CASE STUDY

A structured account of short-term psychodynamic

psychotherapy with a man with learning disabilities
Alison Salvadori
University of Sheffield, UK
Tom Jackson
Barnsley Learning Disability Service, UK

Abstract
This article describes a short-term psychodynamic treatment of a learning disabled adult male, referred to a community psychology service
with social withdrawal and refusal behaviours. It explains the nature of the intervention, progression through the therapeutic process,
development of hypotheses and the emergent formulation, and therapeutic outcomes for the client.
The article identifies the suitability of short-term individual psychodynamic psychotherapy for cases such as this, and demonstrates how
such interventions can be documented through structured accounts of treatments, which link theory to practice.

Key words
learning disability; intellectual disabilities; psychodynamic psychotherapy; clinical practice; structured account

Introduction activities’. Bob was invited to attend a screening appointment,

There is a growing body of work suggesting that people with
learning disabilities make positive gains with psychodynamic
psychotherapy (Beail, 2003; Willner, 2005). Beail (1998) and
Beail et al (2005) showed that adults with learning disabilities
can benefit from individual psychotherapy provided in routine
clinical practice. Further studies have also demonstrated
that significant change can occur in relatively short-term
psychodynamic psychotherapy with this client group (Beail et
al, 2007; Newman & Beail, 2005).
In this type of psychotherapy the therapist is concerned
with the client’s mental representation of themselves. The
relationship between the client and the therapist is used
to bring about therapeutic change. The client is helped
to identify the origin and meaning of difficult feelings and
to integrate unacceptable aspects of themselves and their
relationships into their broader understanding of themselves
(Beail & Jackson, 2008).
The client
Bob (a pseudonym) is a single man in his fifties who acquired
a learning disability following childhood meningitis which also
left him with severe epilepsy. He lives in a nursing home. He
was referred to psychological services due to concerns that
he has periods when he does not eat and ‘withdraws himself
to his room and refuses to attend or partake in organised
where he reported that he felt that his head was sometimes
in a different place and that he often felt sad. He agreed that
at times he had a poor appetite and that he tended to isolate
himself from the other residents. There was no medical
explanation for his problems. Bob said that he would like the
opportunity to talk about his feelings, and he was put on the
waiting list for short-term psychodynamic psychotherapy.
Format of therapy
In psychodynamic therapy the stages of therapy – assessment,
formulation, intervention and to a certain extent, evaluation
– run concurrently (Beail & Jackson, 2008). This case study
is organised in a way that reflects this approach. The work
that Bob and I undertook spanned 10 sessions and is
described here in terms of early, middle and end phases.
The therapeutic endeavour concentrated on managing
the boundaries of the therapeutic relationship, using
basic techniques to help Bob tell his story and seeking to
understand the unconscious content of Bob’s communication.
This was achieved by reflecting upon, and where appropriate
interpreting, the meaning of anxieties and defence
mechanisms. The details and rationale for these processes
will not be described in full here, but followed the basic
principles outlined in standard texts (Jacobs, 2004; Lemma,
2003; Malan; 2001).

