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MYTHS AND REALITIES COOCCURRING DISORDERS MENTAL ILLNESS INTELLECTUAL DISABILITY

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Title: MYTHS AND REALITIES COOCCURRING DISORDERS MENTAL ILLNESS INTELLECTUAL DISABILITY


1
MYTHS AND REALITIESCO-OCCURRING DISORDERSMENTAL
ILLNESS/ INTELLECTUAL DISABILITY
  • 4TH Annual Training
  • for
  • Olmstead State Mental Health Coordinators
  • September 14, 2004
  • Washington, DC
  • Presenter
  • Robert J. Fletcher, DSW, ACSW
  • CEO, NADD

2
DIAGNOSTIC CRITERIA OF INTELLECTUAL DISABILITY
  • Significant sub-average intellectual functioning
  • 1. IQ of 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 onset before age 18 years

3
DEGREE OF SEVERITYREFLECTING DEGREE OF
INTELLECTUAL IMPAIRMENT
  • Mild ID IQ 55-70
  • Moderate ID IQ 35-55
  • Severe ID IQ 20-35
  • Profound ID IQ below 20

4
TERMINOLOGY
  • Intellectual Disability
  • Mental Retardation
  • Developmental Disability
  • Intellectual Impairment
  • Learning Disability (UK)
  • Dual Diagnosis
  • Dual Disability
  • Co-Occurring MI-ID
  • Co-Existing Disorders

5
A SUMMARY OF SIMILARITIES AND DIFFERENCES BETWEEN
INTELLECTUAL DISABILITY (ID) AND MENTAL ILLNESS
(MI)
  • ID refers to sub-average intellectual
  • function (IQ)
  • MI has nothing to do with IQ
  • ID incidence 1-2 of general population
  • MI incidence 16-20 of general population
  • ID present at birth or occurs before age 21
  • MI may have its onset at any age
  • (usually late adolescent)

6
A SUMMARY OF SIMILARITIES AND DIFFERENCES BETWEEN
INTELLECTUAL DISABILITY (ID) AND MENTAL ILLNESS
(MI)(continued)
  • ID intellectual impairment is permanent
  • MI often temporary and may be reversible and is
    often cyclic
  • ID a person can usually be expected to behave
    rationally at his or her cognitive/emotional
    operational level
  • MI a person may vacillate between normal and
    irrational behavior, displaying degrees of each
  • ID symptoms of failure to adjust to societal
    demands are secondary to limited intelligence
  • MI symptom presentation is associated with
    internal and/or external stimuli.

7
DEVELOPMENTAL DISABILITIES INSTATE PSYCHIATRIC
HOSPITALS
  • ? 5.5 of those in state psychiatric hospitals
  • have a developmental disability (DD)
  • ? 17 of individuals with DD in state psychiatric
    hospitals have co-occurring substance disorder
  • ? 54 of individuals in state psychiatric
    hospitals are served in general psychiatric units

8
DEVELOPMENTAL DISABILITIES INSTATE PSYCHIATRIC
HOSPITALS(continued)
  • People with Developmental Disabilities (DD) in
    state psychiatric hospitals have, on average,
    much longer lengths of hospital stays.
  • ? 49 of individuals were discharged within 6
  • months in 2002
  • ? 72 of individuals without DD where
  • discharged within 6 months
  • ? 266 days was average length of stay for
    people
  • with DD
  • ? 88 days was average length of stay for the
  • general population

9
MYTHINDIVIDUALS WITH INTELLECTUAL DISABILITY
(ID) CANNOT HAVE A VERIFIABLE MENTAL HEATH
DISORDER
  • PREMISE MALADAPTIVE BEHAVIORS ARE A
  • FUNCTION OF ID
  • REALITY THE FULL RANGE OF PSYCHIATRIC DISORDERS
    CAN BE REPRESENTED IN PERSONS WITH ID
  • TREATMENT IMPLICATIONS PSYCHIATRIC DIAGNOSIS
    CAN BE MADE USING THE DSM-IV, BEHAVIORAL
    EQUIVALENTS, INTERVIEWS, REPORTS, OBSERVATION AND
    SCREENING TOOLS FOR MOST PEOPLE WITH ID

