2.1 Approach to the concept of third generation therapies
The disability-aging link as an emerging phenomenon.
When disability is discussed in scientific or institutional settings, this term is immediately related to others such as prevention, early care, educational integration, employment, accessibility, rehabilitation, etc. All these areas of research or intervention evoke, as far as their recipients are concerned, the figure of people who have special needs during childhood, youth or adult life. Very rarely is disability related to aging.
Demographic aging, a positive phenomenon in itself, because we are living longer and longer, nevertheless poses great challenges to modern societies. It is trying to respond to them from different countries, as well as from international organisations. The United Nations is promoting a series of initiatives in all countries to try to adapt to the enormous social transformation that the phenomenon of aging is causing, which goes far beyond what is the field of social policies, despite being so important .
But limiting ourselves to the framework of these, we can ensure that, in the case of people with disabilities, we are facing a new social need that can become a problem that is difficult to solve, especially because, due to its novelty, it is not has sufficient knowledge about those programs, resources and services that may be more suitable to fully respond to the needs of aging people with disabilities.
It is not only necessary to think, on the other hand, of the people affected by deficiencies. Their families, who throughout their lives have been their support and support, also age. The uncertainty about the future of their sons or daughters when they cannot continue caring for them or when they disappear acts as a highly stressful factor that adds a negative ingredient to the aging process itself.
Throughout the history of psychology, there have been multiple approaches and theories that have emerged with the aim of explaining how the human mind works, what psychological mechanisms influence and participate in our behaviour and even how they can be altered in a way that maladaptive patterns of thinking and acting in the form of mental disorders.
At the level of clinical psychology, attempts have been made to help those who suffer from disorders and maladaptive patterns and producers of discomfort through what is known as behaviour therapy and the three waves or generations of treatments that it has been producing.
But what are the most frequent disorders that we face when we talk about the elderly with Learning Disability? How are we able to respond to their emotional needs in residential services from the new third generation therapies?
Psycho-emotional disorders
People with Learning Disabilities present the same types of psycho-emotional disorders derived from deeper ones such as psychiatric ones, as the general population, although the vital circumstances and the level of intellectual functioning can alter the manifestation of the symptoms, making the vulnerability to suffer from these disorders is higher.
About 20-35% of people with Learning Disabilities suffer from a psychiatric disorder. Mental and behavioural disorders also occur throughout life and more frequently. Those most closely related to intellectual disability are hyperactivity/attention deficit disorder (30-50%), affective disorders (50%), behavioural and adaptive disorders, schizophrenia (2-3%) and personality disorders (schizoid, paranoid , narcissistic, avoidant and antisocial). However, the symptoms can present themselves differently and complicate the diagnosis, mainly due to expressive problems (they have difficulties expressing their problems) and language. Diagnosis is complicated when the psychiatric disorder manifests as a behavioural disorder, and symptoms may be mistakenly attributed to Learning Disabilities rather than the psychiatric disorder.
The elderly experience a series of losses, associated with age, in their physical, emotional and psychological capacities. People with Learning Disabilities show a more marked decline in cognitive and affective aspects when they have a mild or moderate degree of disability, however, when the deficiency is greater, the level of development achieved is lower, and cognitive impairment must be therefore less. It could be said that “who has more, loses more”.
The presence of psychiatric disorders reduces the quality of life of people with Learning Disabilities and alters their daily functioning, becoming more evident in older people.
Emotional disorders in people with Learning Disabilities do not have a different etiology than those same disorders in the general population, and they also result from an interaction between many factors: biological and psychosocial (labeling, social rejection, restriction of opportunities, vulnerability to abuse, etc). These factors contribute to people with Learning Disabilities developing emotional maladjustments and lacking the cognitive resources necessary to deal with them. Any vital event can provoke a situation of stress or depression in a person with Learning Disabilities.
Anxiety
An anxiety disorder can be triggered in different situations; as an excessive environmental demand or a modification in the daily routine of the older person with Learning Disabilities. The behaviours that can appear in these situations are: agitation, irritability, aggressiveness or panic attacks.
