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The
British
Psychological
Society

British Journal of Clinical Psychology (2010), 49, 113

q 2010 The British Psychological Society

www.bpsjournals.co.uk

Does training improve understanding of core

concepts in cognitive behaviour therapy
by people with intellectual disabilities?
A randomized experiment
Melanie Bruce1, Suzanne Collins1, Peter Langdon1,2,
Stephanie Powlitch1 and Shirley Reynolds1*
1

School of Medicine, Health Policy and Practice, University of East Anglia,

Norwich, UK
2
Broadland Clinic, Norfolk Learning Difficulties Directorate, Little Plumstead
Hospital, Norfolk Primary Care NHS Trust, Norwich, UK
Background. People with intellectual disabilities (ID) experience similar or even
higher rates of mental health problems than the general population and there is a need
to develop appropriate treatments. Cognitive behaviour therapy (CBT) is effective for a
wide range of disorders in the general population. However, there is some evidence
that people with ID may lack the cognitive skills needed to take part in CBT.
Aims. To test if people with ID can learn skills required for CBT, specifically the
ability to distinguish between thoughts, feelings, and behaviours and to link thoughts and
feelings (cognitive mediation).
Method. A randomized independent groups design was used to examine the effect
of training in CBT on two tasks measuring CBT skills. Thirty-four adults with ID were
randomly allocated to the experimental condition N 18 or to the control condition
N 16. CBT skills were assessed blind at baseline and after the intervention.
Results. The training led to significant improvements in participants ability to link
thoughts and feelings, and this skill was generalized to new material. There was no effect
of training on participants ability to distinguish amongst thoughts, feelings, and
behaviours. People with ID can, therefore, learn some skills required for CBT. This
implies that preparatory training for CBT might be useful for people with ID. The
results might be applicable to other groups who find aspects of CBT difficult.

Establishing valid estimates of the prevalence of mental health problems amongst

people who have intellectual disabilities (ID) has been problematic and wide variations

* Correspondence should be addressed to Professor Shirley Reynolds, School of Medicine, Health Policy and Practice, University
of East Anglia, Norwich NR4 7QH, UK (e-mail: s.reynolds@uea.ac.uk).
DOI:10.1348/014466509X416149

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2 M. Bruce et al.

in prevalence have been reported (Borthwick-Duffy, 1994). This has been attributed to
different reasons including the use of inconsistent and perhaps unsuitable assessment
methods and the extent to which challenging behaviours are considered to be indicative
of mental health problems (Moss, 1999). However, there is evidence that people with ID
experience the same types of mental health problems as the general population with at
least equivalent, if not even greater prevalence (Emerson & Hatton, 2007; Smiley et al.,
2008). The reasons offered for this include increased genetic and biological vulnerability
as well as adverse life experiences such as institutionalization, separations, stigma, and
social exclusion.
Despite this context, the development and evaluation of therapeutic interventions
for mental health problems in this population has been slow (Hatton, 2002) and
inadequate (Martin, Roy, & Wells, 1997; Patel, Goldberg, & Moss, 1993).
Pharmacological and behavioural interventions have been the primary interventions
available to adults with ID (Stenfert Kroese, 1997). It has been suggested that therapists
do not engage in psychotherapy with people with ID because of general assumptions
that their restricted cognitive ability and communicative skills would prevent them from
engaging in or benefiting from therapy (Hurley, Pfadt, Tomasalo, & Gardner, 1996).
Currently, there is increasing interest in developing and adapting interventions
specifically for use with people who have ID.
Cognitive behaviour therapy (CBT) has been demonstrated to be effective and
adaptable to a wide range of mental health problems across a number of different
populations. There is some evidence that the underlying cognitive model is applicable
to people with ID in people with ID. For example, symptoms of depression and anxiety
were associated with negative cognitive styles, e.g. negative automatic thoughts and
hopelessness (e.g. Nezu, Nezu, Rothenberg, & DelliCarpini, 1995; Glenn, Bihm, &
Lammer, 2003). In addition, there are reports of successful case studies of CBT with
people with ID (e.g. Barrowcliff, 2008; Lindsay, 1999; Willner & Goodey, 2006).
The successful use of CBT for use with people who have ID is likely to need some
adaptation and currently there is interest in identifying elements of therapy which are
appropriate for use with this group of people. Hatton (2002) identified three aspects of
cognitive ability required for CBT; (1) cognitive capacity (e.g. understanding of
more/less, memory), (2) the ability to identify different emotions, and (3) the ability to
understand the cognitive model.
A number of authors have examined if people with intellectual difficulties can
understand the cognitive model. Dagnan and colleagues (Dagnan & Chadwick, 1997;
Dagnan, Chadwick, & Proudlove, 2000) found that most participants with ID
understood the antecedents, beliefs, and consequences model (Ellis, 1977) and could
identify basic emotions. However, they found that only around 10% of participants could
understand cognitive mediation, i.e. the ability to identify what emotion would be
experienced given a specific situation and belief. Successful performance was positively
correlated associated with language comprehension. The authors concluded that
people with mild ID may possess some of the skills required for CBT, but may require
preparatory training.
Subsequently, other researchers (e.g. Joyce, Globe, & Moody, 2006; Sams, Collins, &
Reynolds, 2006) have reported that people with ID can identify some emotions but find
it more difficult to link thoughts, feelings, and events. Oathamshaw and Haddock (2006)
examined CBT abilities in a sample of people with ID and psychosis and again,
participants could identify emotions but found tasks involving cognition more difficult.
In general, variations in performance are associated with IQ score (Sams et al., 2006)

