Psychotherapeutic Interventions in the Treatment
of Social & Emotional Secondary Effects of
Transpersonal Counseling Psychology
This paper explores the potential psychosocial secondary effects of growing up with anundiagnosed or untreated learning disability. The beginning section of the paper focuses on basic definitions and common etiological theories. The next segment describes some of the cognitive and perceptual difficulties that can accompany learning disabilities, and discusses the importance of metacognitive and compensatory strategies in addressing these difficulties. The middle section focuses extensively on the psychosocial aspects of learning disabilities, and includes a discussion of various treatment options. The last section of the paper embarks upon an in-depth exploration of the risks, benefits, special concerns, and necessary modifications of psychotherapy as a treatment for people with learning disabilities. The paper ends with a personal conclusion that strongly emphasizes the need for greater acceptance of the wide spectrum of learning patterns that exists within our communities.
Learning Disabilities: An Introduction
Learning disabilities are broadly defined as wide discrepancies between general intelligence and specific areas of academic performance. Learning disabilities (LDs) are currently estimated to exist among 5 percent of the population of school-aged children in America (Torgeson in Wong, 1991). Research shows that many children and adults with learning difficulties - especially those with a subtle presentation of symptoms - still go undiagnosed and untreated. There is also an ongoing gender gap in the diagnosis of LD: "The evidence suggests that LD females with the same level of intelligence, and type and severity of LDs as males, will not be as frequently identified" (Adelman & Vogel in Wong, 1991, p. 584). Hopefully, assessment procedures will improve so that every person in need can be diagnosed as early as possible.
In addition to the problems with diagnosis, there are also shortcomings in the treatment of people with LD. There is currently a wide gap between the fields of special education and psychology. Generally, special education teachers are trained to work with academic issues, not to help their students cope with the psychological symptoms that often accompany learning disabilities. Similarly, most psychotherapists do not receive any training in how to work with the issues specific to people with LD, nor do they always understand how to adjust their therapeutic style to the cognitive and perceptual irregularities exhibited by clients with learning disabilities (Shulman, 1984; Wren & Einhorn, 2000).
Research studies conducted within the last 20-30 years have yielded a great deal of information about the painful secondary effects of untreated learning disabilities. In order that people with LD be provided with the most comprehensive and high quality interventions possible, the gap between the fields of psychology and special education needs to be bridged. When these professions begin to share their ample gifts and expertise with each other, the lives of the people they serve will be immeasurably improved. In turn, when all people with LD are given adequate support and treatment, society will reap the full benefits of their unique strengths and creative contributions.
Definitions and Etiology
The cognitive discrepancies endemic to people with learning disabilities often manifest within standardized intelligence tests as significant score differentials between separate sections or subsections. According to the Diagnostic and Statistical Manual of Mental Disorders, "Learning disorders are diagnosed when the individual’s achievement on individually administered, standardized tests in reading, mathematics, or written expression is substantially below that expected for age, schooling, and level of intelligence" (DSM-IV-TR, 2000, p. 49). In this case, "substantially below" is defined as a discrepancy of more than two standard deviations, or two years of a child’s life. The DSM-IV describes three main categories of learning disabilities: Reading Disorder, Mathematics Disorder, and Disorder of Written Expression. The DSM-IV provides brief descriptions of the cognitive and/or perceptual aspects of each disorder and gives ample information about how to make a differential diagnosis.
This section of the DSM-IV is problematic because of its brevity and omissions. It does not provide any information about Nonverbal Learning Disorder or other disorders of a visual-spatial nature; says nothing about the "Gifted/Learning Disabled" population; neglects to discuss related disorders such as Central Auditory Processing Disorder and Sensory Integration Dysfunction; and confines its exploration of the social, emotional, and occupational components of learning disabilities to one brief and perfunctory paragraph. Finally, it does its readers the disservice of portraying learning disabilities as childhood disorders, primarily affecting school-aged children and adolescents.
In fact, LDs are now considered to be life-long disorders, remaining intact throughout childhood, adolescence, and adulthood (Roffman, 2000). Five percent of school children are currently diagnosed with LD (Torgeson in Wong, 1991), but some specialists estimate that as many as 20 percent of elementary-aged children actually have some form of the disorder (Novick & Arnold, 1991; Orenstein, 2001). One explanation offered by learning theorists for this sizable estimate is that many of the children whose learning difficulties represent secondary side effects of primary psychological or behavioral disorders (e.g. Oppositional Defiant Disorder or Depressive Disorder) are mistakenly getting pooled into the same category as those who have LD as a primary diagnosis (Rourke & Del Dotto, 1994).
In addition to the DSM-IV description of LD, two of the most commonly-used definitions are the ones developed by the National Joint Committee on Learning Disabilities (NJCLD) and the Individuals with Disabilities Education Act (IDEA). The IDEA definition is the more minimalist of the two, and emphasizes the fact that LD represents a disruption in one of the cognitive processes underlying various aspects of learning. This definition also provides the basic criteria for making a differential diagnosis between LD and other disorders - for instance, those of a purely psychological or behavioral nature (Shapiro & Rich, 1999). The definition offered by NJCLD is the more comprehensive of the two. It refers to LD as a condition: 1) characterized by difficulties in various cognitive processes (listening, speaking, reading, writing, reasoning, or mathematics), 2) attributable to central nervous system dysfunction, 3) occurring across the life span, and 4) often being accompanied by problems with self-regulation and social perception (Torgeson in Wong, 1991).
There are many different theories about the etiology of learning disabilities,
ranging from purely neuropsychological explanations to those which focus primarily on psychosocial factors such as early childhood trauma. Most learning specialists orient
themselves somewhere between these two polarities, exploring the interaction between
neurochemical or biological factors and those of an environmental nature. The predisposition to having learning disabilities is strongly hereditary; LD can often be traced through several generations of the same family (Smith, S., 1991). According to Shapiro & Rich (1999), there is a 35-45% likelihood of inheriting a learning disability from a parent who has the disorder. Tests that measure electrical activity in the brain have shown distinctive patterns in the parts of the brain related to a specific learning disability. For instance, Positron Emission Tomography (PET) scans have revealed different degrees of glucose consumption in the language-related areas of the brains of people with dyslexia than in those without the disorder (Shapiro & Rich, 1999).
A different biological theory regarding the formation of LD looks at actual anatomical variations in brain development. Magnetic Resonance Imaging (MRI) tests have revealed that in some dyslexics, the hemispheric lobes are of equal size, whereas in the brains of non-dyslexics they are asymmetrical, with the left lobe being the larger of the two (Shapiro & Rich, 1999). Another biological theory suggests a possible link between endocrine system imbalances and the development of learning difficulties (Gaddes & Edgell, 1994). Underproduction of the hormone thyroxin, known as hypothyroidism, can produce poor memory and low IQ. Conversely, hyperthyroidism, caused by an overproduction of thyroxin, can produce hyperactivity, irritability, and difficulty in concentrating - all symptoms which can interfere with learning and attention.