Social anxiety
Social anxiety is a disorder to which specialists have paid little attention in relation to people with Learning Disabilities. It can be defined as the fear of negative evaluation that a person suffers when he fails in his interpersonal relationships and fails to satisfy the image he wants to give socially. It involves feelings of apprehension, excessive concern for oneself and emotional discomfort in social situations.
For a person with Learning Disability to experience social anxiety, they must have a high enough IQ to allow them to recognise themselves. When this is the case, and the person is very aware of their behaviour in public, negative ideas are generated and they believe they are inferior to others, despise themselves and overvalue social demands.
Obsessive-compulsive disorder
It is a little studied syndrome compared to others. It is characterised by presenting obsessions (persistent and intrusive ideas that the person recognises as their own) and compulsions (stereotyped and repetitive behaviours) that occupy a large part of the person’s time and interfere with their life.
It is difficult to diagnose this disorder in people with Learning Disabilities because they have difficulty describing their thoughts, realising the cause of their obsession and finding out the irrationality of their compulsions.
Depression
Depressive manifestations are the central emotional problem in older people. Its high incidence can be attributed to biological causes (biochemical and physiological changes), social causes (social contact) or psychological causes (adaptation to the losses caused by the aging process). When an elderly person goes to a specialist, they manifest different depressive behaviours: insomnia, loss of concentration, fatigue, anxiety, somatic complaints (hypochondriasis) and suicidal thoughts.
When assessing affective functioning in older people with Learning Disabilities, it is important to take into account the masking that can occur due to the Learning Disability itself. It is not yet known whether depression is a risk factor for dementia or an accompanying symptom. To prevent a possible depressive picture in the aging process, there are important processes closely related to the subject’s personality:
- Subjectivation or work of the person to adapt their identity and internalise the changes that occur over the years.
- Bonding or ability to maintain contact with external objects (activities, social relationships) that prevent isolation.
Love and sexuality
It is an important issue in the affective life of the learning disabled person that until now had not received enough attention. The sexual relationship between 2 of these people helps to balance people and promotes an autonomous life that did not exist before.
Conception, abortion, sterilisation and filial care are issues that have not yet been satisfactorily resolved for all those involved (people affected, parents, caregivers, etc.). Established social norms about what sexual behaviour is acceptable vary according to cultural level, religion, etc., so a particular sexual behaviour can be seen by a person in very different ways.
The sexuality of these people is treated inadequately most of the time: the person is infantised, the behaviour is ignored or great astonishment is shown in the face of the problem. Among the factors that limit the development of adequate sexuality we find a lack of consent on the part of parents and professionals who intervene quickly to stop this sexual behaviour.
Grief
It is a natural emotional reaction of people that allows us to face all the losses of our lives. We must accept that suffering, illness, death, losses in general, are part of our lives and generate a series of feelings that it is better to express and learn to tolerate those of other people.
It is important that the learning disabled go through this grieving process and have a real vision of what life is, in order to better accept it. It is good to accompany them in this process, without denying them the right to suffer (crying is not a sign of weakness) or protecting them excessively.
People with Learning Disabilities have feelings (suffering, anger) and it is necessary for them to express them, however negative they may be.
Currently, thanks to advances in medicine and the increase in the quality of life of people with Learning Disabilities, their life expectancy continues to grow, being, at this time, practically similar to the general population, with all that this implies in relation to age-related changes. Therefore, it is necessary to plan new interventions, aimed at preventing or mitigating the effects that these changes may produce.
Intervention
Psychological intervention in the field of older people with Learning Disabilities, framed, of course, within a multidisciplinary framework, must be aimed at achieving the following objectives:
- To ensure that there is a relationship between longer life expectancy and a life with better quality.
- Reduce the interval between morbidity/dependence and death as much as possible.
In order to achieve these objectives in the best possible way, our work must begin in the early stages of the life of the person with Learning Disabilities, in order to promote healthy lifestyles, through the planning and development of specific programs that, in summary, could be the following:
- Personal Life Skills (socialisation, eating, dressing, hygiene, sexuality, etc).
- Academic Skills
- Home Life Skills.