10
FULL RANGE OF PSYCHIATRIC DISORDERSIN
PERSONS WITH ID
  • DISORDERES ASSOCIATED WITH CHILDHOOD
  • LEARNING DISORDERS
  • PERVASIVE DEVELOPMENTAL
  • DISORDERS
  • ATTENDTION DEFICIT DISORDER
  • TIC DISORDERS
  • DISORDERS ASSOCIATED WITH ADULTHOOD
  • SCHIZOPHRENIA AND OTHER PSYCHOTIC
  • DISORDERS
  • MOOD DISORDER
  • DEPRESSIVE
  • BI-POLAR
  • ANXIETY DISORDERS
  • OCD
  • PHOBIA
  • PANIC
  • POST TRAUMATIC STRESS

11
FULL RANGE OF PSYCHIATRIC DISORDERSIN
PERSONS WITH ID (cont)
  • DISORDERS ASSOCIATED WITH OLDER ADULTS
  • DELIRIUM
  • DEMENTIA
  • OTHER DISORDERS
  • SUBSTANCE ABUSE
  • SEXUAL AND GENDER IDENTITY DISORDERS
  • IMPULSE CONTROL DISORDER
  • FULL RANGE OF PERSONALITY DISORDERS

12
PREVALENCE OF MI AND ID
  • 33 OF PEOPLE WITH MR HAVE MI
  • (Rutter, et al, 1970)
  • 1 2 OF GENERAL POPULATION HAVE ID
  • 3-6 MILLION PEOPLE IN U.S.
  • 1 TO 2 MILLION PEOPLE IN US MAY HAVE A DUAL
    DIAGNOSIS OF MI/ID
  • (Reiss, 1994)

13
MYTHMEDICATION TREATMENT IS USED TO CONTROL
MALADAPTIVE BEHAVIORS
  • PREMISE MEDICATION THERAPY DIRECTLY AFFECTS
    BEHAVIOR.
  • REALITY BEHAVIORS SUCH AS SELF-INJURY AND
    AGGRESSION ARE TOO NONSPECIFIC TO BE CONSIDERED
    AS DIRECT TARGETS FOR DRUG THERAPY.
  • TREATMENT IMPLICATIONS THE APPROPRIATE TARGETS
    FOR MEDICATION THERAPY ARE THE CHANGES IN
    NEUROPHYSIOLOGICAL FUNCTION THAT MEDIATE BEHAVIOR
    ASSOCIATED WITH PSYCHIATRIC DISORDERS.

14
A RATIONAL APPROACH FOR MEDICATION TREATMENT
  • USED AS ONE ASPECT OF A BALANCED
    TREATMENT/HABILITATIVE APPROACH
  • MEDICATION TREATMENT
  • THERAPY/COUNSELING
  • BEHAVIORAL INTERENTIONS
  • FAMILY SUPPORTS
  • QUALITY OF LIFE OPPORTUNITIES
  • PSYCHOACTIVE MEDICATION TO BE A TOOL TO ASSIST A
    PERSON IN MOVING TOWARD APPROPRIATE HUMAN
    ENGAGEMENT
  • FAMILY RELATIONSHIP
  • FRIENDS
  • STAFF/CLIENT INTERACTION
  • HABILITATIVE SUPPORTS

15
MYTHPERSONS WITH ID ARE NOT APPROPRIATE FOR
PSYCHOTHERAPY
  • PREMISE IMPAIRMENTS IN COGNITIVE ABILITIES AND
    LANGUAGE SKILLS MAKE PSYCHOTHERAPY INEFFECTIVE.
  • REALITY LEVEL OF INTELLIGENCE IS NOT A SOLE
    INDICATOR FOR APPROPRIATENESS OF THERAPY. VERBAL
    THERAPY APPROACHES AS WELL AS NON-VERBAL THERAPY
    TECHNIQUES (i.e. ART/MOVE/DANCE THERAPY) CAN BE
    EMPLOYED.
  • TREATMENT IMPLICATIONS PSYCHOTHERAPY APPROACHES
    NEED TO BE ADAPTED TO THE EXPRESSIVE AND
    RECEPTIVE LANGUAGE SKILLS OF THE PERSON.