Roffman (2000) asserts that both pre- and postnatal trauma have been associated with the development of learning disabilities. Other possible environmental factors in the formation of LD include pre- and post-natal exposure to pollutants, radiation, and heavy metals (Gaddes & Edgell, 1994). Some studies have linked lead poisoning to hyperactivity, while others have explored a possible connection between harmful fluorescent lighting and impaired classroom learning.
Finally, there are sociological factors to consider. The presence of extreme poverty, substandard living conditions, various forms of environmental deprivation, and any kind of abuse can hamper brain development and produce the sort of severe and chronic stress that makes learning impossible (Gaddes & Edgell, 1994). Dr. Dee Coulter’s understanding of learning disabilities is that they invariably involve early trauma or stress to the system (D. Coulter, personal communication, March, 2002). Whether or not there is an innate biological predisposition, stress is largely what determines whether the vulnerability to learning disabilities will turn into an actual disorder. Dr. Coulter points out that events considered traumatic by adult standards are not necessarily the kinds of events that need to happen in order to cause a trauma response in a child. Because a young child’s nervous system is still in formation, it is much more sensitive than an adult’s, and is therefore more easily brought into imbalance. Examples of mild-to-moderate stressors that might affect a child’s neurological functioning are geographical moves, separation from someone important to the child, and living with a parent who experiences chronic stress.
Another key aspect of these early stressors is the developmental point at which they occur in a child’s life. Dr. Coulter (personal communication, March, 2002) pinpoints the age of six as being a very sensitive time because it marks the onset of concrete operational thought. Trauma occurring before or during this age can disrupt cognitive functioning to the point that certain forms of concrete logic, such as cause-and-effect thinking, won’t begin on schedule or at all. Children who are exposed to extreme, chronic stress or physical threat can actually develop distorted vision and hearing: the eyes start to see panoramically so as to be able to scan for danger, and, with the same kind of exaggerated vigilance, the ear learns to listen for tone of voice rather than word content (tone is often a more accurate purveyor of affect than the words themselves). The physiological effects of these distorted responses are that the eyes become unable to narrow their focus - quite an impediment when learning how to read - and the middle ear muscles become flaccid, resulting in weakened listening and language processing skills.
Learning Disabilities and Cognition
More and more learning theorists are beginning to understand the role of the body in cognition and memory. Maria Montessori, a 19th century Italian scholar turned educator, maintained that early childhood education had to be based on tactile and sensory experiences, because tactual perception is the primary conduit for learning in the early years. Within recent years, brain research has proved her point. It is now understood that the reason why infants explore the world primarily through touch is that "the myelination of cortical cells in the sensory and motor strips and the occipital lobe is most advanced at birth" (Gaddes & Edgell, 1994, p. 189). Young children are hard-wired to experience and learn with their senses.
Smith (1991) talks about the importance of "whole body" learning, with full engagement of the sensorimotor system, within certain subpopulations. She points out that for people with LD, and especially for those who are most at home in the concrete operational stage of reasoning, engaging the senses in new learning tasks is not just a luxury but a necessity. We all start out as concrete learners, and for some, the sensorimotor quality which marks the early stages of human exploration remains a vital paradigm for subsequent learning experiences. One of the impacts that sensorimotor learning has on the cognition of people with LD is that it enables them to understand part-to-whole relationships - normally an area of considerable difficulty - in a tangible and concrete way. Concrete teaching also helps develop inductive and deductive reasoning skills, and ultimately smoothes the way for critical thinking and language development to take place.
If sensorimotor learning channels are the most active ones used by preoperational and concrete learners, then it goes without saying that poor sensorimotor integration during the early years can severely impede the learning process. Dr. Coulter (1988) discusses the various ways in which learning difficulties can be caused by developmental problems of a physical nature, such as reflex patterning that never got completed at birth. Children with Sensory Integration Dysfunction (SID) and other physiologically-based organization problems are so busy using their brains to control their bodies that there is no mental space left for high-order thinking (Coulter, 1985). Dr. Coulter advocates a variety of different approaches to sensory integration problems, including occupational therapy, the enactment of contemplative movement practices such as T’ai Chi, and the interspersing of academic work with physical exercise and other forms of self-care.
Memory and Perception
Many people with LD have trouble with both short and long term memory processes. According to Swanson & Cooney (in Wong, 1991, p. 104), memory is "the ability to encode, process, and retrieve information that one has been exposed to. As a skill, it is inseparable from intellectual functioning and learning." Smith (1998) discusses the fact that what looks like poor memory is often in fact a problem with disorganization. Many people with LD need help in restructuring their mental filing and reference systems so as to be able to find the pieces of information that they’re looking for at any given time.
Research in developmental psychology has shown that sensory input, when combined with verbal description or explanation, helps preoperational children to form schemata (Smith, S., 1991). Schemata are memory banks that form a link between past and present experiences and thus imbed memories firmly in place. Research has proven that the more elaborate and detailed our schemata are, the better our later recall will be (Shapiro & Rich, 1999). Memory formation inevitably involves both the ability to receive new information and the ability to integrate that information with what one already knows to be true (Swanson & Cooney in Wong, 1991). This is especially so for many people with learning disabilities: in order for incoming information to be properly filed and stored, it needs to make sense within a larger network of ideas. It is unlikely that new information will become stored as long-term memory if there is no intellectually, emotionally, or ideologically salient context within which to make sense out of it (Coulter, 2001).
Where people with LD tend to encounter the most severe memory problems is in the realm of short term memory (Shapiro & Rich, 1999). There are various theories as to why things tend to go wrong within this memory stage. Some research has suggested that people with LD often have difficulty with the processing of incoming stimuli and with the mental representation of information (for example, the use of accurate phonological coding). Some of the most heavily-researched theories have to do with information storage; most learning theorists name this memory-related function as the one that is the most difficult for people with LD, and the one most responsible for recall problems. If there is no organized storage system in place, then material will get "lost" in the brain and will ultimately be irretrievable. Memory storage can be likened to an office filing system, in which bits of information are labeled and categorized so that, once put away, they can later be reaccessed. In order for information to be held in short term memory long enough for it to be transferred to long term memory storage, the individual needs to use strategies such as rehearsal, grouping and chunking of material, and elaborative processing - all skills which can and should be formally taught to people with learning disabilities.
Roffman (2000) identifies and describes the perceptual irregularities often experienced by people with learning disabilities, and provides examples of the kinds of real-life difficulties that can result. For instance, auditory memory deficit - an inability to store and retrieve aurally-derived information - might make it challenging to remember a series of verbal instructions. Spatial orientation problems might result in someone getting lost while driving, hence arriving late for an appointment. Since "psychological and social growth rely heavily on the timely development of sensory-perceptual, motor, and linguistic abilities" (Novick & Arnold, 1991, p. 55), impairment in any of these areas can lead to various deficits in psychosocial functioning. The development of strategies designed to soften the impact of perceptual irregularities (e.g. doing a "dry run" drive the day before an interview in order to ensure a timely arrival) is imperative. Psychotherapists, learning specialists, and LD coaches can all assist clients in the formation of such strategies.
