Addressing Multiple Conditions Through Motivational and Person Centered Approaches

1. Addressing Multiple Conditions Through Motivational and Person Centered Approaches Natalie Marr, Psy.D. LP Erwin Concepcion, Ph.D. LP

2. Objectives • Identify three benefits to providing integrating care and services for people with co-occurring conditions • Identify where participants are in their comfort and own change process for engaging and supporting people with co-occurring disorder in an integrated way • Understanding of how current skills can be enhanced to help individuals with co-occurring conditions • Identify one next step participants can take to begin addressing multiple conditions facing the individuals they support

3. Outline • Background • Challenges • Goals • Barriers • Solutions

4. Intellectual Disability Diagnostic Criteria • Intellectual functioning level (IQ) is 70 or below • Concurrent deficits in adaptive functioning in two or more of the following areas: • Communication • Self care • Home living • Social interpersonal skills • Use of community resources • Self direction • Functional academic skills • Work • Leisure • Health • Self • The condition is present from childhood (prior to age 18)

5. Degree of Intellectual Impairment • Mild ID IQ 55 to 70 • Moderate ID IQ 35 to 55 • Severe ID IQ 20 to 35 • Profound ID IQ below 20

6. Mental Illness in People with Intellectual Disabilities • Mental Illness: disorders of the brain that disrupt a person’s thinking, feeling, mood, and ability to relate to others. • Some of the most common types of mental illnesses seen in people with developmental disabilities include major depression, bipolar disorder, anxiety disorders, personality disorders, schizophrenia and other psychotic disorders, and phobias

7. Co-Occurring Conditions

8. ID and MI Contrasts Intellectual Disabilities Mental Illness Not related to IQ Incidence = 16-20% of pop May have onset at any age Often temporary, reversible, and cyclical May vacillate between coping behavior and irrational behavior Symptom presentation is associated with internal and/or external stimuli • Refers to below average intellectual functioning • Incidence= 1-2% of pop • Present at birth or prior to age 21 • Intellectual impairment is permanent • Rational behavior at the person’s cognitive & emotional operational level • Symptoms of failure to adjust to societal demands are secondary to limited intellectual functioning

9. Myth: People with ID Cannot have a Verifiable Mental Health Disorder • Assumption is that maladaptive behaviors are a function of ID

10. Myth Buster • Reality is that the full range of psychiatric disorders can be represented in persons with ID

11. Mental Health Conditions • Associated with Childhood • Learning Disorders • Pervasive Developmental Disorders • Attention Deficit • Tic Disorders • Associated with Adulthood • Psychotic Disorders • Mood Disorders • Anxiety Disorders

12. Mental Health Conditions (con’t) • Associated with older adults • Delirium • Dementia • Others • Substance Use Disorders • Sexual and Gender Identity Disorders • Personality Disorders

13. National Core Indicators Project • NCI analysis based upon: • Large random sample • Cross-state data (17 states) • Respondents in community and institutional settings • Data obtained from consumers and proxies on physical and behavioral health, services and supports, community outcomes

14. ID only Dual dx n=2,453 29% n=6,048 71% Type of Diagnosis (n=8501)

15. Level of [ID] (n=8501)

16. Takes Psychotropic Medications

17. Type of Psychotropic Taken

18. Presence of Problem Behavior

19. Individuals with Dual Diagnosis • May sometimes be seen as adults with failed employment histories who reside in homeless shelters and/or within the criminal justice system • Have complex needs and are often unable to access the services they need due to insufficient resources • Persons with dual diagnosis face difficulties finding appropriate services; often get caught in-between two service systems

20. Potential Consequences for the Person • Homelessness • Overmedication • Incarceration • Hospitalization • Restrictive services • “Falling between the cracks” • Harmful care

21. Commonly Undiagnosed Problems • Seizure disorders (untreated or undertreated) • Chronic pain • Gastro esophageal reflux disease • Autoimmune disorders • Sleep apnea • From Dr. Julie Gentile, M.D.

22. Barriers and Challenges in Collaboration • Funding barriers to integrated treatment • Lack of communication • Training in integrated approaches (both sides) • Philosophic differences

23. Philosophical Differences

24. Behavioral Topography • Although the topography (what the behavior looks like or sounds like) of behavior may be similar for individuals, the causes and functions of behaviors are very different.