Advances in Mental Health and Learning Disabilities Volume 3 Issue 4 December 2009 © Pier Professional Ltd 31
A structured account of short-term psychodynamic psychotherapy with a man with learning disabilities
Early phase
Contracting and establishing boundaries
Psychodynamic approaches emphasise the importance of
the therapist setting up and maintaining the boundaries that
form the therapeutic space: place, time, conduct required and
relationship (Molnos, 1995). Provision of this safe environment
will help to contain Bob while he examines and attempts to
understand past emotional conflicts (Jacobs, 2004). Our first
meeting followed a different format from the subsequent
sessions. I explained the nature of the therapy and set out the
therapeutic boundaries, and then obtained Bob’s informed
consent to treatment.
Content of sessions
Bob was a wheelchair user and was assisted into the therapy
room by one of his carers. He presented as somewhat
unkempt and was wearing a protective helmet, the strap of
which was not secured and was dangling beneath his unshaven
chin. Bob said his nurse had only told him that morning that he
was coming to see me. He said that he had not been coerced
into attending, however, and was happy to meet regularly and
talk to me. He was vague about the nature of his problems, but
said that he had been ‘subjected to the wheelchair’. He thought
he might give it up soon and start walking, but remarked:
‘if I do it, I want it to be on my own terms and no-one else’s’.
In our subsequent early meetings I used a number of basic
techniques such as listening, observing and reflecting to help
Bob to tell his story (Jacobs, 2004). Bob was the only child of
a coal miner and his wife; the family’s life had centred on the
village chapel. His illness had caused him to fall behind at school
and be excluded from chapel. Following his parents’ death,
about 20 years ago, Bob said that his life did not change really
and that he just went to live with his cousins.
The boundary of time was violated in our third session. Bob
was 15 minutes late. He said that there was lots going on in his
home and the carers were late bringing him. The other ‘guests’,
as Bob called them, had been playing snooker and bingo. Bob
said that he never played these games as he was too good and
won every time. This session was punctuated by long silences.
At the end of the session Bob told me he had knocked out a
famous boxer’s twin brother.
Process issues
The developing relationship between the therapist and the
client is a crucial aspect of psychodynamic therapy, known as
transference. The client transfers patterns of behaviour, feelings
and anxieties from his past and current relationships into his
relationship with the therapist (Malan, 2001). This reference
to knocking out a boxing champion was understood to be a
veiled threat in order to keep me at a distance. A pattern of
passive-aggressive behaviour was starting to emerge in the
transference. I felt my heartstrings were being pulled by Bob.
32 Advances in Mental Health and Learning Disabilities Volume 3 Issue 4 December 2009 © Pier Professional Ltd
I wanted to lean forward and secure his chin strap and to tidy
him up and shave him. I could also feel Bob pushing me away.
In these early sessions I had a real sense of Bob slipping
in and out of engaging with me. He appeared at times to be
swept by strong emotions, but they were not verbalised. I
noticed that the muscles in his arms twitched and that he
swung his legs periodically, particularly when he talked about
his father. The fact that he was dependent on his carers to
bring him to the session had made me question my decision
to challenge his lateness. This had, however, given him an
opportunity to air his feelings of superiority over the other
residents and to start to look at issues of dependency.
Supervision
In supervision, I was helped to make sense of my observations
of Bob’s appearance and his untied chin strap on a counter-
transference level. My emotional reaction to Bob was likely to
reflect how others experienced him (Lemma, 2003). Bob was
unconsciously signalling ‘care for me’ but was also holding back
from me. On a number of levels he was expressing irritation
with his carers and feelings of superiority to his fellow residents.
Beail and Jackson (2008) suggest that Klein’s theories
of early development are useful in understanding the
psychic structures of people with learning disabilities. Klein
hypothesised that the developing child’s recognition that
they, as well as their parents, contained both good and bad
within themselves was the source of an unbearable conflict
(Klein, 1975). She posited that a number of primitive defence
mechanisms serve to protect the child from the anxieties which
arise from these unmanageable feelings. Bob exhibited two of
these primitive defences: splitting and projection. Bob had so
far made no reference to his learning disability. Bob’s account
of his present situation suggested that he had split off this
unacceptable, disabled aspect of himself and projected it on to
the other residents.
Tentative hypotheses
Despite being surrounded by people, there was a sense that
Bob was lonely. He did not align himself with his peers; there
was a sense that he was better than them because they had
learning disabilities and this was something in himself that he
would not acknowledge. A primary handicap, such as a learning
disability, may be made worse by a defensive exaggeration
(Sinason, 1992). We hypothesised that Bob’s refusal to walk
and his long-term use of a wheelchair were a secondary
handicap. We thought that it might enable Bob to exercise
some power and control over his carers or give him a reason,