Learning Disabilities and Executive Functioning
Smith (1991) states that many children and adults with LD have problems with internal organization and self-regulation. Self-regulation is a term that refers to the ability to monitor one’s behavior, regulate emotional arousal levels, set goals, plan ahead, think critically, and make decisions. According to Elaine Aron (1996), everybody has his/her own optimal arousal threshold; too much is anxiety-provoking and can flood the nervous system, but too little often results in boredom or depression. One of the tasks of growing up is finding and maintaining one’s own optimal threshold for stimulation, by monitoring how much sensory information one takes in at any given time and filtering out irrelevant stimuli. Other tasks include learning how to regulate one’s affect and stress levels. Self-regulation also involves the ability to take initiative and ask for help when it is needed (Martinez-Pons, 2002).
In people with normal central nervous system functioning and adequate environmental stimulation, these skills of self-regulation develop naturally through childhood and adolescence. However, central nervous system irregularity often predisposes people to needing external help in learning inner regulatory processes. Therapists working with both children and adults with LD need to teach them how to modulate their emotional responses - for instance, to calm themselves when they become agitated, to find ways to express anger that don’t harm themselves or other people, and to screen out excess sensory stimulation. One way of teaching these skills is by modeling them (Martinez-Pons, 2002). Another way is by introducing controllable challenges within a safe environment; coping with moderate and predictable forms of stress helps children gain emotional resilience (Perry, 2001).
Teachers and parents are encouraged by learning specialists to provide extra help to their LD children not only with the above-mentioned psychological aspects of self-regulation, but also with pragmatic and academic components such as behavior-monitoring, goal-setting, organizing, planning, and prioritizing (Smith, S., 1991), all of which are currently known as "executive functions." Teachers need to help students learn how to approach difficult or multi-stepped tasks and encourage the students to pace themselves. Teachers also need to help their students see patterns, categorizations, and relationships, since part-to-whole relating is an ongoing challenge for many people with LD. Finally, teachers need to coach their students in the use of metacognitive strategies.
Metacognition can be defined simply as the knowledge of how one’s mind learns and remembers. Understanding one’s own learning process provides opportunities to acquire and implement the strategies that allow for optimal functioning for people with LD. Dr. Coulter (2001) defines metacognition as the development of what Russian neuropsychologist Alexander Luria termed "inner speech" - the ability to talk oneself through difficult or multi-stepped tasks. In the preoperational years, this inner dialogue happens out loud, but at age seven or eight it usually becomes a silent process (Coulter, 1985).
The ability to use inner speech can be jeopardized by intrapersonal factors such as nervous system overarousal and low self-esteem (Bradley, 1990). People who can’t make use of inner speech are often unable to regulate their own learning or affective processes. Children in whom there is no intervening self-speech between initial impulse and resulting action are without what Dr. Luria once called a "functional barrier" (Coulter, 1985). This functional barrier serves as a mediator between impulse and behavior; it helps buy the necessary time for a person to brainstorm several different options, rather than acting on the first one that comes to mind. While inner speech and other metacognitive functions usually develop naturally as children progress through the school years, children and adults with LD often need external assistance in forming and using these strategies (Shapiro & Rich, 1999).
Learning Disabilities: Risk & Protective Factors
Psychosocial Risk/Protective Factors
At each developmental juncture, there needs to be a balance between risk and protective factors in a child’s environment (Shapiro & Rich, 1999). It is the interaction of external protective factors with internal strengths and resiliencies that will lead to academic and psychosocial success for all children, whether learning disabled or neurotypical. Conversely, it is the interaction of difficult school and family dynamics with internal suffering that increases the associated risks (Wren & Einhorn, 2000). A child who lacks inner cognitive or emotional resources will need extra support from the environment in order to thrive, and a child who functions in a deprived or abusive situation will need to be taught how to cultivate inner resilience. Obviously, the most at risk child is the one who is both intrinsically and extrinsically vulnerable (Shapiro & Rich, 1999).
Psychologist Emmy Werner (as cited in Shapiro & Rich, 1999, p. 94) found that certain protective factors contributed to the later psychosocial success experienced by the learning disabled subjects that she was researching. The specific protective factors found to be beneficial were: "positive temperamental characteristics, the ability to use compensatory strategies, realistic goal setting, and the help of supportive adults." In a study conducted by Susan Vogel & colleagues (as cited in Shapiro & Rich, 1999), the following risk factors were found to have later deleterious effects on the emotional well-being of those researched: increased degree of severity of the learning disability, comorbidity with psychiatric diagnoses, and poor social skills.
Academic & Professional Risk/Protective Factors
Protective factors within the work place involve using self-knowledge about personal strengths and weaknesses to choose a career which capitalizes on areas of strength (Rodis in Rodis, et al., 2001). Also of importance is the capacity to be one’s own advocate, and to identify and ask for necessary accommodations and modifications (Roffman, 2000). Professional success has been correlated both with the use of internally-generated strategies and with the ability to set up one’s environment in such a way that it provides optimal support while minimizing areas of difficulty (Novick & Arnold, 1991).
Within the academic arena, small class size, availability of one-on-one tutoring, and the presence of teachers who are willing and able to teach to different learning styles are all associated with success for students with LD. Other school-related protective factors are self- and other-acceptance of one’s LD, the ability to advocate for oneself, good communication skills, the willingness to garner support and assistance as needed, strong metacognitive skills, self-determination, the willingness to make mistakes and learn from them, and being provided with ample opportunities to experience competence, accomplishment, recognition, and affection from staff (Cohen, 1999; Shapiro & Rich, 1999). Risk factors, on the other hand, include rejection by teachers and peers, academic failure, lack of personal resiliency, severity of symptoms, comorbidity with Attention Deficit/Hyperactivity Disorder (ADHD), and poor social skills.
Another risk factor for students with LD is the possession of a negative attributional style (Bryan in Wong, 1991). Elementary school-aged children with healthy self-esteem and self-efficacy - a sense of trust in their own ability to master challenges - are likely to attribute successes to intrinsic ability (internal locus of control) and failures to the mistakes and misperceptions of others (external locus of control). Children with learning disabilities do just the opposite: they attribute their successes to mere luck and their failures to a lack of intelligence (Smith, C., 1998).
Negative attributional styles are especially dangerous for children with LD, who often struggle to perform at grade level and are therefore extremely vulnerable to feelings of failure and learned helplessness. Developing a positive attributional style is an important antidote to these feelings; it has been linked with success in a variety of different tasks and situations, including classroom behavior, academic performance, and social relationships (Bryan in Wong, 1991). Formal attribution retraining has been shown to be a successful intervention for people with LD, helping them to alter their negative self-perceptions about failure and success (Shapiro & Rich, 1999). In support of this intervention, Tanis Bryan (in Wong, 1991, p. 207) mentions that it "is cost effective, is easy to integrate into the regular curriculum, and requires no special equipment." Traditional cognitive-behavioral techniques have also been shown to help increase the use of healthy attributions and coping mechanisms (Hollins & Sinason, 2000).