- Community Living Skills
- Labour Skills
Once the age of risk in people with Learning Disabilities has been reached, which is around 45/50 years old (40 years in people with Down Syndrome and in people with Severe and Profound Learning Disabilities), it is advisable to consider a screening, especially in those areas that can predict the appearance of symptoms of aging or some type of senile disorder:
- Memory
- Language (aphasia)
- Motor skills (apraxia)
- Perception (agnosia)
- Functional skills
Once these surveys have been carried out and before the appearance of the first signs of aging or, in the worst case, the first deficits in adaptive behaviours, normally associated with Alzheimer-type dementias, we must guide the intervention, so that we strengthen certain areas, as for example:
- Promote, progressively and alternatively to work activity, social integration. Promotion of Leisure.
- Promote the maintenance of Personal Autonomy.
- Promote permanence in the usual environment, with the necessary support in the family environment, if any.
- Coping with illness and death. Help elaborate the idea of pain and loss.
- Maintain the capacity for space-time orientation
- Technical help.
- Dual Diagnosis
From a certain age, and only in some individuals with certain conditions, the risk of suffering disorders with greater impact and affectation, such as dementias, increases. In the case of people with Learning Disabilities, this risk increases when it occurs in association with Down Syndrome or Severe Learning Disabilities. Carrying out a differential diagnosis between Learning Disability and Dementia can be complicated, also taking into account that the coexistence of both disorders, intellectual and mental, has not been recognised until a few years ago, since the second was explained as a consequence, almost inevitable, from the first.
At the moment, the difficulties in approaching this type of diagnosis are due, above all, to the fact that two types of situations usually occur: In one case, the environment itself, excessively overprotective, without significant challenges for the person and which tends to adapt the environment to satisfy the demands, can overlap the symptoms and thus prevent adequate treatment. In another case, they can be identified as dementia, irreversible disorder, other types of symptoms characteristic of a reversible disorder, such as. depression, which, in older ages, can produce similar symptoms.
The main problem that we find when dealing with the aging of people with Learning Disabilities is the difficulty that has been encountered when dealing with it, fundamentally because the scientific studies that have approached it have done from two different perspectives: old age and Learning Disability in isolation.
Research on elderly people with Learning Disabilities is relatively scarce, although contributions can be found starting in the early 1980s. It should be noted that it was only in the 1990s that care services for elderly people with Learning Disabilities.
Future services to be created for this population will have to go beyond the simple “residential” option, with diverse and continuous programs aimed at preventing the natural deterioration that the aging process entails.
Any offer must be based on the principle of standardisation, opening up a range of options, comparable to those existing for the general population. It is evident that each person (with or without mental disability) ages individually, therefore it will be necessary to offer each of them the most suitable resource for their characteristics.
Based on this, we see the need to clarify the different options that should be proposed to the elderly population with mental disability:
We will start from the premise that the vast majority of the elderly population with Learning Disabilities have aged in an institutional environment and that therefore the residential centre is their home. So it would be desirable for them to end their days in this same environment. It would be advisable to establish adjustment processes in programs and revision of technical aids so that the prevention and treatment of the needs that users are going to present in the last years of their lives can be carried out, with guarantee.
This should not be an impediment for these people to continue being part of the community and use community services.
Managers of residential services should bet on the implementation of programs aimed at the prevention and treatment of the effects of the aging process.
To this end, we believe that these initiatives should be supported, facilitating both the technical and human aid that is necessary to carry out these programs. The programs to be developed in these initiatives are:
- Sensory stimulation
- Motor stimulation
- Facilitation of personal autonomy
- Communication stimulation
- Stimulation and prevention of cognitive decline
- Leisure and free time
- Prevention of behavioral adjustments
- Health
Behaviour Therapy: A Brief Definition
We call behaviour therapy the type of treatment based on experimental psychology in which it is considered that behaviour, although predisposed by biology, is determined and can change by learning and applying patterns of behaviour and thought.
In the presence of maladaptive behaviours that generate significant discomfort in the person, it is possible to modify these patterns by teaching other more useful ones.
In this way, the general objective of this type of therapy is to generate a change in the person that can alleviate their suffering and improve their adaptation, enhancing and optimising their abilities and opportunities in the environment. To do this, it is intended to eliminate, add or change one or several behaviours to the individual’s repertoire through learning processes.