aside from his learning disability, to be cared for.
Middle phase
Developments
The middle phase of therapy followed an unplanned break
brought about by my being taken unwell immediately before
Bob’s session. Bob did not then attend the subsequent session.
A structured account of short-term psychodynamic psychotherapy with a man with learning disabilities
I felt that Bob was shutting me out, perhaps even punishing me
for cancelling the session. I reflected this back to Bob and he said
that he had always kept himself to himself. He then remarked ‘I
should be married now’. We spent time exploring what it felt
like to live in a nursing home and not be married. Bob said that it
was ‘rubbish’ and was very moved.
This episode was one of a number of examples in this phase
of the therapy when I used interpretations to help Bob to access
his hidden feelings. Malan (2001) uses the Two Triangle model
to depict the process of psychotherapy. This model was to help
develop the emergent formulation as the following example
demonstrates.
Bob had a new carer who took him to the wrong
department, so he was 25 minutes late for our session and once
again his defence of splitting was evident. He was angry one
minute and then meek and remorseful the next. From working
in the here and now (T) in the triangle of person, we made a
link with the past (P). It became apparent that another carer,
Bob’s father, had also failed to come up to expectations. Bob
thought that the reason he could not express his feelings was
that his parents ‘always dealt with that sort of thing’. It transpired
that his father used to answer for Bob when people asked him
questions. He told Bob that he could get the words out better.
Emergent formulation
In supervision, we identified the recurring conflicts in Bob’s
relationships within himself and with others. The portrayal
of these conflicts is one of the distinctive features of a
psychodynamic formulation. Lemma (2003) recommends
structuring the formulation using a six-step approach, and this
was the format adopted here.
1. Bob’s problem
Bob is reacting to the people who provide him with care and
to people with learning disabilities who are cared for. Bob
feels that he is not worthy and suspects that his parents did
not love him. The feeling that Bob is most afraid of and that
he is trying to avoid is his own neediness and dependence
on others. This difficulty in acknowledging the existence of
the disability and the fear of dependency are two of the five
mutative factors that are recurrent themes for people with
learning disabilities (Hollins & Sinason, 2000).
2. The psychic cost of the problem
Bob’s passive-aggressive behaviour is a way of resisting being
cared for. His mobility is now limited after years spent using
a wheelchair. He is lonely in his home, as he has distanced
himself from the other residents.
3. Contextualising the problem
Bob’s disabilities slowly marginalised him from the community
and ultimately removed him to a residential home. His life
took a very different direction from that of his school friends.
As his awareness of his difference and disability grew, he
Advances in Mental Health and Learning Disabilities Volume 3 Issue 4 December 2009 © Pier Professional Ltd
became increasingly disenfranchised. These significant changes
in his status were paralleled in his developing psyche and he
became increasingly defended to protect himself from his
many losses. Bob’s mother was in many ways absent and his
father did not support him in a way that felt appropriate. Bob
could not be angry with his dad, as he was dependant on him.
Like many people with a learning disability, Bob received
a double blow when his parents died because he also lost
his home (Sinason, 1992). He was pleased that he did not
cry at either of his parents’ funerals; his cousins had told him
that ‘grown-ups don’t cry’. There is a tendency for people
with a learning disability to be infantilised, so it might be
the case that belonging to the group that does not cry was
another way of disassociating himself from those with learning
disabilities. Sinason (1992) also suggests that those with
learning disabilities are encouraged to hide their sad feelings.
There were therefore a number of factors modulating Bob’s
expression of affect.
4. Bob’s most dominant and recurring object relationships
Bob’s relationships are split into good and bad. The
good objects involved in his care become bad once he is
confronted with a negative about them. He finds it difficult
to acknowledge that good and bad co-exist in a person. This
is particularly apparent in relation to his father; Bob cannot
tolerate loving his father and hating him. This splitting of
objects is mirrored by ego splitting, with a ‘nice passive Bob’
who never complains and is usually apparent, and an inner
‘angry Bob’ who is furious with those around him and with his
father. At the heart of his conflict is the dilemma of trying to
reconcile the disabled, dependant, needy Bob with someone
who is also actually ‘OK’.
5. Identify defences
Bob needs to keep anger away from his conscious awareness
and therefore hidden from carers so that they will like him
and care for him. However, his anger is always threatening to
surface in relationships in which he is ‘cared for’. Bob uses the
primitive defences of splitting and projection to keep apart
contradictory experiences of his sense of self and significant
others. Attempts to bring the split part objects together
trigger a range of emotions and further defences in Bob.
Bob used superiority and passivity to disguise his learning
disability. He also disguises poor walking by not walking.
He is over-dependant and blames others for events such
as his lateness for appointments. In addition to his learning
