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Dual Diagnosis 101 Meeting the Behavioral Healthcare Needs of Persons with Intellectual and Developmental Disabilities and Co-occurring psychiatric Diagnoses (IDD/MI)

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Title: Dual Diagnosis 101 Meeting the Behavioral Healthcare Needs of Persons with Intellectual and Developmental Disabilities and Co-occurring psychiatric Diagnoses (IDD/MI)


1
Dual Diagnosis 101Meeting the Behavioral
Healthcare Needs of Persons with Intellectual and
Developmental Disabilities and Co-occurring
psychiatric Diagnoses (IDD/MI)
  • Michael C. Wolff Ph.D., CADC
  • Assistant Clinical Professor, Penn State
    Department of Psychology
  • Assistant Director, Penn State Psychological
    Clinic

2
Goals for today
  • Continue to highlight best practice guidelines
    with respect to working with dual diagnosis
    populations
  • Additional treatment/support strategies best
    practice for responding to resistance and
    difficult behaviors, encouraging services,
    accomplishing goals, etc.
  • Examine staff contributions working with
    difficult clients and working to be the best of
    our ability, and in a less stressed manner
  • Putting it all together. Use of video clips and
    vignettes to facilitate understanding

3
My background
  • Substance Abusenot that kind
  • Community mental health (children and
    youth/probation)
  • Psychotherapy
  • Adults and Children Families
  • Consultation with dual diagnosis populations
  • Convergence of ideas.

4
Some of Mikes Pet Peeves.
  • Meetings where clients are present and
    participants are not speaking directly to the
    client, but talking as if the client is not
    present.
  • Using terms like Manipulative or Attention
    Seeking or Acting like a baby or Scheming or
    Just to make me mad to describe function of a
    behavior
  • Infantilizing clients referring to (or talking
    to) adults as children or kids
  • Referring to a challenging behavior as BEHAVIORAL
    not PSYCHOLOGICALits really a false dichotomy

5
No need to be a diagnostician!
  • Dimensional far outweighs Categorical
  • Impulsivity/behavioral control
  • Agitation/irritability
  • Processing deficits (sensory)
  • Social challenges
  • Mood regulation
  • Thought disturbance
  • Behavioral control
  • Substance induced impairment

6
In the field Anxiety
  • Person experiencing a panic attack
  • Hypervigilance, obsessions, and compulsions can
    look like non-compliance
  • Can appear reckless

7
In the field-Depression
  • Can often take the form of extreme irritability
  • Apathy and lack of cooperation
  • Hopelessness
  • Difficulty concentrating, answering questions and
    focusing
  • Video 200

8
Bi-Polar in the field
  • Dealing with a manic individual is very
    challenging
  • Unable to sustain a reciprocal conversation
  • Sleep disturbances
  • High energy, inability to regulate mood and
    behavior
  • Engaging in many high risk behaviors including
    substance use, sexual promiscuity, and at times
    illegal activities

9
Schizophrenia in the field
  • Disorganized
  • Scared and confused
  • Paranoia can lead to aggression very quickly
  • Actively psychotic individuals are very difficult
    to manage and require a very gentle approach

10
Autism in the field..
  • Non responsive, limited eye contact (can be
    mistaken for suspicious behavior)
  • Irritable and confused
  • Unable to follow commands (can be mistaken for
    non-compliance, non-cooperative)
  • Highly sensitive to sensory input (noise, touch,
    surroundings) hyper/hypo
  • Can become violent due to inability to
    adequately/accurately perceive threat
  • Video clip (16.45)

11
Personality Disorders
  • Enduring pattern of inner experiences and
    behavior, which deviates markedly from the norm
  • Involves cognition, affectivity, interpersonal
    functioning, impulse control
  • Leads to clinically significant distress
  • Stable, long duration (patterns tracked back to
    adolescence or early adulthood)

12
The Clusters
Cluster C Anxious/Fearful
Cluster B Dramatic/Erratic
Cluster A Odd/Eccentric
Avoidant Social inhibition, feelings
of inadequacy, and hypersensitivity to negative
evaluation
Antisocial Disregard for and violation Of the
rights of others
Paranoid Distrust and suspicious of others
Borderline Instability of interpersonal
relationships, self image, and affect, and
marked impulsivity
Schizoid Detachment from social relationships
and restricted range of emotional expression
Dependent Excessive need to be taken care of,
submissive behavior, and fears of separation
Histrionic Excessive emotionally and attention
seeking
Schizotypal Lack of capacity for close
relationships, cognitive distortions and
eccentric behavior
Obsessive Compulsive Preoccupation with order,
perfection, and control
Narcissistic Grandiosity, need for
admiration and lack of empathy
13
Two distinct interactions
  • http//www.youtube.com/watch?vA-8WvDJGHi4
  • 1730

