People With Intellectual Disabilities Research Articles

Public Opinion on the Sexuality of People with Intellectual Disabilities: A Review of the Literature

People with intellectual disabilities (PID) experience the same range of sexual thoughts, feelings, desires, and activities as anyone else. However, the public’s view, especially about stereotypes, is noticeable to have an impact on sexuality and people with disabilities, thereby influencing the population which includes the families of PID, healthcare professionals, and policymakers. This review aims to analyze the opinions of public, family of PID or care staff on the sexuality of PID and the methodology applied. Eleven quantitative peer-reviewed papers were identified. Participants’ attitude could be evaluated as a binary classification of either “Restrictive” or “Acceptance” in four aspects. Demographic background and the conditions of the PID were found to have an influence on people’s attitudes. People acknowledge that PID are not asexual but generally the public holds a more accepting attitude towards the sexuality of PID when compare with family of PID or care staff. Further research on this attitude gap is particularly essential, as this will contribute valuable information and provide insight to policymakers on handling the social, legal and ethical concerns about the sexuality of PID.

Worker roles in the open labor market: The challenges faced by people with intellectual disabilities in the Western Cape, South Africa.

Work holds great meaning and benefits beyond just monetary gain for people with intellectual disabilities. It gives these individuals the opportunity to engage in meaningful occupation. The purpose of the study was to explore challenges that people with intellectual disabilities (PWID) experience when adapting to their worker roles in the open labor market. The study used grounded theory as the research design. Five male participants and two key informants participated in the study. Two semi structured interviews were conducted with each one of the seven participants (five PWID and two key informants). Three core concepts emerged: 1) Unforeseen challenges of change; 2) A well-planned work preparation program enables success and 3) Crossing the bridge into the workplace: "Do I belong here?" This indicated that with sufficient external support, PWID are able to gain a sense of social belonging and develop the necessary skills to cope with challenges that arise in the workplace when PWID transition from protective/sheltered workshops to the open labor market. The findings of the study also indicated that work preparation programs and supportive employment approaches helped PWID transition to the open labor market.

Health Literacy in people with intellectual disabilities – is there a need for an adapted concept?

Abstract Background Health literacy (HL) is a crucial factor in terms of health and health-related outcomes. HL refers to personal and social resources as well as the abilities to access, understand, appraise and apply health information to make self-determined health decisions. Due to reduced resources including cognitive abilities it is assumed that HL in people with intellectual disabilities (PWID) is low. Up to 3% of the general population have an ID (IQ < 70). Methods Current state of the art is presented via a mixed-method literature review published in 2019. Against that, results from 5 target group orientated groups are presented (n = 50). Results Literature Review (12 studies incl.): HL does not go beyond a purely functional understanding. Studies assume that the HL level of PWID is very low, but fail to mention a reference source. Overall, studies are mainly from the health professionals' perspective and exceptions directly questioned or focused people with ID. People with ID still seems to be a 'hidden' population in HL research. Group discussions: An introducing quiz about health-related topics turns into a discussion within the group of PWID. Topics were physical activity, nutrition and health advices from health professionals like GPs. Instructions of physicians were discussed; a critical view of health advices were taken. Bassed on experiences own health decisions are described. Trained caregivers like nurses are stated as an own professional HL resource. Communicative and critical HL have been demonstrated. Conclusions There is only little knowledge about HL in PWID. Promoting HL could be highly beneficial for managing health information with a positive impact on PWID themselves (empowerment), their (family) caregivers, and the health care system (reducing health costs). A debate to conceptualize HL for PWID is mandatory. This must be based on valid data, consider the perspectives of PWID and have to respect the resources of PWID. Future directives will be discussed. Key messages People with ID communicative and critical health literacy is is available but not yet explored how it can be increased. A target-adapted health literacy of people with intellectual disabilities is beneficial, it it takes the perspectives of this target group into account.