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Training in CBT for people with ID

and receptive language ability (Oathamshaw & Haddock, 2006, Sams et al., 2006). Sams
and colleagues speculated that with targeted interventions, people with ID might be
able to learn and understand elements of the cognitive model which were not initially
accessible to them. Similarly, Stenfert Kroese (1997) stated that an integral part of CBT
for people with ID may be the willingness of the therapist to teach the necessary skills.
However, it is not known if training can improve these skills in people with ID.
The research question of interest here is, Can adults with ID learn some of the skills
necessary for CBT specifically the ability to differentiate between thoughts, feelings, and
behaviours and understand the link between thoughts and feelings? Our specific
hypotheses were (i) that a single session of training would improve participants ability
to discriminate amongst thoughts, feelings, and behaviours, and to link thoughts and
feelings compared to an attention control group, and (ii) that the training would
generalize to novel stimuli.

Method
Design
This study used a randomized, independent groups design to examine the impact of
preparatory training in CBT skills on two tasks examining two specific CBT skills,
discriminating amongst thoughts, feelings, and behaviours, and linking thoughts to
feelings. Randomization was stratified for level of receptive vocabulary. The impact of
preparatory training in CBT skills was compared to a control intervention (relaxation
training). CBT skills were assessed at baseline (Time 1) by a trainee clinical psychologist
(M. B.). The manualized interventions were then delivered within a week by a graduate
psychology assistant (S. P.). CBT skills were assessed again after a week by the same
researcher (M. B.), who was blind to the randomization assignment.

Sample
Thirty-nine potential participants were approached, three did not consent and two did
not meet the inclusion criteria. Therefore, this represented an overall response rate of
87.2% with 34 people participating in the study; 18 women and 16 men, aged 2168
years (mean age 40.5, SD 13:8). Eighteen participants were randomly allocated to the
experimental group (10 female and 8 male) and 16 participants were randomly allocated
to the control group (8 male and 8 females).

