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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.

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

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  1. 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

  2. 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

  3. MISSION STATEMENT To advance mental wellness for persons with developmental disabilities through the promotion of excellence in mental health care.

  4. NADD Bulletin • Conferences/Trainings • Training & Educational Products • Consultation Services Robert Fletcher, DSW, ACSW, 2004

  5. 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 Fletcher, 2005

  6. DIAGNOSTIC CRITERIA OF INTELLECTUAL DISABILITY Significant sub-average intellectual functioning 1. IQ of 70 or below Concurrent deficits in adaptive functioning C. The onset before age 18 years Modified from DSM-IV-TR, 2000

  7. 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 Modified from DSM-IV-TR, 2000

  8. Severe disturbance of thought mood behavior and/or social and interpersonal relationships Common Disorders Mood Disorders Anxiety Disorders Personality Disorders Psychotic Disorders Adjustment Disorders Sexual Disorders WHAT IS MENTAL ILLNESS? Robert Fletcher, DSW, ACSW, 2004

  9. 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 Diagnosed 2,000,000 (33% of ID – NADD, 2005) Robert Fletcher, DSW, ACSW, 2004

  10. TERMINOLOGY Intellectual Disability Mental Retardation Developmental Disability Intellectual Impairment Learning Disability (UK) Dual Diagnosis Dual Disability Co-Occurring MI-ID Co-Existing Disorders Robert Fletcher, DSW, ACSW, 2004

  11. 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 Robert Fletcher, DSW, ACSW, 2004

  12. A SUMMARY OF SIMILARITIES AND DIFFERENCES BETWEEN INTELLECTUAL DISABILITY (ID) AND MENTAL ILLNESS (MI) ID: present at birth or occurs before age 21 MI: may have its onset at any age (usually late adolescent) ID: intellectual impairment is permanent MI: often temporary and may be reversible and is often cyclic Robert Fletcher, DSW, ACSW, 2004

  13. A SUMMARY OF SIMILARITIES AND DIFFERENCES BETWEEN INTELLECTUAL DISABILITY (ID) AND 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 Robert Fletcher, DSW, ACSW , 2004

  14. 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 Robert Fletcher, DSW, ACSW, 2004

  15. FULL RANGE OF PSYCHIATRIC DISORDERSIN PERSONS WITH ID • DISORDERES ASSOCIATED WITH CHILDHOOD LEARNING DISORDERS PERVASIVE DEVELOPMENTAL ATTENDTION DEFICIT DISORDER TIC DISORDERS • DISORDERS ASSOCIATED WITH ADULTHOOD SCHIZOPHRENIA MOOD DISORDER DEPRESSIVE BI-POLAR ANXIETY DISORDERS Robert Fletcher, DSW, ACSW, 2004

  16. FULL RANGE OF PSYCHIATRIC DISORDERSIN PERSONS WITH ID • DISORDERS ASSOCIATED WITH OLDER ADULTS DELIRIUM DEMENTIA • OTHER DISORDERS SUBSTANCE ABUSE FULL RANGE OF PERSONALITY DISORDERS Robert Fletcher, DSW, ACSW, 2004

  17. BEST PRACTICEASSESSMENT:BIO-PSYCHOSOCIAL MODEL PERSON BIO PSYCHO SOCIAL Fletcher, 2005

  18. BEST PRACTICEBIO-PSYCHO-SOCIAL MODELMULTIPLE SOURCES OF ASSESSMENT 1.Review Reports 2. Interview Family 3. Interview Care Provider 4. Direct Observation 5. Clinical Interview Fletcher, 2005

  19. BEST PRACTICEBIO-PSYCHO-SOCIAL MODELMULTIPLE 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 Fletcher, 2005

  20. 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 Reiss et al, 1982

  21. FOUR ASPECTS OF MR THAT MAY INFLUENCE THE DIAGNOSTIC PROCESS • Intellectual Distortion • Psychosocial Masking • Cognitive Disintegration • Baseline Exaggeration Sovner, 1986

  22. 1. INTELLECTUAL DISTORTION Emotional symptoms are difficult to elicit because of deficits in abstract thinking and in receptive and expressive language skills. Sovner, 1986

  23. 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

  24. 3. COGNITIVE DISINTEGRATION Decreased ability to tolerate stress, leading to anxiety-induced decompensation (sometimes misinterpreted as psychosis). Sovner, 1986

  25. 4. BASELINE EXAGGERATION Increase in severity or frequency of chronic maladaptive behavior after onset of psychiatric illness. Sovner, 1986

  26. 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? • ASSESSMENT OF DEVELOPMENTALLEVEL: IMPLICATION FOR TREATMENT APPROACHES -COGNITIVE AND LANGUAGE LEVEL - LEVEL OF SOCIAL-EMOTIONAL DEVELOPMENT Thompson, Prout & Strohmer, 1994

