For the purposes of this post the term ‘learning disability’ will be used to refer to people with a significantly reduced capacity to understand new or complex information, to learn new skills, impaired social functioning and a reduced ability to cope independently and that started before adulthood (Valuing people: A new strategy for learning disability for the 21st Century), rather than the wider terms learning difficulties or intellectual difficulties that can sometimes be used to include conditions such as dyslexia, dyspraxia and Attention Deficit Hyperactivity Disorder (ADHD).
Although there has been little research about substance use amongst people with learning disabilities from the perspective of either the substance use or learning disability services, what research there is suggests that the rates of substance use are lower than in the general population, but where substance use exists, it may be likely to result in problematic levels of use (see for example Didden et al. 2009). The move towards more independent community living may have increased the risk of substance use becoming problematic for this client group, in part due to increased exposure to social stressors and the use of drugs and alcohol as a coping mechanism, but also due to increased access to an exposure to drugs and alcohol. It should also be noted that problematic substance use can negatively affect the ability of people with learning disabilities to live successfully in the community. Although the number of people in this client group is comparatively small, the challenges that they pose in relation to their physical, mental and social health are far greater, particularly in terms of vulnerability leading to sexual and financial exploitation from non-disabled peers, psychological trauma and loss of structure in their daily lives. The actual extent of substance use by this client group is also probably underestimated.
Commonly Used Substances
The most commonly used substances amongst people with learning disabilities tend to be alcohol and cannabis, just as in the wider population. Similarly, drug and alcohol use can bring many benefits as well as risks and negative consequences. It can help relaxation and enhance social relationships, and be a way to overcome loneliness, something commonly experienced amongst people with learning disabilities as they are less likely to have jobs or wide ranging recreational options. For many people with learning disabilities use of alcohol and illicit drugs can be a way of socialising with and fitting in with non-disabled peers and can contribute to a self-identity that more consistent with the non-learning-disabled population.
Equality of Service Provision
One of Public Health England’s key aims is to ensure equal access to appropriate substance use services for everyone, regardless of characteristics now covered by the Equalities Act 2010 including age, gender, sexuality, ethnicity and most relevant here, disability. However, there are almost no dedicated services to meet the needs of people with learning disabilities; they face several barriers to accessing and participating in services; and substance use services are not well equipped to meet their needs. There are few policies relating to appropriate psychosocial support for substance users with coexisting learning disabilities, and consequently there is a lack of awareness at all levels of the existence of problematic substance use in this population; a lack of suitable health promotion materials; a lack of evidence around appropriate approaches and responses; poor collaboration between substance use and learning disability services; and a lack of service user involvement in planning how to develop such services. However, there is a recognition that incorporating service users’ voices into the development of treatment services is essential if they are to meet the needs of service users, especially those from minority groups who may have specific needs.
A study by Taggart et al. (2007) found two inter-related explanations for problematic alcohol and drug use amongst their sample of substance users with learning disabilities, with an overarching theme that they labelled ‘self-medicating against life’s negative experiences’. Firstly, psychological trauma caused by negative life events such as the deaths of close family members and physical, emotional, sexual and financial abuse; and secondly ‘social distance from their community’. This was characterised by a lack of friendship, either disabled or non-disabled, loneliness of living alone and feelings of social isolation. Where respondents talked about socialising with peers it often featured varying degrees of ‘mate crime’ where ‘so-called-friends’ exploited their goodwill and ‘friendship’ to use their flat and possession, spend their money, and eat their food. Although ‘mate crime’ can also occur in the absence of substance use, substance use can increase the risk.
There are stark similarities between the risk factors for problematic substance use identified in the wider population such as low socio-economic status, unemployment as the norm, poor problem solving and coping strategies and a lack of social support, and common factors in the lives of people with learning disabilites. This may mean that people with learning disabilities find themselves doubly ‘at risk’ of problematic use if they use drugs or alcohol. Beyond this, the consequences of alcohol and drug use amongst people with learning disabilities can included an increased risk of exclusion from services due to behavioural problems; the exacerbation of existing intellectual, behavioural and mental health impairments; greater physical and psychiatric difficulties associated with substance misuse; greater risk of experiencing unemployment, poverty and crime; and they are already at risk of experiencing of additional marginalisation and exclusion. These problems are compounded when they then experience greater barriers to accessing services.
Service providers and commissioners have often failed to identify the unmet needs of this client group, in part because a lack of integration in services means that many substance users with learning disabilities fall down the gap between mainstream substance use services and learning disability services. Reluctance from mainstream services to offer services to a ‘difficult’ client group or a belief that the type of services they can offer would be ineffective, combined with increased financial pressures on both substance use and learning disability services may mean that this gap will get wider rather than narrower if a more integrated approach to meeting the needs of this client group is not taken.
Beneficial Approaches and Reasonable Adjustments
Under a more integrated approach where learning disability services and substance use services work in partnership, substance use service practitioners can bring expertise of what areas to explore and what questions to ask, whilst learning disability practitioners can offer advice on how to ask the questions and what type of interventions would be most appropriate. Learning disability specialists may also be more knowledgeable about how to develop a therapeutic rapport with this client group, an important aspect of supporting substance users. There would also be benefit from each service sharing good practice and training the other in the best ways to work with clients within their specialism. Such a multi-disciplinary approach would also meet this client groups’ needs in a way that one in isolation cannot.
Thus specific approaches to improve service delivery may include:
- Partnership working (as described previously) including wrap-around services that meet a wider range of complex needs
- Person-centred approaches that more closely meet individual needs
- Strength-based interventions, solution-focused and Motivational Interventions rather than cognitive-behavioural approaches may be more effective and appropriate
- Individual support may be nore accessible than group work approaches
- Increased staff training and awareness in learning disability services of substance use and in substance use services of learning disabilities
- Early screening by both services of learning disabilities and substance use
DIDDEN, R., EMBREGTS, P., VAN DER TOORN, M. & LAARHOVEN, N. (2009). Substance abuse, coping strategies, adaptive skills and behavioral and emotional problems in clients with mild to borderline intellectual disability admitted to a treatment facility: A pilot study. Research in Developmental Disabilities, 30927-932.
TAGGART, L., MCLAUGHLIN, D., QUINN, B. & MACFARLANE, C. (2007). Listening to people with intellectual disabilities who misuse alcohol and drugs. Health and Social Care in the Community, 15(4), 360-368.