Promoting physical activity-related health competences in people with intellectual disability

Abstract Background Physical inactivity is a global health problem. Physically active people show lower rates of chronic diseases or mortality. People with intellectual disabilities (PWID), a vulnerable group for health problems, have significantly lower levels of physical activity (PA) than general population. Due to reduced cognitive abilities, communicative and literacy skills, PWID have less access to health programs. Target-group-oriented interventions are rare. Methods Methodological triangulation to survey PA-related health competences in all 3 subcategories: 3 participating observations and 24 interviews with PWID (inclusion criteria for both: mild or moderate ID); staff online survey (n = 67), all in an integration assistance institution. Participatory approach: 2 expert groups with PWID advise researchers e.g. validating results. Results As expected, movement abilities and body awareness various highly from general population. An effect knowledge is widely spread (PA = health), but execution knowledge of PA is only marginally available e.g. not knowing how to increase PA healthy. Control competences as results from interview and observations: intrinsic motivation is highly present (unlike results from staff survey), but volition - self-efficacy and bring into action - is very poor, self-management and a lack of ideas are identified as a major problem. Low expectation of self-efficacy proved to be the biggest obstacles for PA, but caregiver are an own health resource. Expert groups confirm important of PWID perspectives on living environment. Conclusions To promote a PA lifestyle, health education with a focus on promoting self-efficacy orientated to the living environment (incl. caregiver) regarding own perspectives and health resources is needed. In this way, a vulnerable group for health problems can be empowered. Results indicate a successful approach to promote PA-related health competences in PWID to minimize health inequalities in relation to general population. Key messages Health inequalities among people with intellectual disability through promoting a PA lifestyle can be minimized. Intervention for people with intellectual disabilities must take into account the perspectives and the resources of the users.

The positive impact of knowledge and quality of contact on university students’ attitudes towards people with intellectual disability in the Arab world

BackgroundThis study examines undergraduate students’ attitudes towards people with intellectual disability (PWID) in relation to their frequency of contact with people with intellectual disability, the quality of this contact, and their knowledge of intellectual disability (ID). MethodThe study sample comprised 1001 undergraduate students (458 male students [46 %]; 543 female students [54 %]; mean age = 20.6 years) from Saudi Arabia and Egypt. The Arabic version of the Mental Retardation Attitude Inventory–Revised (MRAI-R) was used to examine attitudes towards PWID. ResultsKnowledge about ID, quality of contact with PWID, and gender were significant predictors of attitudes. Frequency of contact, as well as having relatives with a disability, were not significant predictors of attitudes. No differences were found between participants from the two countries. ConclusionThe results of the study indicate that high-quality contact is a major predictor of students’ attitudes. Therefore, society needs to ensure more than just simple forms of contact between people with and without disabilities.

The life stories and experiences of the children admitted to the Institute for Imbecile Children from 1895 to 1913.

BackgroundSouth African scholarship on intellectual disability has produced a sizeable body of research, yet there are numerous areas where there is a paucity of research. One area in which there is a conspicuous paucity of research is historical studies of people with intellectual disability (PWID). The existing works devoted to the history of PWID in South Africa are primarily focused on the legal provisions and institutions for the protection and care of PWID. Missing from these works are the life stories and experiences of PWID.ObjectivesThe article offers a study devoted to the life stories and experiences of the children with intellectual disability (CWID) who were admitted to the Institute for Imbecile Children from 1895 to 1913. The institute opened in April 1895 in Makhanda (formerly known as Grahamstown), South Africa. The institute was the first of its kind in the Cape Colony for CWID.MethodThe study presents a qualitative investigation of the life stories and experiences of the children that were recorded in the institute’s casebook. The entire set of 101 cases contained in the casebook was analysed by adopting a Gadamerian approach to hermeneutics.ResultsThe examination of the institute’s casebook identified several broad themes relating to the children’s admittance, daily life at the institute and their routes out of the institute. The study also extols the individuality of each child’s life story to provide an awareness and richer appreciation of the humanness and personhood of the children.ConclusionThe article contributes a positive narrative to the identity and the history of South African children with intellectual disability living in the late 19th and early 20th centuries.

Actitudes hacia la sexualidad de las personas con discapacidad intelectual: ¿difiere la población general de las propias personas con discapacidad intelectual?