Inclusion and exclusion criteria

All participants were aged 18 or over, had been identified by their local services as
having an intellectual disability, and were in contact with a day service, college, or
voluntary organisation in West Norfolk. This is a semi-rural area of Eastern England.
Participants were excluded if they were currently engaged in CBT (to reduce
confounding due to any incidental learning during therapy), if they had a confirmed
pervasive developmental disorder, such as autism (to avoid the confounding effect of
interpersonal difficulties) or if at baseline assessment they were at or close to
ceiling level on the tasks (i.e. scored more than 15 out of 18 on the Thought
FeelingBehaviour Discrimination Task (TFB) or 5 out of 6 the Thought to feeling
linking task.

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4 M. Bruce et al.

Measures
Two standardized measures of cognitive ability and language and two tasks to measure
specific CBT skills were used. At baseline (Time 1) both standardized measures and the
two CBT tasks were completed. At Time 2 (following the intervention period) extended
versions of the two CBT tasks (including novel items) were completed.
The Wechsler Abbreviated Scale of Intelligence (Wechsler, 1999)
The Wechsler Abbreviated Scale of Intelligence (WASI) is a short, reliable measure of
intelligence, designed for use with people aged from 6 to 89 years. The measure yields
three categories of ability: verbal IQ, performance IQ, and full scale IQ. It provides an
estimate of intellectual functioning calibrated to the Wechsler Intelligence Scale for
Children (WISC-III, UK) and the Wechsler Adult Intelligence Scale (WAIS-III, UK). The
reliability (0.98) and validity (0.92) of the WASI have been established, as have normal
distributions (Mean 100 and SD 15; Wechsler, 1999). The WASI takes approximately 2030 min to complete and is therefore, well suited to rapid assessment and
screening in research settings.
The British Picture Vocabulary Scale-II (Dunn, Dunn, Whetton, & Burley, 1997)
The British Picture Vocabulary Scale-II (BPVS-II) is a test of receptive vocabulary for
standard English which was originally designed for use with children aged between
3 years and 15 years 8 months. It has since been widely used with people who have ID in
both clinical and research settings. The measure is administered individually and
provides norm-referenced scores. No reading or writing is required of participants and
the measure is brief and easy to administer. Raw scores are converted into an age
equivalent score in years and months.
The measure has a well-established normal distribution (Mean 100 and SD 15).
The BPVS-II has good reliability (median Cronbachs a: .93; median split half: 0.85,
Glenn & Cunningham, 2005). The validity of the test is assumed because it was
developed from the original version. For stratified random allocation BPVS-II scores
were categorized as high or low defined from a cut off score of 7 years. This figure was
based on previous research using a comparable population (Sams et al., 2006).
The ThoughtFeelingBehaviour task (TFB task; Quakley, Reynolds, & Coker, 2004; Sams et al., 2006)
This task was adapted from previous research to measure the ability to differentiate
amongst thoughts, feelings, and behaviours, a skill considered necessary in order to
engage in CBT. In the task the researcher reads short stories to the participant. There are
equal numbers of positive and negative stories. In each story the focal character (for
males Peter and for females Sarah) completes an action and experiences a thought and a
feeling. An example story is as follows:
Sarah is going on a trip to the beach. Sarah is very excited (feeling). Sarah hoped that she
could have an ice cream there (thinking). Sarah put one pound in her purse ready to buy the
ice cream (behaviour).

Each story is read out in full; then the thinking, feeling, and behaving sentences, written
on card are selected at random and read out to the participant one at a time. The card is
given to the participant who is then asked if the sentence is about something the
character had been thinking, feeling, or doing and is asked to post the card into one of

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Training in CBT for people with ID

three boxes labelled thinking, feeling, and doing and illustrated with appropriate
pictures.
Presentation order of the stories is randomized and the order of the sentences within
the stories is counterbalanced, so that participants cannot differentiate the concepts
simply by the order in which they were presented. At Time 1, we used six stories from
Sams et al. (2006); the maximum score was 18 points (1 point per sentence). At Time 2,
four new stories were developed and used with the original six stories; therefore, the
maximum score was 30. The new stories were added to assess if learning generalized to
new material. The four additional stories are shown in the Appendix.
The Thought to Feeling task (Doherr, Reynolds, Wetherly, & Evans, 2005)
The Thought to Feeling task was adapted from Doherr et al. (2005) and assesses the
ability to link thoughts and feelings (referred to as cognitive mediation by Dagnan et al.,
2000). Visual cues of a stick person with a thought bubble and four Makaton faces
(Walker, 1982) representing different emotions (happy, sad, angry, and worried) were
used (see Figures 1 and 2). At the start of the task the researcher described the
visual cues to the participant (e.g. The thought bubble shows what you are thinking,

