertaking process research with clients with IDs in order to explore the process of change.

Conclusion: This is the first known study to move the ID research field forward into exploring the process of therapy for clients with IDs rather than utilising the wellrehearsed case study and outcome research methodologies. The current findings suggest that clients with IDs do experience significant therapy events. Furthermore, the research enabled insights to be gained about the process of therapy for this client group and for exploration of therapeutic factors that may be involved in facilitating a significant therapy event. The findings highlight areas where further research is required.


Wills, S. Significant therapy events: An interpretative phenomenological analysis of psychotherapy with clients with intellectual disabilities. (Thesis). University of the West of England. Retrieved from

Thesis Type Thesis
Deposit Date Jan 30, 2019
Publicly Available Date Jan 30, 2019
Keywords Mental health, intellectual disabilities, significant therapy events, psychological therapy, interpretative phenomenological analysis, qualitative
Public URL
Award Date Jan 30, 2019


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