I recently hosted, in my capacity as chair of the Institute of Psychotherapy and Disability (IPD), a 75th birthday celebration for the charity’s founder
and a most inspirational figure, Dr Valerie Sinason.
The IPD was set up to promote psychotherapy for people with intellectual disabilities. In attendance were many senior figures from the world of psychotherapy but, sadly, few from the learning disability community.
Why was this? I wondered. I believe Sinason is the most critical thinker in our field in my lifetime. Today, she is primarily recognised as the principal innovator of a psychotherapeutic approach for people with learning disabilities, a group of people who have attracted only intermittent psychological interest.
Sinason developed her ideas at the Tavistock Clinic in London, establishing the first specialist clinic and training on working therapeutically with people with learning disabilities.
My first contact with her was at the Tavistock Clinic in 1997, where she chaired a multidisciplinary group that met weekly to listen to case presentations.
I was struck that such a diverse group of professionals was attending – psychiatrists, nurses, teachers, and social workers with different theoretical approaches.
Sinason fostered an open inquiry with all views welcome, not just a psychoanalytic approach.
Landmark publication
Since then, she has contributed a continuous output of published work including her book Mental Handicap and the Human Condition: an Analytical Approach to Intellectual Disability, which is considered a landmark publication in psychotherapy publishing.
It was first published in 1992, has been reprinted almost yearly and the second edition, with three further chapters, was published in 2010. Sinason is currently revising it for a new edition.
Sinason is the foremost innovator behind “disability psychotherapy”. Several contemporary commentators have noted the historical reluctance of mental health specialists to provide psychotherapy treatment for people with learning disabilities.
The IPD, which she was instrumental in setting up in 1992, aimed to promote psychoanalytic psychotherapy. One of its intentions was to promote a new breed of psychotherapists called disability psychotherapists, who would be specially trained and qualified for this role.
The IPD’s first motto was “treating with respect”. This was an acknowledgement of how, historically, patients with learning disabilities had not been treated with respect.
Sinason was trying to develop an interest in the psychotherapeutic community and convince those involved in mental health that psychoanalytic psychotherapy could be an important treatment option for people with learning disabilities.
To this end, she was also involved in the Royal College of Psychiatry’s Faculty of Intellectual Disability’s report into psychotherapy. This report highlighted many difficulties around access to and the quality of psychological support for people with learning disabilities.
Currently, the IPD is discussing a new registration section for disability psychotherapists with the British Psychoanalytic Council.
It is now established that psychotherapists need to work with greater flexibility and willingness to engage with wider systems.
In Sinason’s approach to learning disability, the critical element is not intelligence but emotional response.
“However crippled someone’s external functional intelligence might be, there still can be intact a complex emotional structure and capacity,” she wrote.
Trauma and the ‘handicapped smile’
Today, there is a lot of new interest in trauma, but Sinason’s ideas on trauma have always been at the core of her thinking.
She has suggested that symptoms resulting from trauma are significantly under-recognised in people with learning disabilities and society’s responses to disability tend to exacerbate the initial trauma.
Two of her key concepts were the “handicapped smile” and “secondary handicap”. (At the time, handicapped was the term used for people with disabilities.)
It is worth reading Sinason here on the ever-changing terminology around learning disability. “It is doing a grave disservice to past pioneers to point contemptuously to their chosen terms. Within another five years, the process of euphemism will already be affecting the brave new words,” she wrote in 2010.
This smile is a fixed grin: “People who are close to grief and cannot bear it encourage happiness and smiling.” It is a defence against the knowledge of trauma in the patient and the therapist.
An example is society’s guilt about collusion and the creation of defensive myths about people with learning disabilities who are seen to be always smiling, always happy – yet there is clear evidence that they are not.
“Some handicapped people behave like smiling pets for fear of offending those they are dependent on… when people depend for their lives on cruel regimes, they need to cut their intelligence and awareness,” she wrote.