Figure 1. Stick person and thought bubble for linking thoughts and feeling task (Doherr et al., 2005).

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6 M. Bruce et al.

Figure 2. Makaton faces representing emotions (Walker, 1982).

This face is a happy face). Standard written instructions were used and these are
available from the authors on request. For each item of the task the participant was asked
to imagine him/herself in the specific situation and having a specific thought. For each
item the emotional impact of the situation was modified by the thought. For example,
Imagine that you are going away for a while. You say goodbye to your family. (indicate stick
person).
You think: I cant wait for my holiday. (indicate thought bubble).
How do you think you would feel if you thought, I cant wait for my holiday? (indicate
Makaton faces).
After answering, participants were asked Why do you think you would feel (insert
answer)?

Participants were encouraged to respond either verbally or by identifying the

appropriate Makaton face. If the answer was not clear and did not indicate if the
participant had connected the thought to the feeling (i.e. indicated that they would
experience positive affect rather than negative affect), the researcher prompted further,
OK, can you say a bit more about why you think you would feel like [insert answer]?
and invited the participant to show them how they would feel using the Makaton
symbol, Can you show me how you would feel?.
Two demonstration items were used to explain the task and to show the participant
what was required. At Time 1, six test items taken directly from Sams et al. (2006). Four
new items were introduced at Time 2 to assess generalization. One point was awarded

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Training in CBT for people with ID

for correctly connecting the thought to the feeling for each scenario. The maximum
score at Time 1 was therefore 6; at Time 2 it was 10 points. Items were presented in a
random order. Fifty percent of items were mildly positive and 50% were mildly negative.
The Thought to Feeling task has good inter-rater reliability (Doherr et al., 2005).
Experimental and control interventions
The interventions were delivered in a single session and were manualized to maximize
internal validity. They each took approximately 1 h and were delivered by the same
trainer. The experimental intervention focused on identifying feelings, behaviours, and
thoughts, and on linking thoughts and feelings. Each part had up to three graded levels
with more focused teaching provided if the participant found initial material too
difficult. For example, in the section on feelings, initially the trainer talked to the
participant about different feelings. If participants could spontaneously name different
feelings (i.e. specific emotions happy, sad, worried, and angry) this was recorded and
the participant was encouraged to describe or mime as many different types of emotions
as they could. They would then move on to the thoughts and then the behaviour
section. For participants who could not identify different feelings, the trainer used
mime, repetition, simple language, pictures, and personal examples of the participant,
e.g. to identify times when the participant had experienced positive and negative
feelings. These were elaborated and labelled where possible.
A similar method was used to identify thoughts and behaviours using pictures,
thought bubbles, mime, and drawing on personal experiences as much as possible. For
linking thoughts and feelings, the participant and trainer discussed specific scenarios
where a feeling would be elicited by a thought. Descriptions, coaching, repetition,
pictures, and personal experiences were all used to convey meaning.
The relaxation training was based on the behavioural relaxation procedure described
by Lindsay and Morrison (1996). Full instructions for both training interventions are
available on request from the authors.
Ethical issues
Ethical approval was sought and obtained from Norfolk (1) Local Research Ethics
Committee and Norfolk Consortium Governance Committee. Particular attention was
given to consent, confidentiality, and potential distress. Information sheets and consent
forms were reviewed by user groups to aid this process. The study was also explained
verbally to each potential participant. They were encouraged to discuss the study with
their carer and with staff at the service they used. Specific attention was given to ensure
that participants understood the principle of random allocation, that they were free to
take part in the study or not, and that they could withdraw at any time. It was made clear
to each participant that there would not be any direct benefit to them. Informed consent
was obtained from each participant and this was witnessed by staff member at the
service they used.
Procedure
Information about the study was distributed to service managers. Staff members
identified individuals who they thought would be eligible to take part in the study.
Potential participants were then approached in person at the day centre or college and,
if interested, were given information about the study.