Learning Disabilities: Social and Emotional Aspects and Interventions
Secondary Psychological Effects
The psychosocial aspects of learning disabilities are inextricably bound up with the cognitive difficulties, and often exacerbate - and are exacerbated by - those difficulties. Social/emotional problems are significant because of their profound effect on the psychological development of children and on the occupational and relational functioning of adults. Daniel Goleman (1995) asserts that emotional maturity and social intelligence are far more important than IQ to adult success, both professional and interrelational. Tanis Bryan (in Wong, 1991) describes positive peer relationships as being pivotal to child development. She mentions the link between problematic interactional styles and disrupted learning, mental health problems, and adult criminality. There is boundless evidence for the advantages of having good psychosocial functioning, and for the need to use early, intensive interactions with children who are especially at risk for failure or dysfunction in this area.
Bryan (in Wong, 1991) talks in great detail about the various aspects of social competence and emotional health which can be adversely affected within LD populations.
She cites several studies which report higher levels of negative affect in LD students than in non learning disabled students. "Negative affect" includes depression, anxiety, and suicidality. Because negative affect has an adverse effect on both learning and social behavior, it is to be taken very seriously even in cases where there is no evidence of suicidality. Bryan describes negative affect - especially stress - as an agent that slows learning and memory, whereas a more calm and joyful state of mind activates faster and more efficient processing of information. Affect also impacts social interactions; children who seem depressed are less likely to attract friends, which can then increase their depression.
Many people with LD have a problem controlling and finding healthy releases for
their anger (Roffman, 2000). This can affect their personal, academic, and professional relationships. Anger reactions are often caused by the severe overwhelm experienced on a daily basis by people with LD. Anger also provides a convenient cover for underlying grief or chronic sadness. Finally, anger within this population can represent the secondary effect of a primary narcissistic wound; being told that one is inadequate, and weathering constant put-downs, are bound to cause pain and rage. Anger in people with LD is both a reflection and a potential cause of stress and depression.
Adults with LD often need to do grief work to mourn the loss of such things as the possibility of an easier life, a quality of automaticity that they might never know, a sense of ease in new learning situations, the ability to perform consistently from moment to moment, the chance to grow up with a sense of self-efficacy and confidence, and fluidity in social situations (Wren & Einhorn, 2000). In the words of Myrna Orenstein, "... the individual finally must face the fact that he or she can do certain things, if at all, only slowly and deliberately" (2001, p. 69). In a society that places such a heavy emphasis on quantity, speed, productivity, and the ability to multitask, approaching a task slowly and deliberately - or choosing to avoid it all together - can engender a great deal of internal and external negative judgment.
Smith (1991) describes stress as the "constant companion" of many people with
LD. The stress results partly from daily frustrations and also from fears of inadequacy,
exposure, and revealed incompetence. There is often a quality of hypervigilance, in which "alarm systems" are chronically tuned in to the environment so as to be able to detect signs of possible pending humiliation. Another source of stress is the ongoing need to create and employ compensatory tactics at school, at work, and within social situations, which can cause considerable fatigue. Chronic anxiety predisposes people to depression, rage, learned helplessness, and potential substance abuse problems. Because of this vulnerability to stress and all of its accompanying problems, therapists working with both children and adults with LD are well advised to incorporate relaxation training into their sessions. This training can include deep breathing exercises, meditation, and guided imagery work (Roffman, 2000).
Learning Disabilities and Self-Concept
Bryan (in Wong, 1991) defines self-concept as a person’s sense of how his or her personality traits and abilities compare with others’. Many studies have found lower self-concept among children, adolescents, and adults with LD than in people without LD. Low self-concept is especially problematic for students with LD in that it makes them more likely to put forth less effort and give up sooner, thus widening the already-existing academic gap. One study found that positive self-concept was ultimately a better predictor of academic progress than IQ (Smith, C., 1998). Low self-concept can also have a negative impact on social interactions; exuding insecurity tends not only to keep people away but also to invite various forms of bullying.
Another concern related to low self-concept among people with LD is that it tends
to get generalized from areas of weakness to content areas with which the student has had no prior negative experience (Bryan in Wong, 1991). Perceived incompetence among the learning disabled can be compared to an uncontained bacterial infection; both have the potential to spread indiscriminately, contaminating regions that were once pure and unsullied. It is crucial that people with LD be given repeated opportunities to manifest their strengths and passions, and that they continually and consciously separate their gifts from areas of dysfunction or impairment.
Unfortunately, therapy groups which focus on self-esteem acquisition have not been proven to be particularly effective. One hypothesized explanation for this is that self-esteem is too abstract and global of a concept to be easily broken down into discrete elements which can be taught to and digested by people with LD. Interventions that have been found to be effective in the improvement of self-image are those which hone in on specific and usable skills. In their research with adolescents with LD, Thompson & Littrell (1998) found that brief solution-focused counseling was an effective in-school intervention for addressing some of the emotional secondary effects that were interfering with these youngsters’ learning.
One of the most important ways to counteract negative self-image is to help children identify and develop their strengths (Cosden, Brown, & Elliott in Wong & Donahue, 2002). Children must have arenas within which to experience and demonstrate competence, both academically and extracurricularly (Rodis in Rodis, et al., 2001). Finally, when working with children with LD it is crucial to keep underlining the difference between behavior and personhood: "It is important, in order to avoid reinforcing negative self-esteem, to differentiate clearly between disapproval of a particular action and disapproval of the child in general" (Greenhalgh, 1994, p. 112).
For adults, individual therapy is often effective in addressing self-esteem problems. In order to do this work, however, a therapist must be able to see beyond the superficial personality quirks and masks that the person with low self-esteem often creates in order to cover up his/her insecurities (Roffman, 2000). Once enough therapeutic trust has been established that these "cover-up traits" can be acknowledged, then a conscious choice can be made regarding whether to maintain them or not, and underlying problems can be adequately addressed.
Reframing one’s understanding of LD is often very helpful in working with low self-esteem (Gerber, et al., 1996, as cited in Roffman, 2000). The beauty of diagnosis is that it allows for the emergence of new explanations for old, previously-misunderstood problems. Symptoms can be framed in light of the new information obtained after assessment, rather than being attributed to such "factors" as stupidity and laziness. Reframing can also be a way to facilitate the client’s shift from feeling victimized by and overly-identified with the learning disability to finding a place for it within the larger context of selfhood (Mishna, 1996; Wren & Einhorn, 2000). Affiliating with fellow adults who share a similar diagnosis can also be very helpful in improving low self-esteem and isolation in adults with LD (Roffman, 2000).
The Relationship Between Attachment and Self-Regulation
A crucial protective factor in the lives of children with learning disabilities is healthy early attachment. In their study of attachment patterns among children with LD, Margalit & Al-Yagon (in Wong, 2002) found that secure attachment contributed to lower levels of loneliness later in childhood. Secure infant attachment is also thought to help children deal with loss and endings (Greenhalgh, 1994). Since children with LD often have an especially hard time enduring change and loss, starting out with a strong emotional bond early in life can prevent loss-related fear and resistance from becoming unduly intense. For children who did not have ideal early attachment experiences, and hence might not experience the world as safe or reliable, it is important to provide warning before change is about to occur, give ample preparation time, and create rituals specially designed to mark transitions (Greenhalgh, 1994; Perry, 2001). These techniques can be used with all insecurely attached children, but are especially important for those who also have learning disabilities.
