MYTHS AND REALITIES CO-OCCURRING 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 Modified from DSM-IV-TR, 2000

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 Modified from DSM-IV-TR, 2000

4. 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 -

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) Robert Fletcher, DSW, ACSW - 2004 -

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. Robert Fletcher, DSW, ACSW - 2004 -

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 NASMHPD Research Institute (NRI, 2002)

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 NASMHPD Research Institute (NRI, 2002)

9. 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 -

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 Robert Fletcher, DSW, ACSW - 2004 -

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 Robert Fletcher, DSW, ACSW - 2004 -

12. PREVALENCE OFMI 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) Robert Fletcher, DSW, ACSW - 2004 -

13. MYTH:MEDICATION 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. Robert Fletcher, DSW, ACSW - 2004 -

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 Robert Fletcher, DSW, ACSW - 2004 -

15. 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. 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. Robert Fletcher, DSW, ACSW - 2004 -

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 Robert Fletcher, DSW, ACSW - 2004 -

17. Robert Fletcher, DSW, ACSW - 2004 -

18. MYTH:INDIVIDUALS 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 Robert Fletcher, DSW, ACSW - 2004 -

19. CROSS-SYSTEM BARRIERS 1. FUNDING ISSUES 2. LACK OF COMMUNICATION AND COLLABORATION • LACK OF QUALIFIED AND TRAINED SERVICE PROVIDES 4. PHILOSOPHICAL DIFFERENCES BETWEENMH AND ID SYSTEMS Robert Fletcher, DSW, ACSW - 2004 -

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” Robert Fletcher, DSW, ACSW - 2004 -

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 Robert Fletcher, DSW, ACSW - 2004 -

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 Robert Fletcher, DSW, ACSW - 2004 -

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 Robert Fletcher, DSW, ACSW - 2004 -

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 Robert Fletcher, DSW, ACSW - 2004 -

25. CROSS-SYSTEM BARRIERS 4. PHILIOSOPHICAL DIFFERENCES BETWEEN MH AND ID SYSTEMS Different language  Different service delivery approaches  Different treatment philosophy Robert Fletcher, DSW, ACSW - 2004 -

26. CROSS-SYSTEM BARRIERS • PHILIOSOPHICAL DIFFERENCES BETWEEN MH AND ID SYSTEMS (continued) MH SystemID Systems Rehabilitation Habilitation Recovery Self-Determination Medical Model Development Model Clients Consumers Short Term Approach Long Term Approach Robert Fletcher, DSW, ACSW - 2004 -

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 Robert Fletcher, DSW, ACSW - 2004 -

28. EFFECTIVE SERVICE SYSTEMS THREE INTER-RELATED ASPECTS: • ACCESS • APPROPRIATNESS • ACCOUNTABILITY Robert Fletcher, DSW, ACSW - 2004 -

29. EFFECTIVE SERVICE SYSTEMSTHREE INTER-RELATED ASPECTS • ACCESS TIMELINESS ARRAY OF SERVICES AVAILABILITY GEOGRAPHIC PROXIMITY Robert Fletcher, DSW, ACSW - 2004 -

30. EFFECTIVE SERVICE SYSTEMSTHREE INTER-RELATED ASPECTS APPROPRIATENESS SERVICE MATCHES NEEDS SERVICE MATCHES RECIPIENTS WISHES SERVICE ALLOWS FOR SELF- DETERMINATION WHENEVER POSSIBLE Robert Fletcher, DSW, ACSW - 2004 -

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 Robert Fletcher, DSW, ACSW - 2004 -

32. SYSTEMS WORKING TOGETHER: OHIO’S 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 Schroeder and McCleese, 2004

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 Schroeder and McCleese, 2003

35. ESSENTIALS FOR SUCCESS:BRING TOGETHER THE RIGHT PEOPLE • Department leadership • Representative community people • Clinical people • Administrative people • State resources • Statewide organizations • Consumer/family members Schroeder and McCleese, 2003

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 Schroeder and McCleese, 2003

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 Schroeder and McCleese, 2003

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 bothsystems Schroeder and McCleese, 2003

39. FIRST YEARS • Developed Best Practices document • Series of training events • Stand alone • Fifth column approach • Begin attacking systems barriers Schroeder and McCleese, 2003

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 Schroeder and McCleese, 2003

41. OVERVIEW OF THE NEW ODMR/DD-ODMH INTERAGENCY AGREEMENT • Four Sections • Purpose • Joint Responsibilities • ODMH Responsibilities • ODMR/DD Responsibilities Schroeder and McCleese, 2003

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) Schroeder and McCleese, 2003

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 Schroeder and McCleese, 2003

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 Schroeder and McCleese, 2003

45. COORDINATING CENTER OF EXCELLENCE • Training • Consultation • Follow-along • Research • Technical assistance • Further development of bestpractices Schroeder and McCleese, 2003

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@thenadd.org Thank you! Robert Fletcher, DSW, ACSW - 2004 -