Un aspecto esencial para garantizar la calidad de vida en las personas con Discapacidad Intelectual (PDI) es la salud sexual. Pese a que en los últimos años se ha aumentado la atención en esta cuestión, es determinante conocer si existen prejuicios que pueden afectar al desarrollo saludable. El objetivo de este estudio ha sido comparar las actitudes hacia la sexualidad de las PDI que tienen ellas mismas con las que tiene la población general (PPG). Para ello un total de 100 PDI (50% hombres y 50% mujeres), de 19 a 55 años completaron la Escala de Percepción Sexual, y 454 PPG (39.4% hombres y 60.6% mujeres), de entre 20-82 años completaron la Escala de Actitudes para la Sexualidad en Personas con Discapacidad Intelectual (ASEXDI). El 71.1% de las PPG presenta unas actitudes moderadas hacia la sexualidad de las PDI, el 18.7%, actitudes liberales y 10.1% conservadoras. Ambos grupos difieren en la tolerancia a las caricias siendo superior en el grupo de PPG (68.28% lo considera muy aceptable, frente al 22.78% de las PDI). Por el contrario, las relaciones sexuales con penetración entre PDI están ligeramente mejor valoradas por las PDI que entre la PG, aunque en ambos casos son actitudes conservadoras (el 15% de las PDI lo considera nada aceptable en absoluto, frente al 37.89% de la PG). Sin embargo, la PG tiendeaconsiderar deforma más positivalascompetencias delas PDI parael uso correcto del preservativo. Los resultados permiten concluir que la PG muestra una tolerancia moderada hacia la expresión de la sexualidad de este colectivo, con la excepción de la práctica de penetración hacia la que muestran cierta prevención. La actitud positiva de los PDI hacia esta práctica unida a su baja percepción de competencia en el uso del preservativo justifica la necesidad de programas de educación afectivo-sexual adaptados.

CAPOEIRA: MUSICALIDADE PARA PESSOAS COM DEFICIÊNCIA INTELECTUAL

Através de frequências, vibrações, pulsos e ritmos pode-se sentir a música e reproduzi-la de váriasmaneiras, sendo um instrumento facilitador para o desenvolvimento motor, social e afetivo de pessoascom Deficiência Intelectual. Neste sentido, o objetivo deste estudo foi avaliar o desenvolvimento dacoordenação motora global através da aprendizagem do “Movimento da Palma” e do “Batuque nopandeiro” em três intensidades rítmicas, sendo 64 bpm, 120 bpm e 184 bpm. Foram participantes12 pessoas com Deficiência Intelectual com idade entre 18 e 65 anos. A coleta de dados ocorreu antese após a realização de uma sequência pedagógica para a aprendizagem do Movimento da Palma e doBatuque no Pandeiro. A análise dos dados ocorreu com o Software para Análises Estatísticas SPSS versão21. Os resultados apontam diferenças significativas entre as médias apresentadas pelos participantesantes e pós-intervenção pedagógica. Conclui-se que o ensino do movimento “Batuque no Pandeiro”aliado à expressão rítmica e o ensino do “Movimento da Palma” na baixa velocidade (64 bpm) podemser considerados facilitadores para o processo de aprendizagem da musicalidade rítmica da pessoa comdeficiência intelectual, além de promover aprimoramento rítmico e da coordenação motora global.
 Recebido em: 16/05/2020Reformulado em: 27/05/2020Aceito em: 28/05/2020

Multimorbidity in older people with intellectual disability.

There is paucity of research from Australia about comorbidity in older people with intellectual disability (PwID). This paper examines the burden of chronic diseases and associated sociodemographic correlates in a cohort of PwID aged 60+. A cross-sectional survey was used with community-dwelling older PwID in urban/rural regions of two Australian states. Recruitment was undertaken via a multi-prong approach and each subject (N=391; 236 urban/155 rural) personally interviewed. Findings show older PwID experience considerable multimorbidity (X=3.8; 53.5% had 2-6 conditions). Conditions included arthritis (40%), diabetes (26%), cardiovascular diseases (23.6%), asthma (16.1%), carcinomas (10.0%) and mental health disorders (34.5%). There was significant multimorbidity in older PwID, with evolution of life trajectories of select conditions associated with socioeconomic disadvantage and heath facility access barriers. Greater scrutiny of progressive health debilitation leading into older age and increased engagement by healthcare systems is required earlier in the lives of PwID.

Pre-genetics clinic resource evaluation for adults with intellectual disability: The pre-genetics clinic aid.