Another crucial function served by secure infant attachment is that it paves the way for later resilience and self-regulatory behaviors (Wylie & Simon, 2000). As a result of recent brain research, we now know that it does this partly by stimulating synapses in the orbitofrontal cortex. This part of the brain is in charge of regulating the autonomic nervous system, managing emotion, and allowing for "response flexibility" - the ability to reflect and then choose one out of many possible responses to a situation. Because self-regulatory skills are especially challenging for people with LD to attain on their own, it helps greatly to have a strong neurological foundation early in life.
In contrast to the way in which healthy bonding predisposes children to well-functioning self-regulatory systems, insecure attachment has been shown to lead to a greater vulnerability to trauma responses in children with learning disabilities (Hollins & Sinason, 2000). Once traumatized, people tend to develop a lower threshold for arousal and less of a capacity to contain strong affect, sense perceptions, and thoughts (van der Kolk & Ogden, 2002). Thus occurs a vicious cycle in which diminished coping ability predisposes a person to traumatization which, in turn, decreases his/her ability to cope.
Added to this research is the grim fact that parents of children with LD tend to be at risk for unhealthy attachment processes. This is thought to result from the higher frustration levels commonly experienced by parents raising special needs infants and children, which often lead to a difficulty in providing positive mirroring (Hollins & Sinason, 2000). Positive mirroring is the process by which a child’s qualities and behaviors are clearly reflected back to her by a supportive adult, and is a crucial component of healthy identity development. It enables a child to gain self-awareness, accountability, and a greater capacity for emotional self-holding. In contrast, insufficient or negative mirroring stymies attempts to form a cohesive identity and effective tools of self-regulation. For these reasons, psychoeducation and emotional support are strongly indicated for parents of high needs children.
Society itself can serve as a source of positive, negative, or nonexistent mirroring. Robert Kegan describes the process, so necessary to growing up, of "drawing the cultural air into one’s lungs" (in Rodis, et al., 2001, p. 200). If this surrounding air is toxic, then we will breathe in those toxins as we mature. The combination of belonging to a minority group that tends to be stigmatized within the larger society and learning to "inhale" the prejudices of that society can be especially detrimental to one’s self-image in late childhood and adolescence. The primary risk of being exposed to negative mirroring, not only by parents but by society at large, is that eventually the toxicity will be internalized and turned upon oneself by oneself - the ultimate betrayal.
The first line of defense against this self-betrayal is gaining a belief in one’s competence and innate worth. This requires a willingness to identify, come to terms with, and cultivate an appreciation for the different aspects of the self - including the ones that make life difficult (Kegan in Rodis, et al., 2001). Acknowledging and accepting these parts helps people weather external storms that might otherwise overtake them, and over which they ultimately have very little control. Work done to improve self-esteem and self-efficacy affords people the luxury of not having to rely on outside forces to provide them with an identity or relieve them from a lifetime’s worth of negative mirroring. A more externally-focused means of combating negative mirroring is to begin to find and internalize positive introjects from the outside world. Research suggests that even one supportive relationship with someone who mirrors back the positive elements of oneself can serve as an antidote to the prevailing toxicity often surrounding those who grow up learning disabled (Kegan in Rodis, et al., 2001). Another "antitoxin" suggested by Kegan for adults with LD is to find an alternative community within which they feel fully supported and accepted.
From an object relations perspective, the ability to develop self-regulatory skills and identity cohesion is based partly on gaining enough autonomy so that exploration and risk-taking can be undertaken (Greenhalgh, 1994). Although children with LD often need more guidance and advocacy than other children, they also need ample opportunities to explore and make decisions on their own. Because these children are at risk for having an underdeveloped sense of self-efficacy, it is especially crucial for their caregivers to strike a balance between overprotection and excessive freedom. Much of the work of parenting children with LD involves providing and maintaining strong external boundaries while gradually helping them form their own internal boundaries, judgment, and self-trust. With the transfer from external to internal forms of support comes the ability to trust one’s own judgment and to withstand difficult experiences without needing someone else to absorb the impact.
Learning Disabilities and Identity Cohesion
The experience of living with LD is often one of severe fragmentation of the self, related not only to negative attachment patterns and disturbed object relations as described above, but also to wide discrepancies between areas of ability and relative difficulty (e.g. being brilliant in one context and severely impaired in another) and to a general lack of predictability about how one will function from one day to the next (Wren & Einhorn, 2000). Orenstein (2001) describes the two worlds inhabited by uneven learners: the world of success, in which learning is essentially pleasurable, and the world of academic struggle, in which learning is painful and humiliating. She characterizes people with LD, especially those who have never been properly diagnosed, as having what she calls "imprisoned intelligence" - strong aptitude that remains unexpressed - and discusses the potentially adverse effects that this quality of buried potential has on selfhood. Severe ability discrepancies can make it very difficult to establish and maintain a consistent and coherent sense of identity (Wren & Einhorn, 2000). One of the consequences of identity fragmentation is that people’s level of internal stability begins to be based on external sources of support, which can lead them to search outside of themselves for clues to their identity and fulfillment. (Kegan in Rodis, et al., 2001).
A related problem is that, because of the erratic, unpredictable, and sometimes subtle nature of the presenting symptoms, it is often hard for people to convince others that their learning disability is a real, neurologically-based condition. Add to the ever-changing and discrepant aspects of LD the fact of how sophisticated people’s compensatory strategies can be (e.g. using strong visual-spatial skills to hide a weakness in comprehending certain kinds of logic), and the response from the outside world is often skepticism. According to Roffman, "... this tends to be particularly true for individuals who function well with their LD and who sometimes find themselves in the awkward position of having to defend their assertion that the diagnostic label indeed fits" (2000, p. 110). Part of the hardship of living with LD is feeling the intensity of the daily struggle and yet not being able to convey the tenor of it to the people in one’s life; it can be frustrating to be told that one’s challenge is not real, or not substantial enough to warrant accommodations.
By the time many people with LD find a therapist who understands the special characteristics and concerns of this population, they have often had many negativeexperiences with teachers, administrators, employers, and other therapists (Wren &Einhorn, 2000). Often they have been discounted - not only by professionals, but also byfriends and relatives - when they’ve disclosed their LD, and have been at the mercy of others’ ignorance about what it means to have a learning disability. Thus initial psychotherapeutic work might involve undoing a great deal of previous damage; a substantial amount of time might need to be spent listening, reflecting, and continually exhibiting a belief in the realness of the client’s challenge (Roffman, 2000). Once the client feels as though her symptoms are being taken seriously, she can then form a therapeutic alliance with her therapist and can begin working on underlying identity issues.
