Individual and Group Psychotherapy for Persons with MI/ID: Promoting Mental Wellness

Individual and Group Psychotherapy for Persons with MI/ID:

Promoting Mental Wellness

Presenters:

Robert J. Fletcher, DSW, ACSW, FAAMR

CEO, NADD

Valerie L. Gaus, Ph.D.

Senior Supervising Psychologist, YAI

Private Practice

January 24, 2006

Phoenix, Arizona

Individual and Group Psychotherapy for Persons with MI/ID:

Promoting Mental Wellness

Outline of Presentation

• What is NADD?• Concept of Dual Diagnosis• Bio-Psychosocial Model of Assessment• Application of Individual Therapy• Group Therapy• Cognitive Behavioral Therapy

MISSION STATEMENT

To advance mental wellness

for persons with

developmental disabilities through the

promotion of excellence

in mental health care.

Robert Fletcher, DSW, ACSW, 2004

•NADD Bulletin

Conferences/Trainings

Training & Educational Products

Consultation Services

Fletcher, 2005

CONCEPT OF DUAL DIAGNOSIS

• Co-Existence of Two Disabilities:

Mental Retardation and

Mental Illness

• Both Mental Retardation and Mental Health disorders should be assessed and diagnosed

• All needed treatments and supports should be available, effective and accessible

Modified from DSM-IV-TR, 2000

DIAGNOSTIC CRITERIA OF

INTELLECTUAL DISABILITY

A. Significant sub-average intellectual functioning

1. IQ of 70 or below

B. Concurrent deficits in adaptive functioning

C. The onset before age 18 years

Modified from DSM-IV-TR, 2000

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


WHAT IS MENTAL ILLNESS?

• Severe disturbance ofthoughtmoodbehaviorand/orsocialand

interpersonal relationships

• Common DisordersMood Disorders

Anxiety Disorders

Personality Disorders

Psychotic Disorders

Adjustment Disorders

Sexual Disorders


PREVALENCE

Total U.S. Population:296,000,000

(U.S. Census Bureau, Census 2005)

Number of People In Total Population With ID:

6,000,000(2% - AAMR, 2005)

Number of People With ID Who Are Also Dually Diagnosed2,000,000

(33% of ID – NADD, 2005)


TERMINOLOGY

Intellectual DisabilityMental Retardation

Developmental DisabilityIntellectual ImpairmentLearning Disability (UK)

Dual DiagnosisDual Disability

Co-Occurring MI-IDCo-Existing Disorders


A SUMMARY OF SIMILARITIES AND DIFFERENCES BETWEEN INTELLECTUAL DISABILITY (ID) AND

MENTAL ILLNESS (MI)

ID: refers to sub-average (IQ)

MI: has nothing to do with IQ

ID: incidence: 1-2% of general population

MI: incidence: 16-20% of general population



MENTAL ILLNESS (MI)

ID: present at birth or occurs before age 21MI: may have its onset at any age

(usually late adolescent)

ID: intellectual impairment is permanentMI: often temporary and may be reversible and is

often cyclic

Robert Fletcher, DSW, ACSW , 2004


MENTAL ILLNESS (MI)

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: adjustment difficulties are secondary to ID

MI: adjustment difficulties are secondary to psychopathology


MYTH:INDIVIDUALS 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


FULL RANGE OF PSYCHIATRIC DISORDERSIN

PERSONS WITH ID

I. DISORDERES ASSOCIATED WITH CHILDHOOD LEARNING DISORDERS PERVASIVE DEVELOPMENTAL ATTENDTION DEFICIT DISORDER TIC DISORDERS

II. DISORDERS ASSOCIATED WITH ADULTHOOD SCHIZOPHRENIA MOOD DISORDER DEPRESSIVE BI-POLAR ANXIETY DISORDERS


FULL RANGE OF PSYCHIATRIC DISORDERSIN

PERSONS WITH ID

III. DISORDERS ASSOCIATED WITH OLDER ADULTSDELIRIUMDEMENTIA

IV. OTHER DISORDERSSUBSTANCE ABUSEFULL RANGE OF PERSONALITY DISORDERS

Fletcher, 2005

BEST PRACTICEASSESSMENT:

BIO-PSYCHOSOCIAL MODEL

PERSONBIO PSYCHO

SOCIAL

Fletcher, 2005

BEST PRACTICEBIO-PSYCHO-SOCIAL MODEL

MULTIPLE SOURCES OF ASSESSMENT

1. Review Reports

2. Interview Family

3. Interview Care Provider

4. Direct Observation

5. Clinical Interview

Fletcher, 2005

BEST PRACTICEBIO-PSYCHO-SOCIAL MODEL

MULTIPLE SOURCES OF ASSESSMENT

• Reason for Referral• Presenting Problem• History of Challenging Behaviors• Family History• Personal Developmental History• Medical History• Psychiatric History• Social History• Substance Abuse History• History of Sexual/Physical Abuse• Forensic History

Reiss et al, 1982

DIAGNOSTIC OVER SHADOWING

Suggesting that the condition of mental retardation decreases the diagnostic significance of a co-existing psychiatric disorder. Given this proposal, symptoms of PTSD may be overlooked and be thought of as a manifestation of the condition of mental retardation

Sovner, 1986

FOUR ASPECTS OF MR THAT MAY INFLUENCE THE DIAGNOSTIC PROCESS

1. Intellectual Distortion

2. Psychosocial Masking

3. Cognitive Disintegration

4. Baseline Exaggeration

Sovner, 1986

1. INTELLECTUAL DISTORTION

Emotional symptoms are difficult to

elicit because of deficits in abstract

thinking and in receptive and

expressive language skills.

Sovner, 1986

2. PSYCHOSOCIAL MASKING

Limited social experiences can

influence the content of psychiatric

symptoms (e.g., mania presenting

as a belief that one can drive a car).

Sovner, 1986

3. COGNITIVE DISINTEGRATION

Decreased ability to tolerate stress,

leading to anxiety-induced

decompensation (sometimes

misinterpreted as psychosis).

Sovner, 1986

4. BASELINE EXAGGERATION

Increase in severity or frequency of

chronic maladaptive behavior after

onset of psychiatric illness.

Thompson, Prout & Strohmer, 1994

GUIDELINES FOR ASSESSMENT IN COUNSELING/PSYCHOTHERAPY

I. ESTABLISH A BASELINE-CURRENT STATUS OF PROBLEM-EXTENT, SEVERITY, FREQUENCY

II. PINPOINT TREATMENT TARGETS-IDENTIFY PROBLEM-DOES PROBLEM OCCUR ACROSS SITUATIONS?

III. ASSESSMENT OF DEVELOPMENTAL LEVEL: IMPLICATION FOR TREATMENT APPROACHES

-COGNITIVE AND LANGUAGE LEVEL - LEVEL OF SOCIAL-EMOTIONAL DEVELOPMENT


GUIDELINES FOR ASSESSMENT IN COUNSELING/PSYCHOTHERAPY (CONT.)

IV. ASSESS CONSUMER’S VIEWS OF THE PROBLEM-CONSUMER’S PERCEPTIONS AND UNDERSTANDING-MOTIVATION FOR CHANGE-READINESS FOR TREATMENT

V. ASSESS RELEVANT ENVIRONMENTAL FACTORS-SCHOOL -PEERS-HOME/FAMILY -WORK -SOCIAL/LEISURE-GROUP HOME


GUIDELINES FOR ASSESSMENT IN COUNSELING/PSYCHOTHERAPY (CONT.)

VI. SELECT APPROPRIATE TREATMENT FACTORS

ANXIETY DISORDER RELAXATION PROCEDURES

DEPRESSION COGNITIVE APPROACH

VII. EVALUATE EFFICACY-OUTCOME MEASURES

-TARGET BEHAVIOR-LIFE SATISFACTION-IMPROVED RELATIONSHIPS

Fletcher, 2000

MYTH: PERSONS 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.

TREATMENT IMPLICATIONS: Psychotherapy approaches need to be adapted to the expressive and receptive language skills of the person.