People with intellectual disability (PWID) consistently identify the importance of health service information that is accessible and relevant. Resources tailored to the information and support needs of PWID can facilitate inclusivity in their health care (including access to genomic medicine) and improve healthcare outcomes. Despite the fact that PWID are commonly referred to genetics services, there is a lack of appropriate resources to help them prepare for their appointments. We therefore aimed to evaluate the feasibility and acceptability of a booklet for PWID to read with their carers prior to their genetics appointment, to help them prepare for what they may experience. With input from Easy to Read experts and PWID who were members of the New South Wales (NSW) Council for Intellectual Disability, the information booklet 'Getting ready for your visit to the genetics clinic' was produced. Australian healthcare professionals (HCP) familiar with clinical genetics services were invited to complete an anonymous online survey designed to assess perceived relevance, readability, and utility of the resource. Recruitment of HCPs was pursued via affiliated clinical services and email distribution through clinical genetics organizations. Sixty-six HCPs completed and submitted the survey. The results demonstrated that HCPs believed the booklet represented a typical clinical genetics service appointment and that the majority would provide a copy of the resource to clients and their carers. They reported that the booklet was easy to understand and entailed appropriate content and images which were presented clearly and simply. Some minor modifications were recommended and incorporated into the resource. A model of customizable booklets such as this could be transferrable across clinical genetics services and guide development of other resources for PWID. This may help to reduce healthcare disparities, improve client satisfaction, and facilitate involvement of PWID in their own healthcare decisions.

Marriage Challenges of Women with Intellectual Disability in Iran: A Qualitative Study

Sexual desire is a natural and important human need, and, as part of human diversity, people with intellectual disability (PWID) have the right to have sex, marry and bear children. However, due to the dependence of PWID on their caregivers, their sexuality is influenced by the opinions of their caregivers. This qualitative study was conducted with the aim of discovering opinions of caregivers about the sexual needs and the issue of marriage in women with intellectual disability (WWID). Sampling was conducted in three intellectual disability care centers, two rehabilitation centers and a school of exceptional students in Tehran, Iran. Deep and semi-structured interviews were conducted with 21 intellectual disability caregivers. Data was analyzed using the content analysis method of Zhang and Wildemuth. Data analysis led to the emergence of two main themes and four categories. The first theme was “non-responsive sexual consciousness” with two categories: “positive thinking about the sexual needs of WWID” and “cultural weakness in accepting satisfaction of sexual needs in WWID”; and the second theme was, “the colorless dream of marriage”, with the categories of “wedding dress, dream of WWID” and “marriage of WWID, a challenging issue”. In spite of the desire of WWID for marriage, this issue is controversial from the viewpoint of caregivers. This difference in opinion is due to the lack of knowledge of caregivers about the abilities of PWID, insufficient information of WWID regarding marriage, lack of government support for facilitating the conditions of marriage of PWID and lack of social support in this area.

Psychiatric defence of a Nigerian minor with intellectual disability and co-morbid mental illness: An exploration into legal grounds

People with intellectual disability and co-morbid serious mental illness are sometimes involved as perpetrators of an offence and suffer exploitation in the criminal justice system. Understanding the link between mental illness and crime and the experience of an accused deserves attention because it may be essential in the administration of justice. The subject of this paper is the experience of a 17-year-old boy, suffering from both intellectual disability and schizophrenia, who was accused of theft and charged to court. The aim is to show how psychiatric services can be helpful in the disposal of court sentences for a minor. The relationship between his mental illness (with a focus on intellectual disability) and crime, and potential victimization in the criminal justice system is discussed. We advocate for awareness on the part of the legal system in the protection of people with intellectual disability from being victimized and recommend the need for psychiatric service to educate the court on the stringent application of the insanity rule.

"Constructing a health assessment questionnaire for people with intellectual disabilities: A cognitive interview study".

Health assessment instruments can help to raise awareness among general practitioners of specific health problems in people with intellectual disabilities (PID). The present authors developed a health assessment questionnaire using the cognitive interview technique (CI) to improve the comprehensibility. The utility of this approach to questionnaire development involving PID is assessed. A qualitative approach using the CI was employed. The study included PID and their caregivers. The present authors interviewed 14 participants in 5 subsequent rounds. After each round, the questionnaire was adjusted until saturation was reached. Three hundred and sixty three identified problems led to 316 changes to the questionnaire. Most problems (102) concerned the comprehension of the question, followed by problems in the "missing answer categories" and "inaccurate instruction" section. The comprehensible health assessment questionnaire can help PID to take an active role in communication with their GP. The use of CI helped to improve the questionnaire. CI is a usable and valuable procedure for PID.

Consensus-based good practice guidelines for clinical psychologists to support care staff in enabling sexual expression in people with intellectual disabilities-A Delphi study.