This type of therapy focuses on the present moment, working on the current problem and history being just something that tells us how the current situation has come about. The psychotherapist will apply the treatment according to the characteristics of the subject to be treated and their circumstances, having to adapt the therapy to each situation.
The Three Waves Or Generations Of Therapies
Although many of the applied techniques and therapies have been around since behaviour therapies or behaviour modification appeared, behaviour therapy has not stopped evolving in order to improve both its effectiveness and the understanding of mental processes. and behavioural on which it works.
So far, it is possible to speak of a total of three great waves or generations of therapies that have followed one another over time depending on whether one or another current of thought predominated, each one of them overcoming many of the explanatory and methodological limitations of the previous models.
First wave: Behavioural therapies
Behavioural therapy was born at a time in the history of psychology when behaviourism emerged strongly as a reaction to psychoanalytic therapies born with Sigmund Freud. The latter focused on hypothetical constructs that were not empirically testable and considered that behavioural disorders were the expression of poor resolution of unconscious conflicts related to the repression of instincts and needs.
However, behavioural models were opposed to these considerations, preaching the need to deal with disorders based on verifiable and contrastable data by experience. The behavourists focused on treating the behaviour present at the time of the problem, worrying about the relationships between stimuli, the reactions and the consequences of these.
The first wave methodology
Behaviour was understood as mediated primarily by the association between stimuli and the consequences of the responses given to them. The therapies that appeared at this time are therefore based on conditioning, working on aspects such as the association of stimuli, habituation or sentsitisation to them or the extinction of reactions to stimuli. First-order changes in behaviour are provoked, working on directly observable behaviour.
Some of the treatments belonging to this first generation of behaviourial therapies that continue to be applied are exposure therapies, differential reinforcement of behaviours, aversive techniques, shaping, systematic desensitisation or token economy, and behavioural contract (if although at present they are applied accompanied by more cognitive treatments).
The proposals of the first wave of Behaviour Therapies were used and continue to be used for the treatment of phobias, to create or restore behavioural patterns and/or to train people with reduced capacities.
The behavioural model was for a long time the prevailing paradigm in the field of psychology and the treatment of certain mental disorders. However, their conception and utility are limited: these treatments are only successful in specific circumstances and contexts in which the variables that have to do with behaviour can be manipulated, and they take little account of the effect of psychological variables such as cognition or behaviour. affected.
The main problem with behaviourism is that although it recognises the existence of an intermediate element between stimulus and response, due to the lack of empirical data this point was ignored and considered an unexplorable black box. For these reasons, over time another current arose that tried to make up for the shortcomings of this model.
The lack of answers to multiple questions about the processes that mediate between perception and reaction and the ineffectiveness of purely behavioural therapies on many disorders with an affectation more typical of the content of thought caused many experts to consider that behaviourism was not enough to explain and produce a change in behaviour derived from elements such as convictions or beliefs.
At this point, it began to be considered that the main element that causes behaviour is not the association between stimuli but rather thought and the processing of information, giving rise to cognitive and information processing theories. That is, the second wave of Behavioural Therapies.
rom this perspective, it was considered that abnormal patterns of behaviour are due to the existence of a series of distorted and dysfunctional schemes, structures and thought processes, which cause a great deal of suffering to those who experience them.
The promoters of the second wave of therapies do not rule out the importance of association and conditioning, but consider that therapies must be aimed at modifying dysfunctional or deficit beliefs and thoughts. Thus, this trend has in fact incorporated many of the behavioural techniques into its repertoire, albeit giving them a new perspective and adding cognitive components.
Cognitive-behavioural therapies emerged from this combination.
Emphasizing mental processes
Within this paradigm, great attention is paid to the degree of efficacy of the treatment, maximizing it as far as possible, although at the cost of devoting less effort to knowing why it works.
This second wave has a much higher success rate than the rest in a large number of disorders, in fact the cognitive-behavioural paradigm is one of the most predominant at the level of clinical psychology today. The goal is to change the cognitions or emotions that cause the maladaptive behaviour, either by restricting or modifying them. Some of the best-known behaviour therapies at a general level are typical of this period, such as Aaron Beck’s Cognitive Therapy for depression, self-instruction therapy or Albert Ellis’s Rational Emotive Therapy, among others.