14
What to do?
  • We need to be diligent in our efforts to place
    ourselves in the shoes of our clients
  • Please dont compare their behavior to how we
    would handle a situation or struggle, nobody
    cares, really (we are all just trying to get by)
  • Our job is to find a way to be supportive, be
    empathic, yet maintain personal and professional
    boundariesits really hard to do
  • But first, lets learn to conceptualize why
    someone may behave the way they do

15
Additional Variables SES Vocational Social
outlets Neighborhood Loss/Bereavement Trauma
history Access to health care Quality of
schools Available treatment Cultural Influences
Etiology
Community Staff
Teachers
Case Managers
Individual
Biology/Health Hard Wiring
Parents Family
Thoughts Feelings Temperament
Peers
Romantic
Meaningful Adult
Counselors Therapists Psychiatric
Why does the individual behave this way?
16
Strategies, Part 1
17

Strategies
  • Typically, behaviorally oriented strategies have
    greatest impact on challenging behaviors
  • Function of behavior (ABCs)
  • Individually tailored interventions
  • Incentives prior to punishment
  • Anticipate problems before they emerge
  • Meaningful consequences
  • Consistency
  • Promote emotional/behavioral control
  • Appreciate your own contributions..

18
Specific Interventions Cont. Common Reasons
Plans Dont Work
  • Target behaviors are too broad or not
    operationalized (must look the same to everyone!)
  • Recording procedure too complicated..data
    collection fatigue!
  • Reinforcement not powerful enough
  • Too much emphasis on punishment
  • Not enough emphasis on attention
  • Failure to clearly specify duties
  • Tendency to see plan as closed to modification
  • Not enough planning/oversight/training

19
Specific InterventionsCatch them doing what you
want!
  • Be specific with your praises
  • Attention is a potent antecedent, it should be
    given frequently (positively, that is)
  • Praise effort over achievement (on task, working
    hard, coping, really thinking it through, etc.)
  • Avoid good job or you were really good today
    .too broad and general (and implies bad)
  • Try I liked how you _______ or When you were
    ______, that seemed like you really enjoyed
    yourself, it was nice to see You worked really
    hard earlier when you were

20
What factors contribute to the variations in
challenging behaviors?
Interventions
Client
Staff
21
Staff contributions We have found that
  • How staff respond to challenging behaviors is
    determined by multiple influences/causality.
  • Their understanding or appreciation regarding the
    function of challenging behaviors
  • Their views about challenging behaviors in
    clients, and their views of self
  • Their stress level, training, experience,
    education
  • Characteristics of employing organization (i.e.
    quality of training, supervision, support, etc.)

Video 55 sec
22
Staff Contributions Characteristics and styles
of relating known to have positive impact on
process and outcome of interactions
  • We tend to do better when
  • accurate empathy
  • psychological health
  • well-being and adjustment
  • thoughtful attribution
  • internal locus of control (what can I do
    differently?)
  • sufficient self-confidence
  • low reactance
  • staff-consumer interactions
  • (positive) expectancies

23
Staff Contributions Characteristics and styles
of relating known to have negative impact on
process and outcome of interactions
  • We tend to do worse when
  • highly rigid
  • hostile (view of others and self)
  • highly dominant / directive
  • high desire for control
  • external locus of control
  • lack self-confidence
  • high stress levels/burnout
  • negative expectancies of clients
  • negative attributions/appraisals
  • reactive
  • high tension with consumer

24
Attributions and appraisal
  • Why do they behave this way?
  • They are manipulative, just to get me upset, they
    like doing this, they are hopeless, they are
    ungrateful.how are you feeling?
  • Task avoidance, preference, escape, disability,
    hurt/pain (emotionally/physically), sensory,
    attention, distractiondifferent response?
  • Internal/External
  • Permanent/Temporary
  • Controllable/Uncontrollable

25
Putting it together
26
Stress and Burnout
  • At least some responsibility of employer
  • Leads to increased levels of staff illness,
    absenteeism, and turnover/attrition
  • What can you do about stress and burnout?
  • Increase awareness, identify sources of stress,
    identify outlets for assistance (internal to you,
    within workplace, outside of workplace)

Video (Van 6min)
27
Stress and BurnoutHow do we become stressed in
workplace?
  • Person Environment
  • Interaction between person and work
    environment-mismatch
  • Demand-support-control
  • Demand high, support/control low
  • Cognitive behavioral
  • Perception of stressors in environment (our
    interpretation)
  • Emotional overload
  • Exhaustion and personal accomplishment
  • Equity theory
  • Feelings and perception of inequality

28
Modeling
  • What do we model with respect to our own
    emotional expression?
  • How do we cope with strong emotions and stress in
    general?