PSYCHOTHERPAY/ COUNSELING

• RELATIONSHIP BETWEEN A CLIENT AND A THERAPIST

• ENGAGED IN A THERAPEUTIC RELATIONSHIP

• TO ACHIEVE A CHANGE IN EMOTIONS, THROUGHTS OR BEHAVIOR

Strohmer & Prout, 1994

GENERAL SIMILARITIES BETWEEN LIFE ISSUES FACED BY

ADOLESCENTS WITHOUT MR AND ADULTS WITH MR

• BOTH USUALLY DEPENDENT ON OTHERS

• BOTH TEND TO BE IN SUPERVISED SETTINGS

• BOTH HAVE COGNITIVE LIMITATIONS IN TERMS OF: PROBLEM SOLVING IMPULSE CONTROL CONCRETE THOUGHT

• BOTH STRUGGLE WITH ISSUES OF: INDEPENDENCE PEER GROUP IDENTITY CHOICES VOCATIONAL SEXUAL IDENTITY AUTHORITY ISSUES

• BOTH REFERRED TO THERAPY BY OTHERS

Strohmer and Prout, 1994

COUNSELING & PSYCHOTHERAPY:WHO IS APPROPRIATE FOR THERAPY?

A DEVELOPMENTAL PERSPECTIVE

WITHOUT MR WITH MR

6-7 years old 6-7 years old cognitive level

Mild MR Borderline MR

Wittman, Strohmer and Prout 1989

PROBLEMS THAT CLIENTS WITH BORDERLINE MR AND MR WANT TO

ADDRESS IN THERAPY

Interpersonal Concerns 22%

General Psychological Functioning 18%

Work 12%

Sexuality 6%

Family 5%

Residential Living & Adjustment 5%

Behavior 4%

Financial & Material Resources 4%

Accepting & Coping with Disability 4%

Dealing with Authority Figures 4%

Other 16%

Duetsch, 1989

TYPES OF STRESS EXPERIENCED BY PERSONS WITH

INTELLECTUAL CHALLENGES

I. Ordinary Situations Which Are Not Typically Stressful To The General Population

A. Social InteractionsB. Meeting New PeopleC. Going To Public Places

II. Stress From Difficult To Manage Situations For All People. Even More Stress For People With Disabilities

A. Major Changes In One’s Life1. Job2. Death In Family3. Home Relocation

B. Adult Expectations1. Heterosexual Activities: Dating, Sex, 2. Money Management3. Living Independently4. Employment


ISSUES AND BARRIERS CONCERNING PSYCHOTHERAPY FOR PERSONS WITH MENTAL

RETARDATION

• MENTAL HEALTH PROFESSIONALS PERCEIVE MALADAPTIVE BEHAVIOR AS A FUNCTION OF MENTAL RETARDATION.

• MANY ASSUME THAT PERSONS WITH MENTAL RETARDATION ARE IMMUNE FROM MENTAL ILLNESS.

• PROFESSIONAL BIAS IN VIEWING INTELLECTUAL DISABILITY AS A BARRIER TO PSYCHOTHERAPY.

• DICHOTOMIZATION OF MENTAL RETARDATION AND MENTAL HEALTH REGULATORY ENTITIES.


LIMITED LITERATURE & RESEARCH IN PSYCHOTHERAPY FOR PERSONS WITH MENTAL

RETARDATION

• EARLIER STUDIES SUGGESTED THAT PSYCHOTHERAPY YIELDED NO OR MINIMAL BENEFIT (Eysanck 1952, 1965)

• RECENT STUDIES POINT TO POSITIVE FINDINGS (Lipsey & Wilson, 1993; Prout & Nowak-Drabik, 2003)

• RESEARCH NEEDS MORE EMPIRICALLY BASED MODELS OF INVESTIGATION (Prout et al, 2000)

• LACK OF METHODOLOGICAL RIGOR (Prout et al, 2003)