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8 M. Bruce et al.

At baseline (Time 1) participants completed the WASI, the BPVS-II, the two CBT
tasks and provided basic demographic data. The order of presenting the measures
was randomized and the items within the CBT task were presented in a random
order. Approximately, 1 week later participants met the trainer, were randomly
assigned to condition and received the training session. Randomization was stratified
by BPVS-II score. Two sets of sealed envelopes were prepared by a researcher who
was not involved in the assessment or training (S. R.), one for participants with BPVSII scores below 7 years and one for participants with BPVS-II scores over 7 years. The
envelope assigning the participant to their condition was opened at the start of the
training session so that the trainer and the participant were unaware of the allocation
until the session began. The training intervention was audio taped to ensure
adherence to the training manual and these were used in supervision. One week later
(Time 2) participants completed the extended versions of the CBT tasks. Assessments
at Times 1 and 2 were conducted by a trainee clinical psychologist (M. B.) who was
blind to randomization and reminded participants not to tell her about the
intervention.

Results
We first inspected the distribution of data to assess if parametric analysis was
appropriate. As expected, for this population, mean WASI scores were low and
positively skewed. This was particularly marked for verbal IQ, where 20 participants
(58.8%) had a verbal IQ score of 55 (the minimum score possible) and the majority of
participants (76.5%) scored 59 or below. Scores on the BPVS-II were normally
distributed and, as expected, low. Scores on the CBT tasks at baseline and after the
intervention were normally distributed.
At baseline the mean score on the TFB discrimination task was 8.71 (SD 3:18;
range 414). The maximum possible score for this task is 18 and a score of six correctly
sorted items represents a performance at chance level. Responses for the individual
components of the task (thoughts, feelings, and behaviours) were examined; a
maximum score of six was possible for each component. Mean scores were 2.32
thoughts SD 1:49, 2.94 feelings SD 2:059, and 3.38 behaviours SD 1:82.
Mean score at baseline for the Thought to Feeling linking task was 2.24 (SD 1:046;
range 06). For this task success cannot occur by chance and a score of one or above
indicates that the participant has some ability to connect thoughts with feelings and
therefore recognize the mediating role of cognition.
Next we examined baseline data for the experimental and control groups to ensure
that they were matched on the key variables. Non-parametric tests were used to
compare the experimental and control group on IQ and BPVS scores. There were no
significant differences in the mean ranks of the groups. Table 1 shows the median and
mean values for each group and the results of the MannWhitney tests. There was one
participant in the experimental group with very high scores on the BPVS-II
(Raw Score 153, age equivalent 17 years), and the statistical analyses were
performed both with and without them. Their inclusion or exclusion did not change
the overall results and thus, they have been included in the analysis presented in this
paper. We then compared group means on the CBT tasks at baseline using MANOVA.
There was no significant group difference in performance on CBT tasks, multivariate
F2; 31 0:515, p , :60. Univariate F values also indicated that there was no

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Training in CBT for people with ID