29
Self efficacy
  • Sense of agency or confidence
  • I am able to handle this (optimism)
  • I feel supported in my role
  • I have necessary information to respond
    effectively
  • I am able to predict when this may or may not
    occur

30
Emotional reactions
  • Attention (dont do that, you know you are not
    supposed to do that, no no no.stop)
  • Avoidance (whatever, Im scared of him/her)
  • Empathy, assistance, nurturance, support
  • Fear, anger, helplessness, apathy

Burnout and exhaustion
31
Stressful interactions can lead to
Feelings of inadequacy or impotence
  • Compassion Fatigue
  • Vicarious Trauma Reactions
  • Wounded Healer
  • Countertransference

Over-inflated sense of importance
Avoidance (depression, loss of energy apathy)
Inability to let go of work/consumers
REGARDLESS WHATYOU CALL IT, IT CAN LEAD TO.
Client/work issues encroaching on personal time
32
Interventions Part 2
33
Evidence based approaches-Counseling
34
The importance of the Working Alliance
  • Bordins model
  • Consists of three parts
  • Agreement on tasks
  • Agreement on goals
  • Bond

35
Motivational Interviewing and Stages of Change
36
What you need to know about Motivational
Interviewing
  • Based on theories related to Stages of Change
    model.
  • Does not fit into traditional therapeutic
    orientation models per se, rather it can augment
    any approach
  • It is a theory for Behavior Change
  • Four general principles Express empathy,
    develop discrepancy, roll with resistance,
    support self-efficacy

37
Express empathy
  • Client Everybody tells me what to do but they
    dont understand how I feel
  • Counselor You think people are not understanding
    you.
  • Counselor Well how do you feel?
  • Counselor Maybe they are just trying to help?
  • Counselor It sounds frustrating when people may
    be trying to help you, but they are missing how
    you really feel.

38
Ambivalence The dilemma of change I WANT TO, I
DONT WANT TO
  • Think of a time you wanted to change something
    about your life
  • I want to exercise more, but it is such a time
    commitment
  • My sweet tooth says I want to, but my wisdom
    tooth says no
  • I want to meet new people, but I dont feel Im a
    worthwhile person to meet
  • I dont want to party as much as I have been
    lately

39
Lets take a closer look
  • Client Ive tried so many times to change, and
    failed.
  • Counselor Why have you failed?
  • Counselor You should keep trying
  • Counselor Maybe you need a different approach
  • Counselor Youre very persistent, even in the
    face of discouragement. This change must be
    really important to you

40
Express empathy
  • Client Everybody tells me what to do but they
    dont understand how I feel
  • Counselor You think people are not understanding
    you.
  • Counselor Well how do you feel?
  • Counselor Maybe they are just trying to help?
  • Counselor It sounds frustrating when people may
    be trying to help you, but they are missing how
    you really feel.

41
Some counselor reactions may be negative and
harmful, yet at times can be well intentioned but
unhelpful
  • Negative and harmful
  • Well intentioned but unhelpful
  • Blaming the client
  • Accusing client of being manipulative
  • Avoiding, belittling, or antagonizing the client
  • Fearful of client
  • Angry that client is not changing (and expressing
    it directly with client inappropriately)
  • Giving advice
  • Disagreeing with client
  • Offering alternative suggestions
  • Wanting so much for the client to see the errors
    of their way, or the RIGHT way.

42
I dont want to be this way. It used to be
better. I know I can do this but its too damn
hard. Some things help, but not enough.
I cant cope. You dont understand me. There is
nothing else I can do. Nobody is listening to
me.
43
It does feel good to talk to someone. There was
one therapist who helped me. If I had the time,
I would go back to group as well.
I dont need to be in counseling. It wont help
me anyway. I tried it before and was always let
down. I cant work if I am in counseling. I
have too many other things going on.
44
I dont like my day programming, I dont like
working anymore, you cant make me do things I
dont want to do
I do like to spend time with my friends, I do
like making a little money, I just want to be
able to make decisions for myself
45
I know it is not healthy, but I keep going back.
Many of my needs are not being met, but he needs
me. I have thought about leaving, I just dont
know where I would go.
He is the only one who understands me. I cant
live without him. We must be together. He is
mean, but nobody else understands him. I cant
leave him.
46
Ambivalence is powerful
  • Remember if we focus on Naming and Empathizing
    regarding a consumers ambivalence, rather than
    Changing behavior (at least to start), we are
    more likely to
  • Decrease challenging behaviors, increase our
    sense of self efficacy, decrease our stress and
    burnout, and improve our relationships with the
    people we serve!

47
I guess there was some good information. At
least Dr. McGonigle was helpful. I really could
try and implement some of this information in my
work.
Ok, that Mike Wolff guy was pretty boring. His 3
hour talk was about 2.5 hours too long. I could
have been getting paperwork done during this
time.
One final example of ambivalence
48
Thanks !
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