25. Integrating Approaches

26. Mental Health Overlay on Individuals with Intellectual Deficits • Mental Health conditions are often underdiagnosed in this population for a number of reasons (Gustafsson & Sonnander, 2004; Reiss, 1990): • Some disorders may manifest differently (i.e., different symptoms may be evident) across a range of intellectual ability (Powell, 1999) • Diagnostic Overshadowing: Challenging or disruptive behaviors may be attributed to the intellectual disability instead of a potential mental illness (Moss, 2001); cognitive inefficiencies, slowed processing and/or poor executive functioning attributed to intellectual disability • Many diagnostic tools rely on individuals’ ability to express their symptoms verbally (Moss, 2001).

27. Challenging ID/MI Assumptions • Individuals with ID can benefit from MH services • If a client has a diagnosis that qualifies for mental health services, the presence of any other diagnosis, including intellectual disability, does not exclude that individual from receiving mental health services, and visa versa • Eliminate language like “primary diagnosis” and criteria to receive services that relies on a “which [deficit] came first?” model • Coordinated treatment and support should be the standard for individuals with more than one disability who are served in state funded programs

28. Implications/Recommendations for Individuals with ID/MI • Assessment and proper diagnosis of psychiatric disorders is key to creating and coordinating a plan for treatment • The plan of treatment should incorporate interventions for both MI and ID components • Support providers should note that behavior initially maintained by physical influences can become maintained by social attention or release from demands as well • Pay attention to stages of change for the individual and the providers when creating a plan of treatment

29. How does knowing me help them? • Human service delivery happens between humans • All the same issues that occur in social engagement will be at play in our interactions with those we support

30. Using what we’ve got:Knowing the tools in our toolbox • Communication: What are we telling the person? • Verbal • Non-verbal • Experience: We must pay attention to our tendency to want to use the same tools with every person we support • Relationship: Who are we to this person? How are we using this to his/her advantage?

31. How do we make our tools work? • Communication • Communication • Communication • More Communication

32. Activity: Making our tools work • Split up into pairs in the room • One of you face the back of the room (away from the PowerPoint screen) • The other person in the pair look up at the next screen and describe for your partner what you see in three words or less

33. Describe

34. Activity: Evaluate • How did that go? • Did the person get a good picture of what it was you were describing to them? • If they had to, could they have drawn the very object you described? • If not, why not? • How much more of a description would they have needed?

35. Activity: Making our tools work • Now, switch places with your partner and have the person who was describing the first object now face the back of the room (away from the PowerPoint screen) • Repeat the previous activity and describe for your partner what you see in three words or less

36. Describe

37. Activity: Evaluate • How did that go? • Did the person get a good picture of what it was you were describing to them? • If they had to, could they have drawn the very object you described? • If not, why not? • How much more of a description would they have needed?

38. Importance of Integrated Care • The previous activity is a simple reminder that verbal communication alone will not give us all the information that we desire when we are trying to develop innovative supports • How does Integrated Care help?

39. Medical Model

40. Integrated Care Model

41. Integrated Care • A Person Centered approach • Balance of “Important to” and “Important for” • De-emphasizes any one tool as the most important tool or the tool that will fix everything • Integrates information from many angles/sources • Multiple/Competing conditions: Neurocognitive, Mental Health, Substance Use, Medical, etc. • Gets the right supports at the right time to the person

42. Next Steps: How can we build Integrated Care settings? • Start with the person – What is “Important to” them and “Important for” them? • Team approach – How do we balance the “Important to” and “Important for”? • Look at the person and his/her support needs from all angles • Seek out multiple resources • Become a recruitor of/advocate for enlisting current resources into the integrated care matrix • Never tire of looking for new and more innovative means for supporting the person

43. References • Diagnostic Manual—Intellectual Disability: A Textbook of Diagnosis of Mental Disorders in Persons with Intellectual Disability by Robert Fletcher, Earl Loschen, ChrissoulaStavrakaki, and Michael First (Eds.) Kingston, New York: NADD Press, 2007. 552 pp. • National Association for the Dually Diagnosed (NADD), http://www.thenadd.org/index.shtml • “Mental Illness and Developmental Disabilities: Some Basics” a presentation by Lara Pallay, LIISW-S Mental Illness/Developmental Disabilities Coordinating Center of Excellence (Ohio) • Editorial: Introduction to Special Section on Evidence-Based Practices for Persons With Intellectual and Developmental Disabilities, A. P. Kaiser and L. L. McIntyre, AJIDD, Vol.115, Number 5: pp. 357–363, September 2010