LD: The Formation of Masks & Defense Mechanisms
Smith (1991) describes the use of masks and facades - for instance, the masks of contempt, apathy, and victimhood - within the LD population. These masks serve the primary purpose of deflecting attention away from the learning disability, thereby avoiding any possible exposure or ridicule that its symptoms might incur. An example of this phenomenon is when a learning disabled ten year-old chooses the role of class clown to hide an underlying learning problem, with the reasoning that it is better to look rebellious or funny than stupid. Receiving early intervention and gaining the sense that one is understood and accepted are antidotes to the development or perpetuation of social masks. Once people with LD begin to feel that it is acceptable for them to be who they are in the world, the masks will drop away of their own accord. Smith makes the point that when people are exhausted or overwhelmed it is all too easy for them to fall back into their old masks. She also speaks to the wisdom behind the creation of the masks, and refers to them as places of refuge and safety; like all neurotic mechanisms that seem dysfunctional in adulthood, it is crucial to remember that they once served as tools of survival.
People with LD often grow up using defense mechanisms to try to hide the symptoms of their learning difficulties (Smith, S., 1991). In a similar way to masks, these mechanisms are meant to distract onlookers from underlying cognitive problems. The ability to generate compensatory techniques designed to counteract some of the difficulties of living with LD is often indicative of high IQ and resourcefulness, and is a good predictor of later success. Pellitteri (2002) conducted a psychoanalytically-based research study that revealed a positive correlation between ego defenses and emotional intelligence. The higher one’s adaptive defenses, the better able one’s unconscious mind is to regulate the degree of disturbing emotional content it absorbs at any given time.
However, maladaptive defense mechanisms have the propensity to rob their user of emotional energy to the point where there is little or none left with which to explore deeper aspects of the self (Pellitteri, 2002). Examples of harmful defense mechanisms used by people with LD are social withdrawal, regression to earlier developmental stages, defensiveness, passive-aggressiveness, verbal or physical aggressiveness, and overdependence (Smith, S., 1991). The first step in working with both helpful and destructive defenses is for the therapist to acknowledge the immensity of the effort expended by the client in hiding symptoms, as well as the anxiety that arises from the kind of vigilance necessary to keep unwanted exposure at bay. After this, the bulk of the therapeutic work lies in helping clients distinguish between those defenses that are currently serving them in a positive way and those that are no longer useful. There is always cause to respect the wisdom behind the formation of these mechanisms, but there is also a need to help the client gradually let go of the ones that are causing undue pain and fatigue (Shulman, 1984). Ultimately, therapy involves creating an emotionally safe environment in which healthy compensations can be preserved, unhealthy defenses can melt away, and the personal issues underlying the defenses can finally be addressed (Mishna, 1996).
Once the masks and defense mechanisms have fallen away, what is often revealed is a vast store of shame. Orenstein (2001) delineates two different kinds of shame that affect people with learning disabilities. The first kind is constructive shame, or shame that provides people with helpful cues so that they can avoid unnecessary social gaffes or humiliation. Constructive shame is attached to an action rather than to one’s core identity, and serves merely as a gentle reminder of how to behave appropriately in the world. The second type is destructive shame, which is experienced "too intensely and too often," and can become a chronic reality within the lives of people who are learning disabled - especially those who have gone undiagnosed throughout childhood. Destructive shame can lead to learned helplessness, academic decline, and various forms of social withdrawal.
Social Skills: Individual Intervention
There has been a great deal of sociometrically-derived evidence proving that people with learning disabilities often have impaired social skills, which can lead to peer rejection and isolation. Social skills deficits represent problems with the understanding and interpretation of incoming social signals, as well as the ability to generate socially appropriate responses (Shapiro & Rich, 1999). Children with LD may: " ... not be able to ‘read’ social situations as skillfully as most youngsters, ... lack social tact, ... not have skills in resisting negative peer pressure, and ... exhibit behavior that others find highly irritating or unacceptable" (Hallahan, et al., 1999, p. 236). Smith (1998) describes the many different factors that can interfere with the formation of solid social skills. Some of these are: information-processing difficulties, inattentiveness, hyperactivity, immature behavior (e.g. interrupting others and refusing to take turns in a game), and emotional volatility.
Bryan (in Wong, 1998) defines the problem partly as a difficulty in encoding nonverbal cues such as tone of voice, facial expression, and body posture. This difficulty makes it challenging for people with LD to identify, and therefore empathize with, other people’s affective states when they are not explicitly verbalized. It impairs social perception and judgment, and can make someone behave in seemingly tactless and insensitive ways. Added to this list of potential difficulties is the fact that people with LD are often very absorbed with the task of surviving day-to-day challenges, and this can make them appear egocentric and disinterested in the people around them (Roffman, 2000; Smith, S., 1991).
Social incompetence can have dire effects on all areas of the life of a person with LD. Studies have consistently shown that "the student with learning disabilities is less well-known and popular, less accepted, more rejected, more ignored, and more likely to play alone" (Smith, C., 1998, p. 251). Clearly, there is a strong call for early social skills intervention. Antidotes to poor social skills include learning how to cope with change and transition and how to apply cause and effect logic to social situations (e.g. understanding consequences of remarks and actions). Language therapy is often indicated not only for people with perceptual/communicative disorders and language-based disabilities, but also for people with Nonverbal Learning Disorder (NLD), whose vocabularies are extensive but whose powers of inference tend to be lacking. Language therapy can help people to organize language through improving syntax, the ability to grasp figures of speech, summarization skills, and the ability to speak succinctly and ask appropriate questions (Smith, S., 1991).
Because of their acute difficulty in interpreting nonverbal information, people with NLD have an especially hard time interacting in socially appropriate ways. In the words of Sue Thompson (1997, p. 34), "... more than 65% of the intent of an average conversation is conveyed nonverbally. However, the child with nonverbal learning disorders... has to piece together the meaning from the approximately 35% (verbal) that he actually receives and processes." Rourke & Del Dotto (1994) recommend an early, intensive treatment approach for children with NLD. They emphasize the importance of involving as many caring adults in the treatment as possible, and they advise that treatment start with educating caregivers about the cognitive quirks of the children with whom they interact.
Children and adults with NLD benefit from some of the same aspects of social skills training as do people with other kinds of learning disabilities. The organization and processing of novel, complex information, the use of part-to-whole reasoning, the understanding of cause-effect relationships, and the employment of appropriate inferential and problem-solving strategies are all key components of social skills training with anybody who has a learning disability. However, because of the unique cognitive profile of people with NLD, there are certain adjustments that need to be made to the more traditional programs used with people who have language-based disorders.
Because people with NLD have trouble inferring meaning unless it is explicitly stated, treatment needs to focus on explaining - and teaching them to "read" - the subtleties that occur between the lines of oral and written language (Whitney, 2002). Also of difficulty within this population is applying knowledge from one context to another. Therefore people with NLD need to be taught skills of generalization and transition. Another important element in the treatment of people with NLD is to help them develop step-by-step strategies for accomplishing multi-faceted tasks. Because many of them can not visualize a process, they need to be taught to use their strong verbal skills to "talk out" the sequence of events necessary to finish a job or weather a social challenge. Because people with NLD use language as their primary tool for making sense of a visually overwhelming world, they have a greater need than most others to cultivate and make full use of their inner speech capacities (Rourke & Del Dotto, 1994).
