Alcohol Misuse and Psychological Therapy on Health Promotion for Young Adults With Mild to Moderate Learning Disabilities

This essay concentrates on alcohol misuse and psychological therapy on health services or promotion for young adults with mild to moderate learning disabilities. Alcohol misuse is formally defined as consuming levels of alcohol that can cause an array of physical, psychological and social issues, both short and long term (Cochrane Database of Systematic Review, 2011). Psychotherapy refers to the treatment of a client by a therapist using psychological techniques and making systematic use of the client-therapist relationship. It can also be practiced by trained nurses, social workers and other healthcare professionals (The Merck Manual, 1997). This portion of the population normally comes into contact with other services after committing offences due to being inebriated and under the influence of alcohol. On my third placement, I worked with a client called Mr Green Moon (pseudonym for the purposes of confidentiality), who was aged thirty years old. He resided with his wife in a two bedroom house, receiving two hours support per day in the area of medication administration from a local agency. He was a heavy drinker who drank copious amounts of alcohol. This necessitated him always being always supported by two staff due to his previous accusations and behaviour towards staff. One day he threatened to kill his wife and kicked her out of the house. I accompanied a senior support worker to go and administer his medication during the absence of his wife. When we entered the house, there were empty cans of beer littered everywhere in the house. The house was in a bad condition, with the furniture being out of place and a debris and rubbish strewn all over the house. The issue was referred to the community learning disability team, who came and assessed the gentleman and were at the stage of referring him to the Community Drug and Alcohol Rehabilitation Services when I finished my placement. This case study outlines complications which frequently arise when people with mild learning disabilities are not aware of the consequences of alcohol misuse. Therefore, due to an overlap of mild and moderate learning disabilities (Hardy, Chaplin and Woodward, 2013), this essay will cover both areas, by evaluating current service provision in terms of psychological therapies available within learning disability practice. Where it is reasoned that such services are failing, such deficiencies will be scrutinised and suggestions put forward of how to rectify such problems. The role of the learning disability (LD) nurse will also be explored, bearing in mind a multi-agency approach to learning disability practice. The essay will also outline how, under the present climate or in the future a similar scenario to Mr Moon’s might be avoided. UK Clinical Trial Gateway (2013) and Perry et al. (2011) communicate that issues associated with alcohol misuse are becoming increasingly prevalent in people with a mild degree of learning disability due to alcohol becoming more readily available whilst living in the community. If such a person lives in the community with a low level of supervision, in impoverished conditions, parental alcohol-related issues are abundant, presence of negative role models, limited employment opportunities and excessive amount of free time, then these factors are normally the catalyst for alcohol misuse (Gates and Barr, 2009). They also identify the existence of a mental health problem, low self-esteem, inadequate self-control and cognitive limitations as contributory factors to alcohol misuse.People with mild learning disabilities who are admitted to services are provided with comprehensive needs assessments which integrate physical, psychological, social, spiritual and emotional aspects in a holistic manner, taking into consideration the client’s desires, wishes and aspirations (Gates and Barr, 2009). The assessments also covers the areas of alcohol use patterns and impact, reason for and knowledge of alcohol misuse, mental health, offending behaviour patterns and motivation to fully want to change and engage in the process of helping. Prior to beginning the assessment, the LD nurse or other professionals do provide full information about the process and obtain valid consent from the client for the assessment to be undertaken (Gates and Barr, 2009). Gates and Barr (2009) elaborate that prior to any nursing intervention or therapeutic practice taking place, the nurse must gain the client’s consent which should be obtained through an authoritative local consent policy and documented accordingly. Upon the culmination of the assessment the individual with mild LD may start receiving psychological therapies. Assessing clients without addressing the psychological effects of alcohol-related mental ill health can result in interventions being unsuccessful (Barrie and Loughlin, 2014). Psychological therapy entails numerous methods of education such as anger management, relaxation training and challenging negative statements. It also involves group therapy, promoting feeling of acceptance/ belonging using peer support, behaviour and cognitive approaches, motivational interviews and relapse prevention programmes centering on self-regulation of thinking and feeling. Behavioural interventions help individuals with mild intellectual disability (ID) develop new skills to facilitate their learning and to promote development and social functioning, to decrease destructive and harmful behaviours that an individual may indulge in, which could cause harm to themselves or others. These are founded on behaviourist theory, which posits that behaviours are learned and maintained by reinforcing events or stimuli (Gates and Barr, 2009). Given the multi-faceted and complex nature of mental ill health caused by alcohol misuse, effective management depends on a multidisciplinary approach. The main objective of multidisciplinary or interdisciplinary care in mental ill health caused by alcohol misuse is to provide the necessary knowledge and skills related to alcohol misuse, thus facilitating discussion of all relevant aspects of the client’s physical, psychological and psychosocial needs in addition to other factors pertaining to the client’s care (Barrie and Loughlin, 2014). UK Clinical Trial Gateway (2013) hypothesises that there are no specific