16
GOALS OF PSYCHOTHERAPY
  • ? APPROPRIATE EXPRESSION OF FEELINGS AND
    EMOTIONS.
  • ? IMPROVE INTERPERSONAL RELATIONSHIPS
  • ? IMPROVE SOCIAL SKILLS
  • ? INCREASE COPING SKILLS TO DEAL WITH STRESS
  • ? ACHIEVE HIGHEST LEVEL OF QUALITY OF LIFE
  • ? IMPROVE SELF-ESTEEM AND SELF-IMAGE

17
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18
MYTHINDIVIDUALS WITH MI/ID CANNOT BE SERVED BY
THE MH AND ID SERVICE SYSTEMS
  • PREMISE EITHER ONE SYSTEM OR THE OTHER MUST
    TAKE FULL RESPONSIBILITY FOR THE CARE AND
    TREATMENT
  • REALITY BOTH THE MH AND ID SYSTEMS CAN WORK
    COLLABORATIVELY
  • SERVICE IMPLICATIONS A COLLABORATIVE PARADIGM
    BETWEEN THE MH AND ID SYSTENS CAN PROVIDE A
    COMPREHENSIVE APPROACH TO A FULL RANGE OF
    SERVICES AND SUPPORTS

19
CROSS-SYSTEM BARRIERS
  • 1. FUNDING ISSUES
  • 2. LACK OF COMMUNICATION AND COLLABORATION
  • LACK OF QUALIFIED AND TRAINED SERVICE PROVIDES
  • 4. PHILOSOPHICAL DIFFERENCES BETWEEN MH AND ID
    SYSTEMS

20
CROSS-SYSTEM BARRIERS
  • FUNDING ISSUES
  • What System is Responsible treatment and
    supports?
  • ? Often neither system wants to take
    responsibility for funding services
  • ? Funding services is often regarded as the
    responsibility of the other system

21
CROSS-SYSTEM BARRIERS
  • FUNDING ISSUES (continued)
  • The lack of cross-system funding approach can
    result in
  • ?People with MI/ID falling through the
  • cracks in the service delivery system
  • ? Longer than medically needed stays
  • in psychiatric hospitals
  • ? Individuals and families going into crises
  • ? A crisis in the service delivery systems

22
CROSS-SYSTEM BARRIERS
  • LACK OF COLLABORATION
  • The lack of collaboration will perpetuate status
    quo at the system level
  • ? Funding barriers
  • ? Lack of communication and collaboration
  • ? Lack of trained providers
  • ? Philosophic difference

23
CROSS-SYSTEM BARRIERS
  • LACK OF COLLABORATION (continued)
  • The lack of collaboration will increase the
    likelihood of a consumer experiencing
  • Homelessness Overmedication
  • Incarceration Hospitalization
  • Restrictive services Falling between the
    cracks
  • Harmful care

24
CROSS-SYSTEM BARRIERS
  • LACK OF QUALIFIED AND TRAINED SERVICE PROVIDERS
  • ?MH providers often do not have the knowledge
    or competencies to work with people who have ID
  • ? ID providers often do not have the knowledge
    or competencies to work with people who have MI

25
CROSS-SYSTEM BARRIERS
  • 4. PHILIOSOPHICAL DIFFERENCES BETWEEN MH AND ID
    SYSTEMS
  • ? Different language
  • ? Different service delivery approaches
  • ? Different treatment philosophy

26
CROSS-SYSTEM BARRIERS
  • PHILIOSOPHICAL DIFFERENCES BETWEEN MH AND ID
    SYSTEMS (continued)
  • MH System ID Systems
  • Rehabilitation Habilitation
  • Recovery Self-Determination
  • Medical Model Development Model
  • Clients Consumers
  • Short Term Approach Long Term Approach

27
AS FRAMEWORK TO PROMOTE CROSS-SYSTEMS
COLLABORATION
  • The development of a cross-system committee
  • The adoption of cross-system training
  • The adoption of cross-system crisis plans
  • The adoption of a cross-system dispute resolution
    process
  • The adoption of a cross-system data base
  • The adoption of a cross-system quality assurance
    and case review system

28
EFFECTIVE SERVICE SYSTEMS
  • THREE INTER-RELATED ASPECTS
  • ACCESS
  • APPROPRIATNESS
  • ACCOUNTABILITY

29
EFFECTIVE SERVICE SYSTEMSTHREE INTER-RELATED
ASPECTS
  • ACCESS
  • ? TIMELINESS
  • ? ARRAY OF SERVICES
  • ? AVAILABILITY
  • ? GEOGRAPHIC PROXIMITY

30
EFFECTIVE SERVICE SYSTEMSTHREE INTER-RELATED
ASPECTS
  • APPROPRIATENESS
  • ? SERVICE MATCHES NEEDS
  • ? SERVICE MATCHES RECIPIENTS WISHES
  • ? SERVICE ALLOWS FOR SELF- DETERMINATION
    WHENEVER POSSIBLE