Secondary handicap and self-injury
Sinason describes secondary handicap as having a protective function in shielding the self from the unbearable memory of trauma.
“I also learned how self-injury in some children and adults could represent a ‘secondary handicap’ – a displacement activity that covers up the fear and the shame around the original difference,” she wrote.
This can be linked to the person, who can experience the disability as a trauma: “Opening your eyes… to the realisation that you will not be an Austen, Einstein, Madonna or Picasso can be painful enough to the ordinary adolescent. Opening your eyes to admitting you look, sound, walk, talk, move or think differently from the ordinary, average person… takes greater reserves of courage, honesty and toleration of one’s envy.”
Sinason suggested that the therapeutic task was to get behind the secondary handicap – the angry hurt and painful feelings. This can be explored in psychotherapy sessions with the individual. If the sessions can be maintained, there is often an improvement in internal and external functioning.
The other key area was sexual abuse. In the 1990s, a number of studies highlighted the vulnerability of people with learning disabilities. Sinason opened the door to providing this kind of support and therapy to people with learning disabilities who have experienced the trauma of sexual abuse.
Her view is that working psychoanalytically with people with learning disabilities is clinically important and part of a wider struggle for equality, justice and empowerment. This may involve advocating on their behalf in some situations.
Sinason became aware of sexual abuse during her time at the Tavistock Clinic and noticed a high rate of these referrals. Out of 200 referrals, 140 were for sexual abuse.
As a result of these clinical experiences, she put forward that sexual abuse was more likely to lead to psychological disturbance in learning-disabled than cognitively more able victims.
Through this work, Sinason has played a significant role in highlighting this issue and bringing it to greater attention.
In her writing about how psychoanalytically informed psychotherapy helps patients with learning disabilities who have been abused, self-harm could be understood as an attack on the client’s despised body for being unable to prevent the abuse.
Sinason put forward the view that violent and aggressive behaviour, such as kicking, biting and headbutting, can be understood as an attempt to manage the helplessness inherent in trauma.
One of the central dynamics underpinning the development of disability psychotherapy has been its stop-start nature. There have been brilliant pioneers across the decades, but very little development from one generation to the next, with minimal written theory to develop future thinking.
However, through her writing, Sinason has developed core theoretical concepts that are continuing to be developed by the next generation. Perhaps her highly relational therapeutic style is as important, which stems from her personal characteristics.
Because of this, she has not continued in the tradition of brilliant but isolated disability pioneers. The impact of her thinking on my development as a long-standing disability psychotherapist working currently in the NHS is an example of this.
There are criticisms that psychological therapies do not address the underlying injustices that people experience and that the emphasis should be on health promotion. In my view, this is not an either-or choice.
Sinason described her therapeutic approach as a kind of psychoanalytic advocacy, in that disability therapists, by understanding their clients’ experiences, are in a privileged position to give voice to their needs. This may mean that psychotherapists play a more active role in countering injustice in the lives of people with learning disabilities.
I believe Sinason’s theories are having a profound impact both on how services are run and, more crucially, on how lives are led.
Sinason has written that while the psychoanalytic pioneers have been blamed for exclusion and have, arguably, hindered the continuity of progress of psychotherapy for people with learning disabilities, it is the responsibility of the upcoming generation to question and develop the thinking around this.
This is a philosophy that Sinason has never hesitated to put into practice herself and I remain hopeful that the coming decades will see a blossoming of the ethos of humanity, respect and equality, that she has espoused through all her work with patients.
Further reading
Corbett A. Intellectual disability and psychotherapy. The theories, practical and influence of Valerie Sinason. Routledge; 2019 O’Driscoll, D. A short history of psychodynamic psychotherapy for people with learning disabilities. Advances in Mental Health and Learning Disabilities. 2019;3(4): 4-9. https://doi.org/10.1108/17530180200900032, Sinason V. Mental handicap and the human condition: an analytic approach to intellectual disability. 2nd edn. London: Karnac; 2010