Table 1. IQ and receptive vocabulary scores by group

CBT training
Median
FSIQ
VIQ
PIQ
BPVS

55
55
60
7.1

Relaxation training

Mean

SD

Median

56.4
58.2
61.4
7.7

3.3
6.0
6.0
3.1

56
55
61
7.6

Mean

SD

57.1
58.6
61.3
6.7

4.9
5.8
5.7
2.9

u
138.00
132.00
142.50
125.00

p
.85
.69
.96
.53

significant group difference on either task; TFB task, F1; 32 1:0, p , .32, TF task,
F1; 32 0:33, p , :57.
To test the first hypothesis, we compared group performance at Time 2 on the
original tasks (i.e. the same items that were presented to the participant at Time 1).
To test the second hypothesis, we compared performance on the four new items on
both tasks to assess if learning could be generalized to new material.
For performance on the original items there was a significant multivariate group
difference at Time 2, F2; 31 6:57, p , :005. Univariate F values showed that the
effect was due to a significant group difference on the Thought to Feeling task,
F1; 32 13:56, p , :0001; there was no significant group difference in the TFB
discrimination task, F1; 32 2:3, p , :14. Performance on the original items for the
experimental and control groups at Time 1 and 2 are shown in Figure 3.
We examined performance on the new items also. Mean scores for the new items on
the Thought to Feeling task were 2.4 SD 0:8 for the CBT group and 1.2 SD 1:1
for the control group. For the TFB task the respective means were 6.9 SD 2:9 and
6.6 SD 3:4. There was a significant multivariate difference between the CBT training
and the relaxation training groups, F2; 31 6:53, p , :004. Univariate F values
showed that this was due to a significant difference on the thought to feeling task,
F1; 32 12:89, p , :001; there was no significant group difference in the TFBDT,
F1; 32 0:12, p , :73. After the training intervention, participants in the
experimental group scored significantly better on the six familiar items of the Thought
to Feeling task (mean item score 0.75) than on the four new items (mean score 0.59),
t15 3:31, p , :004. This was likely to be due to practice effects. Their score on the
new items at Time 2 (0.59) was, however, significantly higher than their mean score
(0.37) at baseline; t17 5:29, p , :00001, demonstrating that their performance
had significantly improved and could not be attributed to the effect of practice on
those items.1

Discussion
This experimental study showed that the CBT training intervention increased
participants ability to link thoughts and feelings, a skill which has previously been
referred to as cognitive mediation (Dagnan et al., 2000), which has been deemed
critical for successful engagement in CBT (Willner, 2006) and which, it has been
1

Thanks to an anonymous referee who drew our attention to the difference in performance on the old and new items of the
Thought to Feeling task.

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10 M. Bruce et al.

Figure 3. Group performance (Mean and SEM) on (a) the TFBDTand (b) the linking thoughts to feeling
task.

suggested, may be beyond the capabilities of most people with ID ( Joyce et al., 2006).
Thus, this study shows that with suitable adaptations and support people with ID can
learn these skills and generalize their learning to new material. This is consistent with
the views that training and socialization into the cognitive model should be an integral
part of therapy for people with ID (e.g. Stenfert Kroese, 1997). If significant
improvement can be observed after one standardized, brief intervention, a longer,
individually tailored intervention delivered in the context of a therapeutic relationship
may be even more effective. However, this sample was not clinically referred or in
distress, and therefore, it is not clear how much the results would generalize to a clinical
population. The effect of the intervention was measured after an interval of 1 week and
we cannot infer that learning would be maintained over a longer period. However, in the
context of CBT, maintenance of learning may not be a critical concern as there would be
regular opportunities to review the training and to repeat it if necessary.
Unexpectedly, we found that the effect of training was specific to the ability to link
thoughts and feelings (or cognitive mediation). Participants ability to discriminate
amongst thoughts, feelings, and behaviours, which would seem to be a more basic
requirement of CBT, did not change as a result of the training intervention.
The design had a number of strengths; the confounding effect of receptive language
ability was minimized through stratified randomization, assessments were conducted
blind to avoid potential biases, and we controlled for the non-specific effects of
individual attention. All instructions, tasks and interventions were standardized,
therefore increasing the internal validity of the study, but inevitably limiting the
flexibility with which the intervention was delivered. The sample IQ scores which were
somewhat lower than those of individuals who have been treated with CBT and

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Training in CBT for people with ID