31
EFFECTIVE SERVICE SYSTEMSTHREE INTER-RELATED
ASPECTS
3. ACCOUNTABILITY ? THERE IS CONSENSUS WITH
REGARD TO ROLES AND RESPONSIBILITIES ?
SERVICES ARE COST EFFECTIVE ? RECIPIENT IS
SATISFIED WITH SERVICES ? SERVICES MEET
OBJECTIVELY ESTABLISHED GOALS ? SERVICES
CHANG WITH THE CHANGING NEEDS OF THE SERVICE USER
32
SYSTEMS WORKING TOGETHER OHIOS INTERAGENCY
AGREEMENT
  • Mike Schroeder, ODMH
  • Glenn McCleese, ODMR/DD
  • 2003

33
STATE AGENCY COLLABORATION THE PROBLEM IN 1998
  • People with co-occurring MI/MRDD are underserved
    by both systems
  • Philosophies and approaches differ
  • Customer centered vs. turf or fiscal centered
  • MH blames MRDD and MRDD blames MH
  • Resources are not combined
  • Collaborative approaches are discouraged
  • Liaison is legal office
  • Clinical approaches are difficult

34
ESSENTIALS FOR SUCCESS SHARED VISION AND
MISSION
  • Departments vision and mission are different
  • Identify common grounds to work on
  • Best practices
  • Identify barriers
  • resources
  • beliefs
  • Training
  • Create a process
  • Tangible value and mission approaches will guide
    future developments

35
ESSENTIALS FOR SUCCESSBRING TOGETHER THE RIGHT
PEOPLE
  • Department leadership
  • Representative community people
  • Clinical people
  • Administrative people
  • State resources
  • Statewide organizations
  • Consumer/family members

36
THE OHIO RESPONSE
  • Both Directors recognize the problem and appoint
    an Advisory Committee to
  • Identify Best Practices
  • Recommend Ways to overcome barriers between
    systems
  • Train staff in both systems

37
ORGANIZED SUB-COMMITTEES AROUND THESE PRIORITIES
  • Sub-committees expanded to include knowledgeable
    and interested people from around the state
  • Developed plans which were reviewed by the
    Advisory Committee and recommended to the
    Directors

38
COMPOSITION OF THE ADVISORY COMMITTEE
  • Major stakeholders including
  • NAMI
  • The ARC
  • University Affiliated Programs
  • Medical Schools
  • Boards
  • Agencies
  • Guardianship Agencies
  • OLRS
  • Key staff from both systems

39
FIRST YEARS
  • Developed Best Practices document
  • Series of training events
  • Stand alone
  • Fifth column approach
  • Begin attacking systems barriers

40
RECOGNIZED NEED TO HAVE A FORMAL AGREEMENT
  • Working well together
  • Identify a number of steps that need to be taken
    to assure next steps are accomplished

41
OVERVIEW OF THE NEW ODMR/DD-ODMH INTERAGENCY
AGREEMENT
  • Four Sections
  • Purpose
  • Joint Responsibilities
  • ODMH Responsibilities
  • ODMR/DD Responsibilities

42
PURPOSES
  • Find ways to most efficiently and effectively
    meet the needs of people with MI/MR
  • Work together toward the implementation of best
    practices in all treatment and habilitation
    settings
  • Develop and support a Coordinating Center of
    Excellence (CCOE)

43
JOINT RESPONSIBILITIES
  • Each agency to name a point person
  • Form committees or work groups to work on
    specific tasks
  • Provide information to relevant personnel within
    each department
  • Facilitate meetings between locals to accomplish
    the purposes
  • Develop and revise and annual training plan

44
MORE JOINT RESPONSIBILITIES
  • Cooperate to
  • Coordinate efforts to serve dually diagnosed
    individuals
  • Develop and periodically revise
    training/informational materials
  • Assist communities, on a regional basis, to fill
    gaps
  • Explore development of interagency group with ODE
    and ODJFS
  • Explore methods to best serve individuals who
    require competency restoration and continue to
    serve those who are IST-U
  • Review and seek changes in statues and
    regulations

45
COORDINATING CENTER OF EXCELLENCE
  • Training
  • Consultation
  • Follow-along
  • Research
  • Technical assistance
  • Further development of best practices

46
FOR MORE INFORMATION CONTACT
  • Dr. Robert J. Fletcher
  • NADD (The National Association for the Dually
    Diagnosed)
  • 132 Fair Street, Kingston, NY 12401
  • Telephone 845 331-4336
  • E-mail rfletcher_at_thenadd.org
  • Thank you!
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