interventions for people with mild to moderate learning disabilities that effectively treat a patient who abuses alcohol. Khan et al. (2013) concur, expounding that there is a dearth of evidence based treatment for people who misuse alcohol, arguing that preventive measures should be at the forefront of managing this population. Therefore, the aims of a multidisciplinary approach are to reduce medication consumption, provide education, promote self-management and decrease subjective experiences (Barrie and Loughlin, 2014). In practice, many psychotherapists amalgamate techniques for optimal effect, with a tailored approach taken depending on the client’s needs. Psychotherapy is appropriate for an expansive range of conditions (The Merck Manual, 1997). Those who subscribe to the statement ‘use it or lose it’ believe that frequently challenging the brain with new stimuli is conducive to keeping mentally fit (Steven, 2014). Cognitive behavioural therapy focuses primarily on distortions in the client’s thinking, challenging all the negative statements they espouse and project. Acceptance and commitment therapy is a type of cognitive behavioural therapy that has been proven to be an effective treatment for depression and anxiety when delivered by a suitably trained nurse or allied health professionals (Veehof et al., 2011, as cited in Barrie and Loughlin, 2014). This therapy is based on the principle that emotions such as fear and negative memories can influence behaviour, leading to psychological inflexibility or avoidance of situations or people who may induce and spark such negative emotions. Through a process of changing the association clients have with the thoughts and emotions connected with the element of mental ill health, it can improve functioning and help the client re-engage with his or her life despite the presence of the element of mental ill health. The objective of the treatment is not to cure, but to enhance functioning and wellbeing of the patient (Hayes and Duckworth, 2006, as cited in Barrie and Lougfhlin, 2014). A person-centred approach is suggested and clients should be actively encouraged to participate in ratifying the management plan. It explains options and involves clients in decisions (Barrie and Loughlin, 2014). In an attempt to promote self-management and improve health outcomes, there is a renewed focus on health literacy. Clients with poor heath literacy are supposedly less likely to engage in managing and regulating conditions, having a reduced capacity to self-manage and are less likely to engage with a treatment management plan (Andrus and Roth, 2002, as cited in Barrie and Loughlin, 2014).

In psychological therapy, numerous other alternatives are available for clients. Group psychotherapy and family therapy are popular methods of treatment. The focus of a psychologically based rehabilitative treatment programme, which is delivered in a group setting, is not on finding a miraculous cure, instead being an approach designed to change behaviours and negative thoughts pertaining to the effects of alcohol misuse (Barrie and Loughlin, 2014). Perry et al. (2011) elucidate that identifying an alternative social role for those who like to spend time drinking can help decrease alcohol abuse. Hobbies such as partaking in drama and art therapies are also available to people with mild ID. Art enables the client to explore alternative ways of communicating with others and have a creative form of expression, possibly allowing them to channel their frustrations. Drama offers an integration approach for people with ID, holistically addressing their learning needs (Gates and Barr, 2009). Those who are isolated may struggle to cope, possibly being more likely to drink, to alleviate underlying psychiatric or psychological difficulties, particularly anxiety and depression. Community Drug and Alcohol Rehabilitation Services are available to people with mild LDs who misuse alcohol. These drug and alcohol action teams are composed of local partnerships of professionals from local authorities, and other public bodies such as police, probation services and from private and voluntary sector providers. Their remit is to address drug and alcohol problems in the local area and they plan treatment and commission services from a range of providers in all sectors (Department of Health, 2008). In the UK attempts are usually made, using special provision in the Mental Health Act 1983, to keep offenders with mental illnesses and/ or learning disability away from the criminal justice system (Perry, et al., 2011). Organisations providing intellectual disability and mental health services have procedures in place to address the needs of adults with mild disabilities jointly agreed between services for people with LD, adults’ mental health services and local authorities (Royal College of Psychiatrists, 2012). Adults with mild intellectual disability are primarily treated by the community intellectual disability teams situated in their local communities, and where indicated, alcohol misuse treatment may be provided (Royal College of Psychiatrists, 2012). People with mild ID have access to intensive interactions with staff members, conductive education and anger management within the community. Intensive interaction is a suitable method of appreciating the patients who we interact with and to support them in developing and expanding their social and communication skills. It allows them to be more vocal about how they are feeling and people can subsequently form deeper relationships with them. Anger management aligns well with people with a mild to moderate degree of ID, as the success of these approaches is underpinned by the ability to communicate and reason at a relatively high level. It enables people with ID to manage their anger more effectively (Gates and Barr, 2009). Conductive education helps to build clients’ confidence and ability to problem-solve and regain their independence. Education intervention is defined as one that specifically aims to raise awareness of the potential dangers of alcohol misuse (Cochrane Database of Systematic Review, 2011). Besides personal interaction and multidisciplinary interventions, preventive measures such as liaising with the local media to run educational campaigns to promote abstinence or to avoid alcohol-related harm that may be resultant from alcohol misuse (Cochrane Database of Systematic Review, 2011).