Finally, children and adults with NLD need help in strengthening their visual-perceptual-organizational skills. They need to be taught how to perceive, decipher, and respond appropriately to nonverbal cues such as tone of voice, facial expression, and changes in surrounding visual details (Rourke & Del Dotto, 1994). Whitney (2002) points out that caregivers working with children with NLD shouldn’t ever assume that these children are making inferences in the same way that non-NLD children do. Part of the work with these children lies in a willingness to repeatedly point out to them the nonliteral meanings present in language and the physical environment, so that eventually they can begin to make these inferences on their own.
Social Skills: Group Intervention
There is some controversy about the effectiveness of formal social skills training groups. Many research studies have measured the effects of this kind of training on the social behaviors, peer- and self-image, and academic performance of children with learning disabilities. A 1996 meta-analysis of these studies found that, for various hypothesized reasons such as insufficient length or intensity of training, they have been largely ineffective in reaching their stated goals (Forness & Kavale, 1996). Nonetheless, when groups are done well and practitioners take care to avoid the most common mistakes made in the past (i.e. groups that are too short, don’t allow for real-life practice, or don’t emphasize people’s strengths), group work can be especially helpful for this particular population (Vaughn in Wong, 1991). Social skills can’t be taught in a vacuum; groups provide an indispensable opportunity for children to give and receive feedback about their behavior, to practice new skills without fear of getting criticized or put down, and to form ties with other children who have similar challenges. They can gain "strength in numbers," and can begin to appreciate and be proud of their collective gifts. Finally, the very act of coming together in a group can counteract the sense of alienation so often experienced by children with LD and ADHD.
Vaughn (in Wong, 1991) asserts that the following elements of social skills training have been found to be effective: involvement of non learning disabled peers and school personnel, providing students with the opportunity to be the "knower," or expert, in a situation, and the targeting of specific skills both within and outside of the group. Shapiro & Rich (1999) point out that social skills tutoring and group experiences can make up for lost real-life opportunities to interact; training programs can help people learn to adapt to new social situations, teach them effective communication skills, and assist them in learning how to establish and maintain friendships. To combat the loneliness so often reported among students with LD, Margalit & Al-Yagon (in Wong, 2002) advocate social skills groups that discourage social passivity and facilitate the development of empowered social behavior. Procedures found to be effective by these clinicians are peer tutoring, modeling of skills, role-playing scenarios, and problem solving sequences which involve identifying and understanding the problem, developing personal resources for coping, and generating sufficient hope and motivation to see the sequence through. Finally, learning how to advocate for oneself - a crucial skill for those with LD (Roffman, 2000) - can be successfully practiced and perfected within a group context.
Based on the history of research in this area, we know that social skills training is best undertaken early and intensively, with a great deal of attention paid to in-vivo practice, so that newly-acquired skills can be transferred to real life situations. In addition to these criteria, it is imperative that any form of social skills training start with a sense of respect for people’s uniqueness. No group which places sole emphasis on personal deficits or areas of awkwardness can possibly succeed in the long term. People change by first accepting who they already are. As applied to children and adults with LD, this means helping them to appreciate their distinctiveness and to see it as a source of pride, rather than shame. It also means explaining to them that change is about acquiring skills to help them express their gifts in the world, rather than eradicating unwanted or inconvenient parts of themselves. Change is about gaining tools, rather than losing a disability.
A phenomenon often embodied by people with LD - especially those who weren’t diagnosed and treated as children - is that of learned helplessness (Smith, S., 1991). Learned helplessness (LH) can perhaps best be described as a resignation to the feeling of having no positive impact on one’s environment, no matter how much effort one puts forth. Both social and academic LH can start in childhood, but they inevitably become more serious and entrenched in adolescence. By the time many students with LD reach adolescence, they have had so many brushes with academic and social failure that they have learned to stop trying, and they yield completely to the feelings of incompetence that have been nipping at their heels for years. At this stage it begins to feel more adaptive to conserve energy and keep a low profile in school than to keep putting forth effort toward a seemingly unattainable goal. LH also leads to a burgeoning fear and/or avoidance of new situations which represent the threat of further failure or embarrassment. The desire to take risks becomes extremely diminished (Smith, C., 1998).
The social aspect of learned helplessness manifests as an avoidance of contact (Smith, C., 1998). Many of these individuals have gotten a great deal of negative feedback about being different, and gradually decide to stop trying to fit in. Social LH can show up in the form of withdrawal, drastically reduced efforts to form and maintain friendships, and increasing amounts of time spent alone. Children with LD who were actively teased or excluded in elementary school are likely to be bullied even more severely in middle school. Teenagers who suffer from LH are also at increased risk for addictive behavior, truancy, and depression. Their self-concept and self-efficacy are impaired or nonexistent and they are often extremely lonely and isolated.
Dr. Coulter (2001) identifies two different kinds of learned helplessness: anxious and depressed. Within the context of LD, anxious learned helplessness is exemplified by a panicked response to cognitive or emotional challenges that feel unmanageable and unavoidable. Panic and other forms of stress tend to create a mental climate within which cognitive processes can become further compromised, thereby setting in motion a vicious cycle of anxiety and impaired learning. A key aspect of anxious LH is the tendency to worry that painful or traumatic learning-related events can occur at any time, with no warning or predictable pattern; paired with this worry is the suspicion that one lacks the resources necessary to stave off or cope with these events. Anxious LH produces a series of Autonomic Nervous System (ANS) symptoms, including increased heart rate, sweating, accelerated breathing, and tense muscles. The psychological symptoms include hypervigilance, emotional agitation, and increased tension.
Depressed learned helplessness is characterized by a "shut-down" response to the same sorts of upsetting trigger events that can cause anxious LH: trauma, rejection, and ridicule which occur within a learning or performance context (Coulter, 2001). Physiological and psychological symptoms of depressed LH are the opposite of those likely to occur when one experiences anxious LH: slowed heart rate and breathing, lowered blood pressure, slowed muscle reflexes, increased pain threshold, dulled sense of touch, chronic fatigue, excess sleep, slowed reaction time, and increased threshold for stimulation.
In discussing learned helplessness, Dr. Coulter cites the research of Dr. Martin Seligman, who was the first person to delineate the concept. At some point in their research, Dr. Seligman and his colleagues began to study the 30% of individuals who seemed to possess an unusual degree of resilience in response to traumatization. These individuals were found to make use of the following protective factors: 1) effective protest, 2) the ability to mentally switch the outcome, 3) the willingness to redefine success, 4) ceasing to appear helpless by changing posture and breathing, 5) the willingness to undergo and learn from attribution retraining, and 6) learning to define the problem as time- and space-bound. These skills, when taught to people with LD, have been shown to counteract the accumulated and nefarious effects of learned helplessness (Coulter, 2001).