  27. GUIDELINES FOR ASSESSMENT IN COUNSELING/PSYCHOTHERAPY (CONT.) • ASSESS CONSUMER’S VIEWS OF THE PROBLEM -CONSUMER’S PERCEPTIONS AND UNDERSTANDING -MOTIVATION FOR CHANGE -READINESS FOR TREATMENT • ASSESS RELEVANT ENVIRONMENTAL FACTORS -SCHOOL -PEERS -HOME/FAMILY -WORK -SOCIAL/LEISURE -GROUP HOME Thompson, Prout & Strohmer, 1994

  28. GUIDELINES FOR ASSESSMENT IN COUNSELING/PSYCHOTHERAPY (CONT.) • SELECT APPROPRIATE TREATMENT FACTORS ANXIETY DISORDER RELAXATION PROCEDURES DEPRESSION COGNITIVE APPROACH • EVALUATE EFFICACY -OUTCOME MEASURES -TARGET BEHAVIOR -LIFE SATISFACTION -IMPROVED RELATIONSHIPS Thompson, Prout & Strohmer, 1994

  29. 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. Fletcher, 2000

  30. PSYCHOTHERPAY/ COUNSELING • RELATIONSHIP BETWEEN A CLIENT AND A THERAPIST • ENGAGED IN A THERAPEUTIC RELATIONSHIP • TO ACHIEVE A CHANGE IN EMOTIONS, THROUGHTS OR BEHAVIOR Robert Fletcher, DSW, ACSW, 2004

  31. 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 & Prout, 1994

  32. COUNSELING & PSYCHOTHERAPY:WHO IS APPROPRIATE FOR THERAPY?A DEVELOPMENTAL PERSPECTIVE WITHOUT MRWITH MR 6-7 years old 6-7 years old cognitive level Mild MR Borderline MR Strohmer and Prout, 1994

  33. 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% Wittman, Strohmer and Prout 1989

  34. TYPES OF STRESS EXPERIENCED BY PERSONS WITHINTELLECTUAL CHALLENGES I. Ordinary Situations Which Are Not Typically Stressful To The General Population A. Social Interactions B. Meeting New People C. 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 Life 1. Job 2. Death In Family 3. Home Relocation B. Adult Expectations 1. Heterosexual Activities: Dating, Sex, 2. Money Management 3. Living Independently 4. Employment Duetsch, 1989

  35. Robert Fletcher, DSW, ACSW, 2004

  36. ISSUES AND BARRIERS CONCERNING PSYCHOTHERAPY FOR PERSONS WITH MENTALRETARDATION • 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. Robert Fletcher, DSW, ACSW, 2004

  37. 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) Robert Fletcher, DSW, ACSW, 2004

  38. 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 Robert Fletcher, DSW, ACSW, 2004

  39. 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 Robert Fletcher, DSW, ACSW , 2004

  40. 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 Robert Fletcher, DSW, ACSW, 2004

  41. SERVICE COMPONENTS Robert Fletcher, DSW, ACSW, 2004

  42. TECHNIQUES FORPROMOTING MENTAL WELLNESS HELP PEOPLE BETTER COPE WITH DAILY PROBLEMS • LISTEN • REFLECT • PROBE • SUPPORT • FACILITATE PROBLEM SOLVING • EVALUATE OUTCOME YAI

  43. TECHNIQUES FORPROMOTING MENTAL WELLNESS ACTIVE LISTENING • ATTENTIVE • INTERESTED REFLECT • REPEAT A FEW WORDS • REFLECT DEMONSTRATES ACTIVE LISTENING YAI

  44. TECHNIQUES FORPROMOTING MENTAL WELLNESS PROBE • ASK DIRECT QUESTIONS • AVOID INTERROGATION • HOW AND WHAT QUESTIONS ARE USUALLY EASIER TO ANSWER THAN WHY QUESTIONS YAI

  45. TECHNIQUES FORPROMOTING MENTAL WELLNESS SUPPORT • SUPPORTIVE STATEMENTS INDICATE UNDERSTANDING • EXPRESS THAT YOU CARE • ACKNOWLEDGE HAVING BEEN IN A SIMILAR SITUATION YAI

  46. TECHNIQUES FORPROMOTING MENTAL WELLNESS FACILITATE PROBLEM SOLVING • EXPLORE ALTERNATIVE OPTIONS • SUPPORT ACCEPTABLE SOLUTIONS YAI

  47. TECHNIQUES FORPROMOTING MENTAL WELLNESS EVALUATE OUTCOME • WAS OUTCOME ACCEPTABLE? • WAS IT POSITIVE? • WHAT WAS LEARNED? YAI

  48. Robert Fletcher, DSW, ACSW - 2004 -

  49. STAGES OF PSYCHOTHERAPY WITH PERSON WHO HAVE MENTAL RETARDATION • INITIAL STAGE - THERAPY GOALS ESTABLISHED - GROUND RULES - RAPPORT DEVELOPED • MIDDLE STAGE - SOLIDIFIED THERAPEUTIC RELATIONSHIPS - THERAPIST IS EMPATHIC - EMOTIONS ARE EXPRESSED - PROBLEMS ARE IDENTIFIED - ALTERNATIVE SOLUTIONS Robert Fletcher, DSW, ACSW, 2004

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