People with mild learning disabilities may find it hard to navigate through services and to secure the care they need, especially those who abuse alcohol. Therefore, it is essential that service providers do not present barriers to them gaining access to treatment because of an intellectual disability or impairment (Royal College of Psychiatrists, 2012). Community learning disability teams play a vital role in helping such individuals. Their services are the union of specialist provision and enabling access to other services (Public Health England, 2013). Under specialist provision, LD nurses deliver specialist and targeted support for alcohol abuse clients, carers and their families. They assess and commission appropriate interventions and consider the needs of clients within the environment they work within (McGillivray and Moore, 2001). They conduct assessments of alcohol use, physical health, psychological state, ability to maintain independence and general practitioner (GP) registration for the function of helping clients to access an array of services such as social and mental health services (Nursing and Midwifery Council (NMC), 2008). The degree of alcohol misuse and its severity and effect should be assessed prior to treatment commencing. This provides a base line from which to quantify effect, progress and possible adverse effects of the therapy (Barrie and Loughlin, 2014). LD nurses provide direct support to people with LDs and their families when their needs cannot be met by mainstream services alone. They collaborate at length with the client’s family, care providers and other healthcare professionals. This wide-ranging approach unearths very important and essential information to supplement assessments, as well as care plan development, delivery and management (Gates and Barr, 2009). Working collaboratively with family members is integral to current government policy within LD services and an eminent professional requirement by the Nursing and Midwifery Council. For those who are literate, LD nurses distribute information leaflets about the debilitating effects of alcohol on people’s bodies, minds, relationships and lifestyle in an accessible format. Barrie and Loughlin (2014) emphasise that LD nurses should provide sufficient information in a manner clients can understand, for them to gain the necessary skills and confidence to achieve their goals, anticipate when the condition is changing and know what measures to take to self-manage their problems. Community learning disability nurses visit clients with mild LD to assess, counsel and assist them in accessing community facilities and to liaise with the consultant psychiatrists and other members of the community mental health teams (Perry et al., 2011; Public Health England, 2013). Community LD nurses work within several community settings, addressing the health needs of people with LD (Talbot, Astbury and Manson, 2010). They help clients with communication when accessing facilities in the community. Talbot, Astbury and Manson (2010) stress that communication is everything and central to life. Within the field of learning disability, professional advocacy is integral to empowering clients. After careful consideration of the issues involved, LD nurses are allowed to advocate on behalf of clients. They employ a person centred service provision, which is available to people with mild LD (Gates and Barr, 2009). Its service philosophies in the UK and elsewhere are expected to promote independence, choice, rights and inclusion. Rylance and Graham (2014) state that care planning should be a collaboration between the service user, caregiver and relevant professionals. It is based on recovery principles, where clients identify their goals and the paths to take them, rather than centering on illness, symptoms and problems. Materials like photos, pictures, objects and symbols are provided to people with mild ID may allow them to exercise their autonomy, independence and choices. Including people with mild ID in making important decisions about their lives as well as day to day decisions involves taking care to communicate in a way that make sense to any one individual, as well as comprehending and listening to the different ways people with ID communicate to staff. Effective communication is at the core of the delivery of person-centred services (Gates and Barr, 2009).