Care staff supporting people with intellectual disabilities (PWID) report accepting views on PWID's sexual expression, but people with intellectual disabilities report their sexual expression is restricted by care staff. We recruited a panel of 17 UK clinical psychologists experienced in helping care staff support PWID's sexual expression. We used the Delphi Method to develop consensus-based practice guidelines for UK clinical psychologists supporting care staff in this way. Having proposed three guidelines each in Round One, panel members reached consensus (≥90% agreement) that 12 were important, falling under four themes: "Addressing staff attitudes," "Addressing uncertainty about rights and responsibilities of people with intellectual disabilities," "Locating the problem, being part of the solution," and "Supporting care staff to understand and reflect upon their role." Clinical psychologists help care staff support PWID's sexual expression by normalizing care staff concerns, encouraging reflection, clarifying PWID's rights, and prompting those at managerial and service level to support care staff.

Dermatological manifestations and medico-social correlates among intellectually disabled students in Central India

Background: People with intellectual disabilities (PwID) are particularly more vulnerable to dermatological manifestations due to their associated disabilities and hygiene negligence.
 Aims and Objective: To estimate the prevalence and pattern of skin diseases considering various medico-social correlates among PwID in two districts of Central India. To apply multinomial logistic regression analysis to examine the medico-social factors associated with no, one and more than one dermatological manifestations.
 Materials and Methods: A total of 204 PwID receiving rehabilitation services under a NGO serving two districts were examined for dermatological manifestations and various medico-social factors were studied. Descriptive analysis like chi-square and multinomial logistic regression analysis (MLR) was performed.
 Results: We found that 87.25% of study participants had one or more dermatological manifestations {infectious (64.7%) and non-infectious (84.3%)}. Among the various medico-social variables studied, socio-economic status, education of parents and associated co-morbidities were independently associated with increase in frequency of skin disorders. MLR analysis showed that Illiteracy of parents, lower socio-economic status and associated co-morbidities in PwID had higher odds of developing one and more than one dermatological manifestations when compared to literate and high income families and PwID with no associated co-morbidities.
 Conclusion: This study delineates the importance of additional attempts to be made by dermatologist while dealing with PwID while considering carefully their associated co-morbidities and various social factors. Strict hygiene measures, periodic skin examination and health education of persons caring for students with disabilities are recommended.

Validation of an instrument to assess informal caregivers\u2019 perceptions about the delivery of patient-centred care to people with intellectual disabilities in residential settings

BackgroundValidated instruments are needed to assess the delivery of patient-centred care (PCC) to people with intellectual disabilities (PWIDs) needing 24-h care in residential settings. Eight dimensions of PCC have been identified: taking patients’ preferences into account; access to care; emotional support; physical comfort; information and education; involvement of family and friends; coordination of care; and continuity and secure transition. Objective of this study is to validate an instrument to assess these eight PCC dimensions among informal caregivers of PWIDs in residential settings (institutional settings as well as group homes in the community). The original 24-item instrument was developed and validated among professionals providing care to PWIDs.MethodsThis study was conducted in a disability care centre in the Netherlands. All informal caregivers of PWIDs living in institutional settings or group homes in the community in need of 24-h care were invited to participate (n = 941). The response rate was 31% (n = 289). We tested the instrument using structural equation modelling, and examined its validity and reliability.ResultsConfirmatory factor analyses revealed good indices of fit and overall internal consistency, as represented by Cronbach’s alpha values. All eight dimensions of PCC were related positively to satisfaction with care (all p ≤ 0.001). As expected, informal caregivers were less critical of PCC and its underlying dimensions, except for information and education, than were professionals working in the same disability care centre.ConclusionsThe psychometric properties of the 24-item PCC instrument for informal caregivers (PCC-IC) were satisfactory, indicating that the PCC-IC is valid and reliable for the assessment of the eight dimensions of PCC among informal caregivers of PWIDs in residential settings.