disability, feelings are also absent in Bob’s dialogue.
6. Identify the aims of treatment
In the long term it was to be hoped that Bob could be
helped to recognise that the loved and hated objects
are one and the same. This recognition would bring new
anxieties for Bob which would be confronted in what Klein
called the Depressive Position (Klein, 1975).
33
A structured account of short-term psychodynamic psychotherapy with a man with learning disabilities
The Assimilation Model (Stiles, 2001) provides a
structured account of the changes that may occur within
psychotherapy. Stiles proposed a sequence of eight levels of
assimilation of a problematic experience. We hypothesised
that Bob was at the warded off stage (level 0) although his
carers were making a clear problem statement (level 3). The
initial referral of Bob’s disordered eating and not socialising
could be conceptualised as behaviour that challenges the care
staff rather than Bob’s problems. As in Bob’s case, people
with learning disabilities often present for treatment without
awareness of their problems. Psychodynamic therapy can
help them to move towards recognising them and facilitate
movement to higher levels of assimilation of the problematic
experience (Beail & Jackson, 2008; Newman & Beail, 2005).
End phase
Using this formulation I started to communicate to Bob
unconscious aspects of his thinking. This was achieved by
linking issues in the therapy room, in the here and now, to
the problems in his current relationships at his home and his
past relationship with his father.
Bob started to use his feet to propel himself into the room
in his chair. He also started the sessions without prompting,
telling me what he had been reflecting on since the previous
session. Bob wanted to talk about his father but was worried
that he would hear him; ‘it’s like he is sitting next to me’. I
asked him what he would like to say to his dad; ‘butt out and
let me do the talking!’. As therapy progressed Bob started to
explore his anger towards his father – ‘I thought he was going
to be there the whole time’ – and the guilt he felt for having
these angry feelings: ‘It shouldn’t take away the love that I
felt for him’. He started to show signs of integrating the two
part objects, realising that the ‘good dad’ who stood up for
him was also the ‘bad dad’ who would not let him speak. Bob
managed to integrate these splits with the realisation that ‘he
didn’t know more than me’.
As we entered the termination phase of the therapy
Bob appeared to struggle to relate to me, and a negative
transference emerged. I continued to make gentle
interpretations while being the object of his negative feelings
and containing him. I reflected back to Bob the sense I had
of his disappointment and sadness that we were going to
be finishing. I suggested that it was hard for him to relate
to me now because we had developed a good relationship
but I was leaving him. In this way the two parts of me as the
therapist and a caring object were presented for him to try
and integrate. By making T/P/O links in the Triangle of the
Person I was able to show Bob the parallels between his
feelings towards his father, the care staff and myself.
Bob started to acknowledge that he acted one way but
felt different inside. He was ‘nice Bob’ who was no bother to
anyone, but he said that there was also an ‘inside Bob’ who
was very different and had lots of anger, passion and feelings
that no-one could see.
34 Advances in Mental Health and Learning Disabilities Volume 3 Issue 4 December 2009 © Pier Professional Ltd
Outcome
Subjectively, Bob appeared to have had a meaningful
experience. During our last session Bob reflected on his
experience of therapy. He said it helped him to realise that
his father was still a major influence on his life, although he
had been dead for more than 20 years. He said that he felt as
if a veil had been lifted from his face.
In terms of the assimilation model, the outcome of
psychotherapy is understood as change in relation to
problematic experiences (Stiles, 2001). Bob moved from
being warded off (level 0) to understanding/insight (level
4). At the evaluation meeting the carers reported that Bob
had been refusing to bath and comply with staff. When this
was explored it appeared that Bob was less passive and was
starting to assert himself. Rather than refusing to bath, he
had told staff that he did not find it necessary to bath every
day. One of the four guiding principles of Valuing People
Now (DH, 2009) is that people with learning disabilities
should have greater choice and control over their lives.
Offering psychotherapy services to people like Bob is one
way of empowering them and moving towards fulfilling these
objectives.
Among the strengths of this piece of work was the
suitability of the model for the client. The analytic attitude has
been described as Freud’s greatest creation (Schafer, 1982
p3). Adhering to the boundaries of therapy created a frame
that contained Bob and allowed him to tell his story. This was
particularly poignant in Bob’s case as he had previously been
denied the right to speak by his father. The various instances
when these boundaries were violated were highly symbolic
for Bob, and provided him with tangible examples of the
sources of his difficulties.
What new information does this case study add?
This case study shows how psychodynamic
psychotherapy can be reported in a structured way.
The paper shows how links are made from theory to
inform practice.
Address for correspondence
Alison Salvadori
Clinical Psychology Unit
Department of Psychology
University of Sheffield
Western Bank
Sheffield
S10 2TP
UK
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