By enabling access to other services, LD nurses provide health facilitation, teaching, advice and support to both mainstream and specialist services, including access to those responsible for wider health and wellbeing (Public Health England, 2013). LD nurses are central in facilitation, by helping mild ID clients receive proper services. The Royal College of Psychiatrists (2004) outlines that ensuring a comprehensive service means making it important to implement a network of psychotherapy-based approaches across service areas. Lamp and Joels (2014) advocate that multi-agency care planning meetings should take place, assisting cohesive working between agencies. Through integrating services, LD nurses ensure that care is provided by multidisciplinary teams with members clearly understanding the roles and decision authority for client care. Well-integrated health systems are client focused that consider the needs of clients and their families across transition points, integrated processes and client choice (The Change Foundation, 2009). The practice setting for LD nursing is immersed in a complex landscape of service provision. This includes residential care homes, independent living homes, supported accommodation and people with mild LD living in their own homes as well as family homes. The role of the LD nurse is becoming ever specialised. They operate on a referral basis, taking on clients from other agencies, relatives, primary and secondary care. They compile an accurate contact list of local agencies such as outreach teams and drug and alcohol services for referral purposes. LD nurses work closely with such agencies in supporting people with minor ID. They normally work with these people from birth through to death, requiring various degrees of support throughout their lives which range from none or minimal support through to intensive holistic nursing aimed at meeting the complex needs of people with LD (Gates and Barr, 2009). LD nurses procure the consent of the client to look at their GP records in order to ascertain the level of disability and make appropriate referrals. The current system allows LD nurses to work on a referral basis, facilitating the accessibility of services such as Community Drug and Alcohol Rehabilitation Services, Marriage Guidance Services, Anger-Management Services, Legal Services, Local Council Services and various charitable organisations for people with learning disabilities (Perry, et al., 2011). LD nurses often employ motivational interviews in helping clients to alter their behaviours and attitudes. Miller (1995, 2002, as cited in Foxcroft, et al., 2014) articulates that motivational interviewing helps people work through ambivalence and commit to change. It is a direct and client centred counselling style for eliciting behaviour change by helping clients to explore and resolve any lingering feelings of ill doubt they may have. It encompasses nurses portraying an empathetic non-judgemental stance, listening reflectively, developing discrepancy, rolling with resistance and avoiding argument. People with communication difficulties may not be able to communicate to a medical professional the nature of their problem or be able to understand the advice or treatment options. LD nurses deliver information and education about care packages and service plans and support the person in making important decisions about the events which occur in their life (Gates and Barr, 2009). They promote effective communication between clients, families and other professionals by introducing communication systems such as photos, pictures, easy read, objects and so forth. Gates and Barr (2009) advocate a communication strategy which is multi-sensory and used meaningfully across a range of services. LD nurses advocate on behalf of people with ID and also school other people on how to work with clients with ID.

In essence, the research undertaken by Kerr et al. (2013) illustrates that the behavioural determinants of health among people with mild/moderate intellectual disabilities are becoming an issue of increasing concern. With the closure of long-stay institutions, more people with ID are living in the community leading ordinary and less restricted lives. They may be subjugated to social and environmental pressures that encourage them to adopt behaviours that negatively affect their health. Alcohol consumption in this client group are a pressing issue. The aim of the research was to improve the health of this client group and reduce health inequalities. The Department of Health (2008) clarify that dependent drinking can be explained by variables such as family history, psychological factors such as anxiety, depression, the addictive pharmacology of alcohol and the environment in which people live. Accordingly, LD nurses take these factors into account when performing their assessments. Furthermore, the Department of Health warns that those who exceed the recommended amount of alcohol may not be aware of the adverse health effects it has. Despite the UK Clinical Trial Gateway (2013) and Khan et al. (2013) observing that there are no specific interventions or evidence based treatment for people who misuse alcohol, LD nurses do assist them psychologically in a tangible manner. LD nurses work collaboratively with families and other professionals in helping people with mild/moderate learning disabilities. They assess clients and use psychological therapies as treatment. Barrie and Loughlin (2014) state that within the LD specialist setting, the value of psychological therapies are highly regarded as important components of the multidisciplinary approach to facilitate the client towards the ultimate goal of self-management and independence. LD nurses educate and provide full information to clients about the harmful effects of alcohol misuse. By inter-agency working, LD nurses help clients to access other services through the referral system. Gates and Barr (2009) clarify that LD nurses have several dimensions and responsibilities within their role, although supporting people with mild/moderate ID to reach their goals in the form of living their lives as fully and independent as possible is the most pertinent. The Department of Health (2008) observes that for a significant and growing number of people in England, alcohol consumption is a major cause of ill health. Therefore, LD nurses help people with mild to moderate ID, who abuse alcohol to access drug and alcohol action teams. The role of these teams is to address drug and problems in the local area and plan treatment and commission services from a range of providers in all sectors (Department of Health, 2008).

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