The interaction between knowledge and quality of contact to predict Saudi university students’ attitudes toward people with intellectual disability

Background Positive attitudes toward people with intellectual disability (PWID) are essential for full social inclusion. Two variables that may shape public attitudes toward PWID are “knowledge of intellectual disability” and “quality of contact” with individuals who have disabilities. Method: Participants were 455 undergraduate university students in Saudi Arabia (241 male [53%] and 214 female [47%]). The Mental Retardation Attitude Inventory–Revised (MRAI-R) was used to examine attitudes toward PWID; two other scales were adapted to measure knowledge of intellectual disability and quality of contact with PWID. Cronbach’s Alpha for reliability, analysis of covariance (ANCOVA), and Pearson’s correlation were used to analyze the data. Results: The combination of knowledge of intellectual disability and quality of contact with PWID showed significant influence on participants’ attitudes toward PWID. Neither knowledge about intellectual disabilities nor quality of contact with PWID alone significantly predicted attitudes toward PWID. Conclusion: Having a relative with a disability was a significant covariate of participants’ attitudes. For Saudi university students, having both high levels of knowledge about intellectual disability and quality contact with individuals with intellectual disabilities were associated with more positive attitudes toward PWID. In addition, having relative(s) with disability was associated with positive attitudes toward PWID.

Ascertainment and Prevalence of Post-Traumatic Stress Disorder (PTSD) in People with Intellectual Disabilities

ABSTRACT Introduction: Post-traumatic stress disorder (PTSD) may be under-recognized in people with intellectual disabilities (PWID) and reviews on appropriate screening tools and prevalence are lacking. This review aims to identify PTSD screening tools for PWID and estimate the prevalence of PTSD within this population. Method: Medline, PubMed, Embase, PsycINFO, Cochrane, Global Health, and Web of Science databases were searched (inception to October 2017) to identify eligible literature. Papers were also found via manual searches of the references of eligible studies. Studies were reviewed in accordance with the Preferred Reporting Items for Systematic reviews and Meta-analyses (PRISMA) guidelines, subjected to exclusion criteria and quality appraised using STROBE criteria for observational studies and an adapted form of the Newcastle-Ottawa scale for cross-sectional studies. Seven studies were identified. Meta-analysis was carried out on the prevalence studies and heterogeneity quantified using I2. Results: Three tools for screening PTSD in PWID were found: two for use in adults (the Lancaster and Northgate Trauma Scale and the Impact of Event Scale – Intellectual Disabilities) and the Adapted Anxiety Disorders Interview Schedule for Children with PTSD. Five studies reported PTSD prevalence in PWID. The weighted pooled prevalence of PTSD in PWID was found to be 10%, 95% CI [0.4%, 19.5%], toward the upper limit of estimated PTSD prevalence in the general population (5–10%). Conclusion: PTSD can be diagnosed in PWID but may go unrecognized by health-care professionals. The identified tools should be further compared and assessed for acceptability and efficacy to improve the identification of PTSD in PWID.

Restrictions, Power, Companionship, and Intimacy: A Metasynthesis of People With Intellectual Disability Speaking About Sex and Relationships.

Examining literature that tells us what people with intellectual disability (PWID) think and feel about their sexual lives may enable families and professionals to offer a more person-centered approach to education and support. Examining the voices of many individuals across several studies may provide more convincing evidence about the experiences of these individuals-turning a solo into a chorus. Thus, the purpose of this article is to describe the results of a metasynthesis of qualitative studies highlighting the voices of PWID with respect to relationships and sexuality. Combining the results of 16 qualitative studies, 271 participants with intellectual disability were interviewed individually or in focus groups about their feelings and experiences regarding intimate relationships. Studies were conducted across Europe, in Australia, China, and in the United States. A little more than half of the participants were male; ages ranged from 13 to 89. Results revealed two competing themes of control and desire. Participants across studies desired friendships and close interpersonal relationships, yet were restricted from developing these relationships by policies, program staff, and family members.

Adapting dialectical behaviour therapy in forensic learning disability services: A grounded theory informed study of "what works".

Emerging evidence indicates effectiveness of dialectical behaviour therapy (DBT) for people with intellectual disabilities (PWID) in forensic settings; however, little is known about "what works" facilitating engagement and change. Eleven interviews were conducted with nine service users across two secure inpatient services. Grounded theory was used to develop a model of perceived engagement and change. The model provides insights into how change occurs during DBT delivered in forensic settings. DBT constitutes a challenging journey, yet provides the motivation and means to address individual's intra-/interpersonal aggression and progress towards release. Participants experienced engaging with DBT as difficult and coercive, moving from compliance and avoidance to acceptance and change. Key factors included participants' motivation, beliefs about safety and ability to change, and interactions with staff. Recommendations are made for increasing intrinsic motivation, reducing perceived coercion and distress, and for future research to address potential aversive elements and enhance effectiveness.