To prevent or lessen the extent of anxious and depressed learned helplessness in students with LD, Dr. Coulter (2001; 1985) suggests that teachers: 1) de-emphasize normative evaluations, 2) discourage self-other comparisons, 3) utilize cooperative small group structures for learning, 4) reward based on effort and quality rather than on quantity, 5) teach positive affirmations and relaxation training, and 6) retrain negative attributional styles, through depersonalizing failure and showing the connection between effort and success.
Parents, teachers, and caregivers have a tough line to walk. Clearly, they have to provide extra support for children with LD, who are by definition "high needs" children. However, they have to do this in such a way that they are not disempowering or creating overdependence within their children. In the words of Arlyn Roffman (2000, p. 64), "Those who over-manage their child’s life promote the development of a learned helplessness that is far more incapacitating than the disability itself." The eventual goal of all advocacy work done for another person is to provide them with training in self-advocacy, lending one’s presence only as long as it is absolutely necessary.
The enabling of adults with LD can play out in the context of both friendships and romantic relationships. For instance, when one partner in a marriage has LD, it is common for the other partner to adopt a caretaking role (Roffman, 2000). Antidotes to this problem are education and inter-spouse communication about LD-related issues. If these tactics are insufficient to re-establish healthy power dynamics, then couples’ counseling is advised. In the same way that individuals with LD who are diagnosed later in life often have both primary and secondary issues to deal with, couples also have this dilemma. There can be problems of a mundane nature which call for pragmatic solutions, but there are often additional and more complex emotional issues that need to be addressed. Like all other forms of assistance offered to people with LD, the ultimate goal of psychotherapy is to foster the kind of independence that will empower individuals and couples to find their own solutions and means of supporting each other.
Final Notes on Psychotherapy for People with LD
Psychotherapy’s success within normal neurotic populations is contingent upon its ability to help clients cultivate a witness perspective or "observing self" (Wren & Einhorn, 2000). This witness can help people pause long enough, when faced with a challenge, to consciously choose a new response, rather than being at the mercy of older and more dysfunctional reactions. The ability to choose one’s responses is based partly upon insight and mental control, but also on the practice of relaxing into present reality; significant present-day change can not be undertaken by someone whose mind is living in the memories of the past or the fantasies of the future. Many people with learning disabilities are continually waiting to step into a parallel world in which their symptoms will no longer exist. Aside from the obviously problematic element of self-hatred imbedded within this future-focus, the wishing and hoping are counterproductive, in that they bind up precious energy that could be better used to cultivate self-love - the prerequisite for all forms of change.
The therapeutic treatment of learning disabled clients should include a discussion of the ways in which growing up with LD has affected their sense of self, sense of purpose in the world, perceived self-efficacy, ability to trust and relate to others, ability to change and adapt, and understanding of how to work with personal strengths and weaknesses. Issues related to identity formation and self-image are especially important ones to address during the therapeutic treatment. Also crucial is to assess the emotional age of one’s clients. Many adults with LD are stuck in some of the earliest Eriksonian stages: Trust vs. Mistrust, Autonomy vs. Shame and Doubt, and, especially, Industry vs. Inferiority. The developmental milestones of these early stages need to be addressed and navigated before the more ambitious psychological tasks of adulthood can be successfully undertaken.
Wren & Einhorn (2000) describe the use of "frozen metaphors" by people who have weathered intense emotional experiences. Frozen metaphors are ways of reacting to the world that are inflexible and reflective of painful past experiences. The use of fluid metaphors, on the other hand, involves fresh, creative, and present-centered responses to the world. Many people with LD engage in the use of frozen metaphors or templates, which can manifest as flawed perceptions of the self as "broken" and faulty projections about how emotionally unsafe the world is. One of the primary roles of the therapist working with people with LD is to help them feel safe enough that they can make the shift from frozen metaphors to those which are fluid and spontaneously-generated. The willingness to gain self-acceptance, and to redefine one’s relationship with the outside world along more positive and reality-based dimensions, are key aspects of the healing process. For clients with learning disabilities, psychotherapy can aid in the transforming of a distorted or negative self-construct to one which appreciates its own unique strengths (Rodis in Rodis, et al., 2001).
In working with some of the more severe secondary effects of LD, such as chronic learned helplessness or trauma-based stress reactions, it is helpful to depart from traditional talk psychotherapy to sensorimotor-based methods. According to Wylie & Simon (2000), traumatic memory gets emblazoned onto the amygdala and sets the stage for recurring cycles of overarousal and emotional flooding. Once this process has been set in motion, it is unlikely that intellectual insight or verbal exchange alone will shift the resulting visceral patterns. Because of the biologically-ingrained nature of these patterns, therapists need to help clients change them by using body-based therapy techniques that calm the nervous system, build new neural networks, and increase communication between the two hemispheres of the brain (van der Kolk & Ogden, 2002). Therapeutic tools such as EMDR (Eye Movement Desensitization Response), that enable the brain to reorganize itself in the aftermath of severe stress, can aid in the emotional healing and self-regulation of clients coping with trauma.
Because surviving daily life can be such a challenge for adults with learning disabilities, the most pressing needs initially presented in therapy are often those of a practical nature. Therefore, teaching rudimentary self-care is sometimes the first step in counseling people with learning disabilities; beginning therapeutic interventions should in this case be directive and solution-focused, aimed at helping clients to develop their own goals, support systems, strategies, and self-advocacy skills (Roffman, 2000; Wren & Einhorn, 2000). When necessary, therapists can help their clients find housing, employment, and childcare. Once these basic needs are met, the therapy can progress to deeper levels, incorporating cognitive-behavioral, experiential, or body-based modalities as appropriate.
I believe in the humanistic concept that people have an innate need to unfold emotionally and spiritually throughout their lives. Creative energy needs a way to be discharged and expressed; people who lack a sense of purpose or who are unaware of how to manifest their passions can become dangerous to themselves and others. As parents, peers, teachers, and health care professionals, we need to help children and adults with LD build on their strengths and attain a strong sense of self-efficacy, so that they feel inspired to find and express their true voice within the world.
Roffman (2000) describes some of the unique strengths that people with LD are likely to possess. These include tenacity, focus, insightfulness, intuitiveness, ingenuity, and "learned creativity" - a term used by Gerber et al. (1992, as cited in Roffman, 2000) to describe the resourcefulness of people with LD in devising unusual problem-solving strategies. When the usual routes are blocked, people tend to form new and ingenious ways of navigating the surrounding landscape. I am certain that people with learning disabilities have a special niche to fill in society, and are destined to provide creative solutions to a wide variety of problems that no one has yet been able to solve.
All people, no matter how severely their learning profile may deviate from accepted norms, have something unique to bring to the collective community into which they are born. As a society and as a species, we benefit from diversity; each individual’s contributions add to the richness of the whole. The most important treatment goal underlying the interventions described in this paper is to help children, adolescents, and adults with learning disabilities learn to appreciate and express the luminosity of their minds and spirits. When this goal is met, the rewards will be plentiful for all of us.
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