11

reported in published case studies. Thus, whilst the sample do not represent the
broader ID population, it may reflect those individuals who use day service provision.
Some sampling bias was unavoidable because, for ethical reasons potential participants
were identified by staff members. However, very few potential participants were
unwilling to take part and there was no evidence of a self-selection bias into the study.
Although not explicitly required by the design, all participants had some verbal
communication. The ethical challenges of carrying out research with participants who
have ID have been highlighted elsewhere (e.g. Iacono, 2006; McCaron & McCallion,
2006) and we took steps to enhance the extent to which participants could give fully
informed consent.
A key assumption in this experimental study (and in other related studies of CBT
abilities in people with ID) is that the assessments of CBT skills are valid. This presents a
challenge as research in this area is relatively new, tasks to assess CBT skills have not
been fully developed, therefore whilst their face validity to researchers is good, their
predictive validity is unknown. The specific tasks used in this study were adapted from
tasks developed for use with young children and were adapted to be suitable for, and
acceptable to, adult participants. Some features of the tasks may have overcome
problems identified in previous research. Dagnan et al. (2000) identified that their tasks
may not have adequately assessed individuals ability to understand the role of cognitive
mediation. The Linking Thoughts to Feelings Task (Doherr et al., 2005) used in this
study gave participants the opportunity to use their own language to explain their
reasons and may be more flexible than the tasks developed by Dagnan et al. (2000).
The finding that specific training did not improve participants ability to discriminate
amongst thoughts, feelings and behaviours was unexpected. The nature of the tasks may
be relevant in that the discrimination task involved stories describing a fictional
character, whereas the linking task asked participants to imagine themselves in a
situation and to consider their own thoughts and feelings. This may have been more
meaningful to them. Alternatively, it is possible that discriminating amongst thoughts,
feelings, and behaviours is a basic skill and that people with learning disabilities have
regular opportunities to learn it thought day-to-day experiences. In comparison, linking
thoughts and feelings (cognitive mediation) may not be something to which individuals
are regularly exposed and thus the training intervention may offer a more novel
opportunity for learning this specific skill.
Although preliminary, these results could have important implications for the
delivery of CBT to adults who have ID. The data suggest that some aspects of the
cognitive model can be taught to adults with ID in a single session of training. If
replicated clinically this may mean that this group of people can have access to an
effective psychological intervention. The results may also have relevance for the
delivery of CBT to other groups who may find the initial model unfamiliar or cognitively
challenging and who might benefit from specific training in the early stages of therapy.
This training would fit naturally within the psycho-education and socialisation phases of
therapy.
Many other factors also influence the success of CBT including the quality of the
therapeutic relationship, the clients willingness to engage in therapy, their self-efficacy
and motivational barriers (Willner, 2006). The extent to which the skills assessed in this
study are associated with engagement, understanding and outcomes in CBT has yet to
be established. In addition, for people with ID, systemic issues may be of particular
importance given their typically complex social network of family, carers and
professional staff. The delivery of CBT for adults with ID requires substantial further

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12 M. Bruce et al.

development and systematic evaluation. However, this study demonstrates that lack of
skills in specific areas need not be an absolute barrier to CBT, but should highlight areas
in which therapists could begin to enable individuals to develop specific skills.

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Received 17 July 2007; revised version received 14 January 2009

Appendix: Additional items for the TFBDT

Item 7: Sarah is on her way to watch her favourite football team. She hopes that they win
the match. Sarah is excited when her team scores a goal. Sarah cheers and claps.
Item 8: Tomorrow Sarah has an appointment at the dentist. Sarah is very worried. Sarah
wonders if her teeth are ok. Sarah goes to clean her teeth.
Item 9: Sarah is playing her new CD. Sarah dances to the music. Sarah wonders if her
friend will like her new CD. She is happy when her favourite song comes on.
Item 10: Sarah wonders where her bag is. Sarah is angry that she cant find it. Sarah asks
her friend to help her look for her bag.

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