PRINCIPLES FOR ACHIEVING A THERAPEUTIC RELATIONSHIP

• EMPATHETIC

UNDERSTANDING

• RESPECT AND ACCEPTANCE

OF CLIENT

• THERAPEUTIC GENUINENESS

• CONCRETENESS

• ACCEPT THE CLIENT’S LIFE

CIRCUMSTANCES

• BE CONSISTENT

• CONFIDENTIALITY

• DRAW THE CLIENT OUT

• EXPRESS GENUINE

INTEREST IN YOUR CLIENT

• BE AWARE OF YOUR OWN

FEELINGS


CONSIDERATIONS IN THERAPY WITH PERSONS WHO HAVE MENTAL ILLNESS AND

MENTAL RETARDATION

• SPECIAL CONSIDERATIONS

• WATCH FOR PLEASERS

• SLOW PROGRESS

• MULTIPLICITY OF PROBLEMS

• RELIABILITY OF REPORTING

• DIFFICULTY RELATING TO ANALOGIES

• PROBLEMS WITH TERMINATING


CONFIDENTIALITY

• What is discussed in therapy must be kept private

• Care providers may bring pertinent information to the therapist. The information will be discussed with person in a manner he/she can understand

• Nothing discussed in therapy will be released without the person’s permission

• With the client’s permission, the therapist will work collaboratively other care providers


Person

Transportation

Medical and Dental

Family Support

Housing

Outpatient Mental Health

Hospital Diversion

Inpatient Mental Health

Crisis Prevention and Intervention

Positive Behavioral Support

Vocational/ Employment

Day Service

Substance Abuse Service

Sexual Offender Service

SERVICE

COMPONENTS

YAI

TECHNIQUES FORPROMOTING MENTAL WELLNESS

HELP PEOPLE BETTER COPEWITH DAILY PROBLEMS

• LISTEN

• REFLECT

• PROBE

• SUPPORT

• FACILITATE PROBLEM SOLVING

• EVALUATE OUTCOME

YAI

TECHNIQUES FORPROMOTING

MENTAL WELLNESS

ACTIVE LISTENING

ATTENTIVE

INTERESTED

REFLECT REPEAT A FEW WORDS

REFLECT DEMONSTRATES ACTIVE LISTENING

YAI


PROBE

ASK DIRECT QUESTIONS

AVOID INTERROGATION

HOW AND WHAT QUESTIONS ARE USUALLY EASIER TO ANSWER THAN WHY QUESTIONS

YAI


SUPPORT

SUPPORTIVE STATEMENTS INDICATE UNDERSTANDING

EXPRESS THAT YOU CARE

ACKNOWLEDGE HAVING BEEN IN A SIMILAR SITUATION

YAI


FACILITATE PROBLEM

SOLVING

EXPLORE ALTERNATIVE OPTIONS

SUPPORT ACCEPTABLE SOLUTIONS

YAI


EVALUATE OUTCOME

WAS OUTCOME ACCEPTABLE?

WAS IT POSITIVE?

WHAT WAS LEARNED?

Robert Fletcher, DSW, ACSW - 2004 -


STAGES OF PSYCHOTHERAPY WITH PERSON WHO HAVE MENTAL RETARDATION

I. INITIAL STAGE- THERAPY GOALS ESTABLISHED

- GROUND RULES - RAPPORT DEVELOPED

II. MIDDLE STAGE- SOLIDIFIED THERAPEUTIC RELATIONSHIPS- THERAPIST IS EMPATHIC- EMOTIONS ARE EXPRESSED- PROBLEMS ARE IDENTIFIED- ALTERNATIVE SOLUTIONS


STAGES OF PSYCHOTHERAPY WITH PERSON WHO HAVE MENTAL RETARDATION

III. TERMINATION STAGE

- EXPLORE PAST LOSSES

- REVIEWS GAINS MADE DURING THERAPY

- EXPLORE FEELINGS OF TERMINATION

Levitas and Gilson, 1989

PREDICTABLE CRISIS ASSESSMENT OUTLINE

• Confirmation/realization of diagnosis of mental retardation

• Birth of siblings

• Starting school

• Puberty and adolescence

• Sex and dating

• Being surpassed by younger siblings

• Emancipation of siblings

• End of education

Levitas and Gilson, 1989

PREDICTABLE CRISIS ASSESSMENT OUTLINE

• Out-of-home placement and/or residential moves

• Staff/client relationships

• Inappropriate expectations

• Aging, illness and/or death of parents

• Death of peers or loss of friends

• Medical illness

• Psychiatric illness

• Other

Robert Fletcher, DSW, ACSW - 2004 -


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Individual and Group Psychotherapy for Persons with MI/ID: Promoting Mental Wellness

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