However, despite its clinical success, this type of therapy also has some problems. Among them, the fact that there is a tendency to try to eradicate everything that generates discomfort stands out, without taking into account that eliminating everything negative can cause patterns of rigid behaviour that, in turn, can be maladaptive. In fact, the attempt at control may end up inciting effects contrary to what was intended.
The second wave of therapies also has the added difficulty that the fact of having focused so much on making the therapies effective, neglecting the study of why, means that it is not well known exactly which parts of the process produce a positive change. Finally, generalising the results of this therapy to the usual context of the patient’s life and maintaining them is complicated, and problems such as relapses appear with some frequency.
These problems have caused the relatively recent birth of new therapies that try to account from a renewed perspective; It is the third wave of Behaviour Therapies.
This is the latest wave of behaviour modification therapies. Those elaborated from the perspective of the need to establish a more contextualised and holistic approach to the person are considered to belong to these third generation therapies, taking into account not only the symptoms and problems of the subject but also the improvement of the vital situation and the connection with the environment, as well as the generation of a real and permanent change in the individual that allows the definitive overcoming of discomfort.
This type of Behaviour Therapy considers that psychological problems are largely due to the individual’s sociocultural and communicational context, and to the fact that a given behaviour is considered normal or aberrant. Rather than fighting symptoms, therapy should focus on redirecting and refocusing the individual’s attention towards important goals and values, improving the person’s psychosocial adjustment.
These therapies, although their use is not yet extensive, are very suitable for use with elderly people with hereinafter LD since they adapt perfectly to the special needs and difficulties that the group presents.
A context-focused therapeutic perspective
From the third generation therapies, a change is sought at a deep level, going more into the core of the person and less into the specific situation of the problem, which helps to make the changes produced more permanent and significant. The third wave is also focused on providing a better understanding of symptoms. Also, the goal is no longer to avoid discomfort or negative thoughts at all costs to help the person with Learning Disabilities to be able to vary the type of relationship and vision they have of themselves and the problem.
Another element to highlight is the importance given to the therapist-patient relationship, which is considered to be capable of producing changes in the elderly with LD. Through communication between the two, it is sought to make the functionality of the person’s behaviour change, producing changes at a deep level.
Within this third wave we find therapies such as analytical-functional psychotherapy, dialectical behavioural therapy or Acceptance and Commitment Therapy. Mindfulness is also very interesting within this wave of therapies, although not as a type of therapy in itself but as a tool that helps in emotional management.
Most therapeutic approaches to the elderly population are based on psychosocial, cognitive-behavioural, problem-solving and/or activity programming interventions. This type of intervention presents a marked emphasis on changing or controlling thoughts as the causal axis of the problem, an excessive importance of immediate well-being and a tendency to standardise treatments, thus adopting an eminently psychoeducational style.
We cannot validate this approach in the care of elderly people with LD since, on the one hand, it requires the person’s active participation and, on the other hand, it seeks immediate answers that can rarely be achieved when working with elderly people with LD.
During the last years, a large number of psychological therapies have emerged that maintain a radically different approach to the problems of the human being. Such therapies are strongly empirically oriented, with an emphasis on learning principles. The objective of these therapies is focused on altering the function of thoughts, memories, emotions or others through the context in which these symptoms are problematic in order to build flexible and effective repertoires. As a way of grouping this new set of therapies, they have been called Third Generation Therapies or Contextual Therapies.
Third generation therapies or the third wave of behavioural therapies are that set of therapies and treatments created with the purpose of modifying the patient’s behaviour, but from a global approach and closer to the person rather than to the problem, taking into account the patient’s experience of their problem and how the social and cultural context has caused their behaviour to be less adaptive.
These therapies, unlike others, absolutely respect the experiences of people, without belittling or judging them. These experiences are used as a starting point to help the person, in this case the elderly with LD, to modify them by converting painful experiences into moments that can be lived from serenity.
Unlike other behaviour modification techniques, third generation therapies are based on the power of context and dialogue to achieve said modification through the acceptance of the problem by both the patient and the therapist.
The main objective of this type of therapy is to change the way the treated individual perceives the problem, without attempting extreme control or eliminating their behaviours as if they were something to be ashamed of, but rather helping them to observe and rethink the relationship between said behaviours and the functionality that has been given to them, as well as the link itself with their usual functioning, modifying them from acceptance.
In other words, there is a need to see treatment not as a fight against symptoms, but as a vital reorientation that allows significant, real and permanent changes to be generated.
Third-generation therapies make up for some of the shortcomings of their predecessors, such as the lack of focus on the specific aspects of the treatment that produce improvement, the provocation of rigid behaviours that in turn can be poorly adaptive, and the little attention paid to the context habitual communication of the patient, as well as the perception of their own suffering.
Third generation therapies have a series of characteristics of great interest in the treatment of psychological problems. In the first place, they consider that the behaviour of an individual is not fully explainable if its context is not taken into account. If the treatment is reduced to treating some symptoms directly without taking into account the variables that make the behaviour something useful or necessary for the patient, the generalisation of the treatment to real life will be complicated for the individual in treatment.
Another aspect to consider is that third generation therapies take into account the modulating influence of language, the fact that what other people tell us and what feedback they give us regarding our behaviour will make us see the behaviours carried out in one way or another.
Linked to the previous point, the fact that third-generation therapies give a fundamental role to the therapeutic relationship is noteworthy. It is noteworthy how this therapy modality is based on the patient-therapist relationship which, in the case of the elderly with LD, is especially important. Often the lack of tools for verbal communication or even the cognitive deterioration typical of the special characteristics of the individual make it essential that this relationship be generated and maintained through links that go beyond language.
Although this is common to all or almost all existing types of psychological therapy, in the case of third-generation therapies, this relationship is seen as an element or instrument of permanent change, by producing a communicative and social interaction that can modify the behaviour directly or indirectly. Other types of therapy, although they consider the therapeutic relationship fundamental, see it more as the means by which the patient applies the techniques and not as something that produces a modification by itself.
Although they are not the only ones, others such as Mindfulness-based cognitive therapy also exist, below are briefly explained some examples of third-generation therapies that have an interesting application among the group of older people with Learning Disabilities.
Acceptance and commitment therapy
This technique is one of the best known within third generation therapies, its main objective being to help the patient to self-discover the fundamental values of the patient and help him accept the pain of the search for a happy life. It focuses mainly on working on values without evading or pathologising suffering.
Through self-acceptance, the observation of what we think and what beliefs provoke these thoughts and focusing on the current, we seek to guide the patient to get involved and commit to following their own values regardless of what society dictates, living how you think you should live.
In the case of the elderly with LD who live in residential services, this necessarily involves activating self-governance and self-determination programs that favour people having a certain autonomy for decision-making when deciding how they want to live their lives.
Dialectical Behaviour Therapy
Another of the best-known third-generation therapies, dialectical behavioural therapy, has been designed to help patients with serious emotional problems that lead to self-destructive behaviour, such as self-mutilation or suicide attempts.
Currently, one of the therapies of choice when treating Borderline Personality Disorder is based on the acceptance and validation of the patient’s suffering to work dialectically and through various modules to control and manage extreme and unstable emotions. The patient is helped to trust his emotions and thoughts and is helped to find factors that push him to want to move on and to improve his skills related to emotional self-regulation, tolerance to discomfort, self-observation and management of interpersonal relationships.
Objectives
- Promote knowledge of those factors that can contribute to active and healthy aging of the group of people with disabilities.
- Determine the attitudes and values that the professional must have for proper care and comprehensive support of people.
- Guide and give guidelines.
- Develop skills in identifying needs for the promotion and maintenance of the person’s health.
- Promote the social integration of older people by fostering their relationships among equals, as well as with other groups and increasing their social support network.
- Promote healthy lifestyle habits among the elderly population in order to promote health and prevent diseases.
- Make older people aware of the importance of physical exercise as a means of improving their quality of life, providing them with the necessary skills to practice it.
- Provide the elderly with strategies to deal with emotional processes that are more likely to predominate at their age, such as depression, anxiety, sleep problems, eating problems, sexual relations,…